IJ TRANSGENDER - Transgender Individuals' Experiences of Psychotherapy

Paper presented at the American Psychological Association 109th Annual Convention, San Francisco, CA. August 24-28, 2001

This research examined Transgender and Transsexual individuals' experiences in psychotherapy accross a range of treatment settings. Participants completed a survey that asked why they had sought mental health services and what their experience of treatment had been. The sample consisted of 93 participants (70 Female-to-Male and 23 Male-to-Female) who reported on 150 contacts with various psychotherapists. Results indicated that it was common to have seen a psychotherapist for general personal growth issues earlier in life and to later seek out a therapist who had experience in transgender work in order to focus on gender issues. Provider experience in working with gender issues was associated with a higher number of positive changes, higher patient satisfaction with progress in both general personal growth, and gender related issues. Individuals consistently expressed appreciation for therapists who were flexible in their treatment approach and demonstrated respect for the patient's gender identity.

Transgender and Transsexual individuals may seek mental health services for a variety of reasons. Psychological assessment and psychotherapy are often suggested, and sometimes required, in the treatment of individuals with gender concerns. The sixth version of the Standards of Care For Gender Identity Disorders (Meyer III. et al. 2001) describes in detail the potential benefits to be had from psychotherapy and outline the role of the psychotherapist in the treatment of Transsexual and Transgender individuals. This research attempted to look at individual experiences in psychotherapy across a range of treatment settings.

Clinicians treating this population are apt to see a wide range of gender identity and expression. Rather than a simple 'opposite sex' identity (most typical of Transsexual individuals), Transgender individuals may have non-traditional and complex experiences of gender. This research is concerned with all people who may seek psychotherapy for gender concerns. The term 'Transgender' is used in this paper to refer to the combined population of Transgender and Transsexual individuals. Being Transgender is not in itself pathological or indicative of a need for psychiatric treatment. However, Transgender individuals do experience a number of unique stressors and are no different from the rest of the population in their potential to experience emotional problems and other concerns which may lead them to seek psychotherapy.

Psychotherapy has a multifaceted role in the gender exploration and transition process. Psychotherapy can provide support for coping with external stressors, treat comorbid conditions, provide increased insight into personal history and motivations, facilitate exploration of the options for living with one's gender identity and enhance decision-making regarding gender transition options. Mental health professionals may see Transgender individuals in formalized gender programs, therapy clinics, or private practice. In every case the therapist will be challenged to provide treatment that is sensitive to the client's unique gender identity and individual circumstances.

Transgender individuals may find ways of living with non-traditional or cross-gendered identities that do not involve altering their bodies. Yet, for some people, there is no substitute for taking actions to create a body that is more truly reflective of their identity. This may include a number of procedures such as electrolysis, hormones, and various surgeries. Hormonal and/or surgical gender-confirming medical interventions have proven to be very satisfactory for a select population. Individuals who undergo hormone therapy may find the effects of hormones sufficiently satisfying so that they need no further medical interventions. Other people will want surgical modification in order to feel personally comfortable and satisfied. Caroll (1999: 128) reviewed "the empirical research on the psychosocial outcomes of treatment for gender dysphoria" and concluded that "The large body of research on the outcome of gender reassignment surgery indicates that, for the majority of those who undergo this process, the outcome is positive." Kuiper and Cohen-Kettenis (1988: 439) also concluded "that there is no reason to doubt the therapeutic effect of sex reassignment surgery."

Though in many cases the most helpful treatment is surgical, there is no reliable diagnostic test that a physician might prescribe to assess the appropriateness of such a patient for surgery. Most of the known correlates of post-surgical success are psychosocial and are best assessed by a trained clinical behavioral scientist. The incidence of postoperative regret is generally extremely low (Pfäfflin (1992) found less than 1% in Female-to-Males and 1-1.5% in Male-to-Females). However, researchers continue to study incidents of regret in an effort to decrease the occurrence even further. A better understanding of the factors which contribute to both postoperative satisfaction and postoperative regret will enable clinicians to improve diagnostic and selection criteria and presurgical preparation.

