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The Tempest Over Sex Identity*
(revised 9/03) By Lisa M. Hartley, ACSW-DCSW
_____ Thomas N. Wise, MD., Professor of Psychiatry and Behavior Science, The Johns Hopkins School of Medicine wrote the following to The Dartmouth, the newspaper of Dartmouth College. It appeared as a letter to the editor in the online version, October 12, 2001 with the title “Transgender Truths.”
Well, I have serious concerns about Dr. Wise’s comments, which, at most
could very well result in an injection of considerable suffering for transgender
people and, at least, continues the tired mythological and stigmatizing belief
that transgender is just another way to say “we’re crazy.” Those
who read his comments, made by a man of obvious standing and influence, may
seize upon his “diagnostic” opinion about “gender dysphoria”
and use it as another reason to fear transgender people as potentially or
completely unstable. This could worsen the already serious issues encountered
by transgender people in areas such as employment and housing, in receiving
adequate medical care and health insurance coverage, or in numerous other areas
that mainstream society enjoys. Although Dr. Wise has worked for years studying individuals who have significant problems with “self identity,” the idea that transgender is a psychiatric disorder that exclusively involves “internal psychological conflicts” seems quite interesting to me. Dr Wise states that there is “lack of data” establishing homosexuality as a psychiatric disorder. Does this mean that there is data that transgender is a psychiatric disorder? After 25 years of study, there must be a vast body of information to support his assertion. If so, where is it? There also seems to be little scientific curiosity or motivation to discover any physiological components associated with transgender. Yet studies that have been conducted over the years have often shown a physical component to emotional disorders, whether they are neurotic or psychotic in nature. As a result, most, if not all emotional disorders, are remediable to forms of medicine that are designed to relieve the symptoms presented, thus allowing the person to regain control and proceed with insight that leads to resolution of the problem(s). For example, if a patient is suffering from an anxiety disorder, a medicine can be administered, such as Valium, to relieve the physical symptoms while talk therapy continues. Having no apparent motivation to understand the physiological components of
transgender means that there are no medicines identified that would impact the
specific “symptoms” of transgender. Anti-anxiety medicine will not
work. Anti-depression medicines will not work. Anti-psychotic medicines will
not work. Even electro-shock therapy will not work. In fact, there is no medicine
to help a person relinquish the symptoms of a perceived “psychiatric
disorder” defined by an unhappiness with a culturally designated
sex identity, that is often accompanied by a “delusion” of
wanting to be the other sex and gender. However, counseling can be an important adjunct to help support the transgender
person in navigating the stormy seas of cultural ignorance. What seems interesting
is that the counselor will, at the request of the “patient,” write
a letter to the person’s physician approving the administration of opposite
sex hormones. Upon receipt of the letter, the physician will do so. Later in
time, another letter might be written to a qualified surgeon to confirm that
the person is appropriate for “reassignment surgery.” Upon receipt
of the letter, the surgeon will do the surgery. This would appear to be antithetical
to the idea stated by Dr.Wise, that “gender dysphoria” is specifically
an internal psychiatric disorder. Indeed, these actions might appear to be symptomatic
of the counselor and the medical professionals being drawn into the “delusion”
of the patient! But, of course, that is not the case. It is a widely accepted belief among most in the professions that although there are physical elements in transgender, there is not, as yet, a precise understanding of the impact of these elements at this time. It is agreed, however, that it is absolutely crucial to provide transgender people with competent assistance in issues of adjustment in the transitioning process, including supportive counseling, advocacy, resource referrals, and so on. Counseling almost always focuses on issues associated with being transgender, not about the physical reality of transgender per se, which appears to be in-born and immutable. There have been recent developments in research that provide important new and challenging insights concerning everyone, including transgender individuals. Ground breaking research studies reported in journals and the popular press within the past decade include work done with the BSTc in the hypothalamus at the Institute for Brain Research in Amsterdam, Netherlands by Dr. Zhou et al, and also by Dr. Wilson Chung et al in the USA. Another study, involving intersexed persons, reported by Dr Reiner et al of Johns Hopkins Hospital, has added significantly to our understanding of the origin of sex identity. These studies have substantially challenged the traditional thinking about sex identity designation, and present the thesis that sex identity is an inborn physical reality that originates in the brain. The genitals, which have been the focus of “biological” sex identity designation for millennia, appear to be only incidental to sex identity, whether functional or not. The genitals appear to have three important functions. First is the elimination