The substantial body of literature that looks at the outcome of gender confirming surgeries has explored the relationship between measures of post-surgical satisfaction and a number of biopsychosocial factors such as: the quality of surgical results; quality of social and family relationships; quality of professional life; pre-surgical emotional stability; quality of presurgical counseling; and quality of life in preferred gender role prior to surgery (Carroll, 1999; Green and Fleming, 1990; Bodlund and Kullgren, 1996; Brown, 1990; Landen, Walinder, and Lundstrom, 1997; Ross and Need, 1989; Lundstrom, Pauly, and Walinder, 1984; Pfäfflin and Junge, 1998; Pauly, 1981). Kuiper and Cohen-Kettenis (1998: 2) reported that:

More than 20 possible risk factors that influence the result of SRS [sex reassignment surgery] negatively, are mentioned throughout the literature. However, none of them has proved to be an absolute contra-indication for SRS. Negative prognostic factors tend to lie in the area of psychological dysfunction, family background, sexual orientation, disrupted social contacts, insufficient professional support during the 'real life test', and complications in surgery.

It is important that treatment providers be informed about such research when evaluating people for surgery and making treatment decisions.

Psychological evaluation is recommended to assess 'eligibility' and 'readiness' for surgery as defined by the Standards of Care for Gender Disorders (SOC) (Meyer et al. 2001). If factors are present which have been associated with negative outcomes, then psychotherapy may provide an opportunity for the individual to address these issues prior to surgery.

The current SOC (Meyer et al. 2001) are intended to be guidelines for treatment and suggest that physicians obtain a letter from a mental health professional prior to prescribing hormones, and letters from two mental health professionals prior to performing surgery. The first letter for surgery is traditionally written by a psychotherapist who knows the client very well. The second opinion letter is written by a clinician who conducts an evaluation of some briefer duration. It is also possible for two clinicians who are part of a 'gender team' to collaborate on one letter. Such letters generally include a psychosocial assessment, a description of psychotherapeutic treatment, and support of the patient's ability to make decisions regarding gender transition (see SOC for an in-depth discussion of the content of such letters). The physician prescribing hormones or performing surgery may rely on the psychological assessment to inform his or her medical opinion about how best to treat the patient. Patients may not be able to obtain hormones or surgery without such letters. 'Gatekeeping' is a word used to refer to the role of the mental health professional who may control access to medical care through such letters.

Descriptions of the role of the clinician in treating transgender individuals invariably list a large number of tasks. Ettner (1997) provides guidance for clinicians by encouraging them to shift paradigms and approach gender treatment with a different theoretical orientation, and different assumptions and skills than they may use with their other clients. Schaefer, Wheeler, and Futterweit (1995), and more recently, Brown (2001) illustrate how necessary it is for treating professionals to have detailed knowledge of the medical and psychosocial components of the transgender experience. It is also essential for them to be aware of all possible options and treatment strategies. Bockting and Coleman (1992: 134) describe a comprehensive treatment model, which uses a number of treatment modalities, and incorporates the contributions of professionals on an interdisciplinary team. In their comprehensive treatment model, "five treatment tasks can be distinguished: (1) Assessment; (2) Management of comorbid psychiatric disorders; (3) Facilitating identity formation (analysis of biography, family of origin intimacy dysfunction/abuse recovery, sexual identity exploration); (4) Sexual identity management (decision making, sexual functioning, social support); and (5) Aftercare."

The treatment of Transgender individuals provides an opportunity for a multifaceted and potentially non-traditional role for the psychotherapist. The SOC describe the potential for psychotherapy to educate, clarify options in Transgendered living, facilitate transition, improve personal familial, social and working relationships, provide information about medical, legal, and community support resources, provide support for family and significant others, and even suggest that the therapist be available to advocate and educate in the workplace. So much is expected of the therapist that it is clear why a high level of specialized expertise is needed. The SOC provide suggested criteria for professional competence in this area and Israel and Tarver (1997) also propose criteria for the designations 'Gender Specialist' and 'Senior Gender Specialist' in their 'Recommended Guidelines.' Qualification for 'Gender Specialist' includes, but is not limited to "a minimum of two years of direct supervision or consultation with a practicing 'Senior Gender Specialist' who is recognized as having advanced experience in providing consultation to peer practitioners," (Israel and Tarver, 1997: 12). Schaefer, Wheeler, and Futterweit, (1995: 2047) in describing the basic requirements for good treatment, state:

Essential to an effective psychotherapeutic relationship is that psychotherapists be informed about all aspects of gender identity disorders and conditions, be knowledgeable about all known options available for learning how to live with this condition, be completely versed and educated about the unique challenges on working with all levels and intensities of gender identity ideation and expression in patients.