of waste from the body. Second is the production of sex hormones that promote
the physical characteristics of that particular hormone. And third, the genitals
facilitate procreation. The sex identity designation, so often done by looking
at the genitals, is a socially ascribed action, a mythical power given
to the genitals that, as we now know, is a catastrophic error, especially in
the instances of transgender or intersex infants. We must challenge the current perception that the genitals define sex identity. We must also challenge the view that the transgender person is psychiatrically disturbed. We must begin to understand and integrate the physical data from research. We must understand that transgender is an inborn physical incongruity where the origination of sex identity, located in the brain, is not matched by the genitals. This shifting of the paradigm is required of those in the counseling and medical professions, the insurance and allied industries, the systems of government and law, and everyone in the culture as well. The dysphoria that Dr. Wise describes is, in all probability, not the
result of “internal psychological conflicts” at all. It is most probably
a product of an incongruity in physical structure that has been missed
in the past due to a lack of understanding about the true origination of sex
identity, which is located in the brain, and not the genitals. The mistake
in sex identity designation at birth, followed by an intensive socialization
in the wrong gender role, results in serious stress for the transgender person—an
external stress induced by the culture that will challenge the very core of
the transgender person, as will be explained later in this paper. It is important to distinguish the terms we use. Transgender is not a sexual
minority. It describes issues with sex identity. Sex identity is also
distinguished from the sexual minorities in that identity describes,
“Who am I?”(girl, boy, or whatever) and sexual minorities describe
a sexual orientation toward another person, as in “who do I want to have
a relationship with?” All too often, sex identity issues, as seen
in transgender, have been included with the orientation groups, i.e. gay, lesbian,
bisexual, and heterosexual. This is not only confusing but it is entirely incorrect.
Schools of Thinking about Transgender Much of the transgender journey is a private internal struggle. Thus, each
transgender person has his or her own unique way of explaining the ‘why’
of his or her situation. When they connect with other transgender persons
and share their explanations about “the journey,” there are often
similarities and differences in their understanding of the process. Much is
subjective and, for those who have researched, there are “factual”
positions on the topic. Often there are heated discussions over who is more
correct. Over time transgender people gravitate to others who, like themselves,
believe in the same transgender process, resulting in the development of several
“schools” of thinking. Those professionals and allies who desire to
assist the transgender people have also developed their own views adding other
“schools” of thought. All the “schools” have made contributions
to our understanding of transgender, and all “schools” have their
passionate devotees. First, there is the school of thought that says a person has the right to express whatever gender, or claim whatever sex identity she or he desires, including androgyny. This is what I call the “naturalist school.” The generally held view expressed by this school is that there is no need to prove anything or to explain the “why” of transgender. It just is and that is sufficient, period. transgender persons have endured a multitude of negative experiences with the whole range of professionals and the systems in which they work. As a result, proponents of the “naturalist” school are suspicious of professionals in general. There is, then, a tendency to suspect professional people, often including transgender professionals, and to dismiss professional views as arrogant, assumptive, trite, and unnecessary. The “naturalist school” encompasses a significant number of
transgender people, including those who were our early “pioneers.”