Because there are comparatively few therapists with such expertise, individuals often search out other sources of support such as peer support groups, internet contacts, and therapists who have no experience with Transgender issues.

The requirement that individuals see a mental health professional prior to medical intervention presents some challenges. Individuals who want psychotherapy may not be able to afford or locate an appropriately trained therapist. The suggestion in the SOC that individuals see a therapist is especially burdensome for those people who do not want therapy at all. Some Transgender people do not believe that they have a need for psychological services and oppose the recommendation that they meet with a mental health provider. Individuals may resent having to spend time and money for psychological services in order to obtain medical services. They may also have fears concerning speaking with someone who holds the power to grant or deny them access to the interventions they feel they need. This fear and resentment creates a dynamic between therapist and client which may have an impact on the process and outcome of treatment. A number of therapists have explored the ethical dilemmas raised by the dual roles of gatekeeper and therapist. Vitale (1997: 254) emphasized that the ethical issues become more treacherous when professionals do not have the training and expertise and sensitivity to competently assess and treat Transgender clients. In response to the fractured relationship and long time mistrust between the Transgender and professional communities she proposed:

As the first step in resolving our difficulties, I suggest we start with a more clearly defined idea of what constitutes a qualified gender therapist. ...a licensed professional with sufficient training and supervision to handle this extremely debilitating disorder. The individual should be ready to accept crossdressing and sex or gender incongruity as a psychologically unalterable, congenitally attributed, natural phenomenon.

Anderson (1997: 189) offered a solution to the dual role raised by evaluator and therapist by suggesting that

The therapist's singular role would be to counsel, support, interpret unconscious material, and educate and encourage the client in the interest of exploring all possibilities that promise growth and change in a desired direction. At the end of the period of therapy the client could meet with a second clinical behavioral scientist who, furnished with records of the process and outcome of therapy, would evaluate the applicant and ultimately recommend or withhold endorsement.

Bockting and Coleman's (1992) 'comprehensive treatment model' takes some of the gatekeeping power away from the primary therapist by utilizing a multidisciplinary treatment team to make that final recommendation for surgery.

All of these approaches assume that it is necessary for a transgender person to undergo an evaluation prior to medical treatment. Hale (2001) proposes a different approach. He advocates taking the responsibility for treatment decisions away from behavioral clinicians. He argues in favor of an informed consent procedure which would eliminate the universal need for a psychological evaluation and which would transfer the task of evaluation and diagnosis from the psychotherapist to the physician. He also suggests that the relationship created when a psychotherapists acts as a gatekeeper is both unethical and may prevent transgender individuals from benefiting from psychotherapy. These issues continue to be debated as interested practitioners attempt to provide the best care possible.

Though the exact numbers are not available, it is reasonable to assume that a large portion of the people who consider or undergo gender transition engage in some form of psychotherapy. What are they seeking when they enter into psychotherapy and what do they get out of it? Are they there because of a medical mandate or because they want increased insight and personal growth? This research attempted to look at how Transgender people approach psychotherapy and what their experiences of treatment have been. Ultimately such information may suggest direction for training and practice in psychotherapy and assessment, so that professionals can provide Transgender clients with services that will be most valuable and satisfying.

A survey was designed to ask Transgender people why they had sought mental health services, what they looked for in a psychotherapist, their opinion of their therapist's level of competence in working with gender issues, and the outcome of treatment. Each participant was allowed to describe their experiences with two therapists.

Surveys were distributed at a Transgender conference in Baltimore Maryland, USA in February 1999. They were also distributed by individuals who had heard about the survey and wanted to participate. People also learned about the survey via Transgender newsgroups on the Internet.

Thirty-one percent (n=29) of the surveys were completed and collected at the conference. Fifty-two percent (n=48) of the respondents obtained surveys at the conference, through the Internet, or through another person and mailed in their surveys with an identifiable return address on their envelope. Seventeen percent (n=16) obtained the survey on the Internet and responded via e-mail. The response rate is unknown as individuals accessed the survey through a number of channels and researchers did not keep track of the number of copies distributed.

The sample consisted of 93 subjects (70 assigned female at birth and 23 assigned male at birth) who reported on 150 contacts with various psychotherapists. Participants represented 28 of the 50 states of the USA and ranged in age from 17 to 57 years with a median age of 37. Twenty-eight percent of the respondents reported that they had some college education: 36% reported that they held a Bachelors Degree, 15% a Masters Degree, and 15% a Doctoral degree. Forty-six percent reported that they lived in an urban area, 32% in a suburban area, and 19% in a rural area. Eighty-five percent of the sample identified themselves as Caucasian, 8% as African American, 3% as Mixed Heritage, 2% as Native American, and 1% as Hispanic.