They are the true “sheroes” and “heroes” that continue to
exert a powerful influence in the transgender community. There are also many
advocates for social and legal justice who embrace this school of thought, as
it espouses the human right of self-determination. Secondly, there is an “anthropological-historical” school. This school, which is very supportive of the naturalist school, outlines the presence of transgender throughout history. The fact of historical presence further legitimizes the transgender community by revealing its roots. Also in this school are those who document current trends and events that occur in the present time. Sobering is the website “Remembering Our Dead,” by Gwen Smith, who documents those of the transgender community who have been killed simply because they were transgender. Then, there is a “psychiatric school.” Proponents of this school believe that “gender dysphoria” is present in the so-called ‘transgender’ persons. The “patient” reportedly suffers from an inner psychological unhappiness involving their biological sex identity designation, which, for some curious psychological reason, is unacceptable to that “patient.” The “dysphoric patient” is viewed as seriously neurotic, or perhaps even more seriously impaired, reflective of major diagnoses like, schizophrenia, dissociative personality disorder, bi-polar disorder, and so on. Also in this school are those who feel that the male to female “dysphoric patient” suffers from a condition described as “autogynephlia.” To me, that designation seems evidence of, “when psychoanalysis goes bad!” Others see transgender as a format of homosexuality, which is, of course, an obvious misunderstanding of the difference between identity issues and sexual orientation. The psychiatric school sees the transgender person as a patient, i.e.
one who is disturbed (ill). Therefore, an appropriate “professional distance”
from the “patient” must be maintained. This attitude, of course, inhibits
meaningful collaboration between the naturalist and psychiatric “schools,”
and provokes the flow of negative transference and counter-transference phenomena,
so evident in the “naturalist” school toward the professional community
and vice-versa. Another “school” embraces the “hard science” of medicine. In medicine, the transgender person is often viewed as a congenital anomaly, which occurs during the gestation process. After the proper clearance from the “patient’s” counselor, the physician develops baseline data collection, followed by careful administration of hormones, if the “patient” is desirous of taking them. Unfortunately, there is nothing to compel a physician to spend much time understanding transgender. Information and training in “transgender medicine,” if there is such a thing, is not readily available, unless provided by the “patient.” To many physicians, treatment given to a transgender person seems like sailing in uncharted waters. Many physicians refuse to provide care to transgender people because of perceived risks. Others feel compassion and try to be helpful. Still others accept transgender persons into their practice, yet seem unconcerned about the quality of care provided to them. Perhaps care is referred to the doctor’s Nurse or Physician’s Assistant, or ARNP, without much in the way of preparation. Some of these people turn out to be helpful, but the majority seems to view the transgender patient as an ‘organism from outer space.’ When a physician does accept a transgender person for treatment, there seems
little, if any, sensitivity training provided to the office staff and nurses.
All too often, the attitudes and behaviors of office staff and nurses destroy
the “patient’s” motivation to trust the health care professionals
or the process. Another curious phenomenon that is evident, especially in the medical world,
is an attitude of sophistication that is reflected in a calm exterior when a
transgender person appears for care. There seems an aura of, ‘we treat
everyone the same and are completely objective.’ The use of an “objective
professionalism” most likely will be perceived by the transgender person
as a defensive cover for a good deal of anxiety that lies within. All this foolishness
is exposed when one looks at the quality of treatment, which all too often reveals
a betrayal. It might be refreshing for the doctor to be open and honest when
treating a transgender patient. The doctor might see the transgender patient
as part of the care team—a valuable member indeed! But with the increased volume of information, and the presence of transgender people in the world today, many professionals feel less fearful and more interested in helping. I thankfully acknowledge the array of professionals from many different disciplines who are crucial to the emotional, legal, and physical health and welfare of transgender people. As more and more transgender persons identify themselves, the diverse bio-psycho-social needs of the transgender community will require more and more supportive professional resources to assist them. Next, there is the important arena of the “Research School.”
There are two different parts to this school. The first part is focused upon
understanding the “why” of transgender through physical research.
The prevalence of physical research on transgender is very limited at present,
perhaps because there is little financial or cultural support for such work.
Still, I believe that the physical research findings about the BSTc in the hypothalamus
have been ground breaking and crucial to our development of a clearer understanding
of the physical/biological etiology of sex identity. The second part, social research, looks at the physical health, emotional well-being, and social issues that impact the transgender community. Most of the work has been done by activists in specific cities and states, who use the data to show the need to protect transgender persons by including ‘gender identity or expression’ in anti-discrimination laws. As yet, there continues to be no definitive understanding of the incidence
or prevalence of transgender. There are many guesses, but no one knows the numbers.
In most census data collections, transgender is not mentioned, as if we do not
exist. If we knew more about the incidence and prevalence of transgender, we
could develop a clearer understanding of the issues, needs, and the many positive
contributions made by the transgender community. Finally, at least finally at this time, there is the “Legal/Political
School.” Proponents of this “school” borrow heavily from
the psychiatric and hard sciences schools in their work as legal advocates or
policy makers. However, this school is vulnerable to the strong influences of
social customs and deeply held values and ideals that often reflect entrenched
mythical beliefs of culture. As we know, cultural traditions change very slowly,
especially in the integration of new knowledge gained from research. This vulnerability
can result in maintaining the status quo, which, for the transgender population
means serious delays in obtaining social justice. Another issue, which often
influences decisions, is the practice of citing past court decisions, reflective
of old myths and outdated “facts.” This only perpetuates the myths
and misunderstandings about transgender. Yet the “legal and political school” holds great promise. As lawyers
and policy makers become educated about transgender, they are recognizing the
urgent need to protect and defend transgender persons’ civil rights,
as well as to advocate for their acceptance in the mainstream of culture. Even though the field of transgender study is relatively new, the “schools”
have somehow maintained an independent status from one another that creates
a sense of “turf” separateness. As they are not compelled to work
together, any attempt to identify an “eclectic school”(my preference)
or develop communication strategies that link the “schools,” would
probably encounter significant barriers. As a “resolved dysphoric” and a surgically “confirmed” female Master’s level clinical social worker with over thirty years experience, I learned long ago that each of us is a bio-psycho-social entity. I have become acquainted with the various “schools” of thought on transgender, and reviewed much of the vast amount of wonderful material associated with each school. There are good things in each of the “schools.” I agree with the “naturalists,” who feel that there is an implicit human right to be oneself. After looking at the findings from physical research, and from understanding my own experience and the experiences of many in the transgender community, I do not agree with the “psychiatric school” position that transgender is a psychiatric problem. I do not believe that there is a “gender dysphoria” evident in transgender. I do believe that there are strong cultural components that complicate and exacerbate the transgender person’s struggle to define their true sex identity as reflected in the brain. I believe that the response to transgender by so many in our culture reveals a cultural dysphoria. Culture is unhappy with, and cannot accept the reality of transgender. I agree with the “hard sciences school,” in that there must be a significant biological component that strongly contributes to the human motivation to express another gender role or sex identity, either on a part time or on a full time basis. Although I may be making premature assumptions from the studies done in Amsterdam and elsewhere, I believe that the ongoing work in the BSTc of the brain will eventually prove to be an important factor that defines the origin of everyone’s sex identity. As I mentioned earlier, there are many good people doing a lot of good things to serve the transgender community. I do not believe that there is an evil plot against transgender people. I do believe that we are wrongly perceived by many in our culture as a foolish, unwholesome, unstable, and worthless minority. These negative descriptors get further associated with all sorts of other negative images. In time, myths develop that pose a significant barrier to any legitimate effort at educating the public about the true etiology of transgender, or in obtaining social justice and equality for transgender people. Fortunately, tireless efforts by many including transgender individuals,
professionals from many disciplines, as well as advocates from human rights
organizations, have made a significant impact in the education of everyone about
the truth of transgender. Little by little facts are beginning to replace the
fear and the many false and destructive myths about us. Yet I still continue
to wonder why the archaic and mythological thinking about transgender is so