Participants were given a check list of gender designations such as 'Male', 'Male-to-Female', 'Transgendered', 'Transsexual', etc. and were invited to check the words that they used to identify themselves. Many individuals identified with more than one label.

Among those assigned female at birth: 91% identified with the term Female-to-Male or FtM, 77% identified as Male, 34% as Transgender, 31% as Transsexual, 3 % as both Male and Female, 1% as Female, and 1 % identified as other. These numbers add up to more than 100%, which reflects the fact that individuals often found that no single term was adequate to describe them. For the sake of simplicity this group of female-bodied masculine-identified individuals will be referred to in this paper as FtM (Female-to-Male).

Among those assigned male at birth: 87% identified as Male-to-Female or MtF; 83% as Female; 70 % as Transgendered, 17 % as Transsexual, 13 % as both Male and Female; 9% as other, 4% as cross-dresser; and 4% as Male. Again, may individuals identified with more than one term. For the sake of simplicity this group of male-bodied female-identified individuals will be referred to in this paper as MtF (Male-to-Female).

The majority of subjects had undergone hormone therapy (64% of MtFs and 80% of FtMs) and/or a name change (45% MtF, 71% FtM). (See Table 1)

Table 1. Gender Transition Choices and Physical Status
		Number of respondents who made this choice
Gender Confirming Action		Definitely Not		Considering		Actively Planning		Have Had
		n	%	n	%	n	%	n	%
Hormones
	MtF	1	5	1	5	6	27	14	64
	FtM	2	3	5	7	7	10	55	80
Name Change
	MtF	0	0	6	27	6	27	10	45
	FtM	2	3	9	13	9	13	49	71
Top Surgery
	MtF	7	33	10	48	4	19	0	0
	FtM	4	6	6	9	23	33	36	52
Genital Surgery
	MtF	2	9	7	32	8	35	5	23
	FtM	20	29	35	51	11	16	2	3

The FtM and MtF groups showed very different patterns in decisions regarding surgery. While none of the MtFs had top surgery (breast augmentation), 52% FtMs had undergone top surgery (mastectomy and reconstruction) and another 33% were actively planning it. Twenty-three percent of the MtFs had undergone genital surgery and another 35% were actively planning it. Only 3% of the FtMs had genital surgery, 16% were planning it and 29% had decided definitely not to have it. Only 9% (n=2) of the MtFs had decided definitely not to have genital surgery. These results speak to the reality of FtM surgical options. While MtF genital surgery is relatively accessible and offers a potentially satisfying outcome (cosmetically and functionally), FtM procedures are regarded by many people as requiring an unreasonable degree of cost, risk, and compromise. (Though it should be noted that many FtMs are more than satisfied with their choices post-surgery.) In contrast, FtM hormones and chest surgery deliver impressive results and are seen as generally desirable and usually necessary.

Sixty-eight percent of those male-identified (FtM) and 48% of the female-identified (MtF) were living full-time in their preferred gender (defined as presenting in that gender at least 90% of the time) (See Table 2). The rest of the subjects were at various earlier stages of transition or had, for the moment, found ways of expressing their gender that did not involve a full-time social commitment to one gender.

Each participant was given the option of reporting on their experience with two therapists. 57 participants chose to report on two therapists and another 13 indicated that they had seen more than one therapist but only reported on the most recent. The Former, or earlier therapist, and Most Recent therapist, did not always represent two equivalent therapy experiences. Either therapist may have been someone the person saw primarily for an evaluation and/or a letter for hormones or surgery. In some of those cases a second therapist was consulted while therapy with the primary therapist was ongoing and the primary therapy continued during and after the evaluation. This was a rare occurrence (only nine individuals indicated that they were there for a 'second opinion' letter). In most cases there appeared to be two temporally distinct experiences with psychotherapists.

Survey items which asked about the reasons for seeking therapy were submitted to a principal components analysis and two factors emerged: Factor I - General Psychotherapy/Personal Growth, and Factor II - Gender Exploration/Transition. People rated the Former therapist higher on Factor I and rated the Most Recent therapist higher on Factor II (see Table 3). This suggested that earlier experiences were more likely motivated by general concerns and more recent experiences were more likely motivated by gender concerns.