amazingly persistent in professional circles, as well as in the general population,
despite important research developments that have been reported. Perhaps it
is very difficult to let go of long held belief systems, despite strong physical
evidence to the contrary. The situation with transgender people is not so simple and easy to dismiss as Dr.Wise has stated, “not bad people who often have serious psychological issues.” With ongoing study, my own experience, and listening to many anecdotal accounts from those in the transgender community, I have developed an explanation that, I trust, reflects a more accurate picture of reality, and embraces elements of several of the schools of thought outlined above. A Formulation Concerning Transgender First of all, “transgender” is an inclusive, umbrella term under
which a continuum of behavior is revealed. At one end of the continuum are the
most secretive (“closeted”) transgender persons. As one moves toward
the center of the continuum line, behaviors include progressively more and more
open expressions of opposite gender or gender-neutral behavior. Moving along
the continuum toward the other end are transgenderists, who live in the opposite
gender role. And finally, at the other end of the continuum are the transsexuals,
many of who obtain corrective genital surgical procedures to confirm their true
sex identity. Most transgender persons fall near the center of the continuum
line. I think that what we see in transgender is related in some way to the intersex
community. But in the instance of transgender, the person is born with completely
formed genitals. Because the new and important research has not been incorporated
by the medical community to date, an archaic protocol continues to be used,
in which the designation of a “biological” sex identity is made by
looking at the external genitals of the infant. Although the genitals should
reflect the brain sex identity, in transgender there is no match. Thus, a catastrophic
error in sex identity designation occurs in the case of a transgender baby.
This error starts a chain of events that are outside the control of the child.
Events like naming the child, completing legal papers that include the error
in sex identity designation, primary socialization, and the continual reinforcement
of wrong gender role expectations is carried out by a culture that is unaware
of the primordial error. Equally devastating is when the genitals are ambiguous, as is often seen in
an intersexed infant. Surgery is all too often the solution to a perceived medical
or social “emergency.” In these cases, a transgender person
is all too often surgically created! Yet the practice of surgical assignment
of sex identity upon intersex infants continues to be done by rigid, unsophisticated
professionals. Surgery on helpless infants seems to me to be a serious violation
of their rights. In my opinion, it constitutes a criminal surgical assault upon
the helpless infant. In addition to the work with the hypothalamus, which continues in Amsterdam and elsewhere, a study done at Johns Hopkins Hospital by Dr. Reiner et al on intersexed infants with incomplete external genitals, has demonstrated that the brain is the primary site in determining a person’s true sex identity. As Dr. Reiner stated:
This finding strongly reinforced the conclusions by many in the scientific
community concerning the famous “twin study,” where one of the infants,
David Reimer, was injured in a botched circumcision. Clearly, Dr Milton Diamond
did science a great service by discovering that John Money, PhD was in error
in his assumptions that genital manipulation could be done without the child
ever knowing the difference. Despite all the surgical technology used to impose
a female sex identity upon David Reimer’s genital region, all the hormones
administered, and all the psychosocial strategy with the family designed to
reinforce the surgical sex identity assignment, he refused live as a girl. His
true sex identity as a male, originating in his brain, would not be denied. Overview of Culturally Induced Stress (Internal and External)* When the transgender community is viewed as a whole, a pattern of stages emerge that reflect an intense struggle which every transgender person must navigate in order to “be.” As the person moves from one developmental stage to another, the awareness of a need to express the “other” sex identity intensifies. While trying to “be” what culture assigned him/her to be, the transgender person must also privately address the relentless inner struggle to understand their true sex identity as reflected in their brain. This struggle often results in outward signs of a culturally induced stress that can take the form of mild to moderate depression, isolation, anxiety, low self-esteem, and other stress related behaviors. The inner struggle to understand their brain sex identity, versus the culture’s designation of a sex identity via the genitals, will never cease until the transgender person resolves the struggle by getting information, finding and joining supportive groups, going into counseling, or by a courageous exploration on their own. Once the true sex identity is understood and accepted, a “coming out” process begins. The external struggle to achieve acceptance by the culture is a scary one indeed.
Ideally, the culture should recognize the error made in the sex identity designation,
and then assist the transgender person in the transition process to confirm
their true sex identity as expressed in the brain. But the rigidity of socialization
is enforced by many persons of influence in the culture, such as those in positions
of power and authority, like physicians, psychologists, law makers, the courts,
law enforcement, the church, employers, and others, who continue to insist on
forcing the transgender person to live with the sex identity designation mistake
that was made at birth, regardless of the human suffering it induces. Even the media participates in this rigidity, referring to transgender persons
with the wrong pronoun or using the person’s former name. After speaking
in Nyack, NY, a newspaper reported me as a “former man!” There are
countless other examples, including the use of the birth given name in referring
to transgender persons. For example, Eddie “Gwen”Araujo instead
of just Gwen Araujo. The stress phenomena experienced by the transgender person is what I call
“Culturally Induced Stress”(CIS)*. There is an “internal
CIS” component, and an “external CIS” component. Internal CIS The “ CIS” component involves the transgender person’s dealing
with the struggle that exists between the constantly reinforced culturally designated,
genitally based “sex identity,” versus the opposite
and true biological sex identity that is physically present and expressed in
the brain. The inner struggle may be more clearly understood by referring to the process
of homeostasis (physical balance) as described by Walter B. Cannon, MD,
ScD, in his book entitled The Wisdom of the Body, (Second Edition, WW
Norton, New York, 1939). Simply explained, homeostasis can be understood by the following example. If
you had a headache, you would be experiencing an imbalance, a lack of homeostasis.
The pain you feel would be a signal for you to do something to eliminate the
discomfort. Perhaps you would take an aspirin or enjoy a brief rest, or do whatever
you do to find relief. Soon the pain is gone and you feel like yourself again—you
have achieved a physical balance called homeostasis. Most people are born with genitals that match the brain sex identity. But in
the instance of transgender, an incongruity is present. The genitals do not
match the brain sex identity. But to be in physical balance, to achieve homeostasis,
the incongruity must be resolved. The process of homeostasis, then, includes the person’s internal struggle
to understand and accept that the culture’s designated sex identity
that was imposed upon him or her at birth was an error, and then recognize
and accept that the true biological sex identity located in the brain
is what defines his or her true sex identity. This process, in the final analysis,
is truly “mind over culture.” The process of working through the internal component of CIS to achieve homeostasis,
is exceedingly difficult. After all, there are observable, “normal”
genitalia. Everyone says she is a girl, or, he is a boy. Yet, there is the continuous
feeling that something is wrong-- that things are slightly out of focus. For
most transgender persons, the awareness of the incongruity of their sex identity
begins in early childhood as a preconscious awareness, which is usually not
fully understood or articulated by the child. The ever-present internal struggle to understand their true sex identity is
continuously frustrated by the relentless external efforts to reinforce the
primary cultural socialization. There is a strong prohibition (“taboo”)
on any conversation that questions the sex identity designation made by the
doctor, let alone the “preposterous” idea of “changing”
one’s sex. These rigid external pressures constitute a culturally induced
stress that inhibits the transgender person’s freedom to outwardly explore
and understand his or her true sex identity. transgender persons, like everyone
else, have learned that there is retribution for openly embracing and expressing
their true sex identity, which is at odds with the initial designation made
by the culture. It should not be surprising that the transgender person will most often choose
to struggle with their sex identity incongruity alone. It is much safer, and
avoids the likelihood of punishments from others who would not understand. Like
the ‘skeleton in the closet,’ the struggle is almost always regarded
as a private and carefully guarded “secret”—a “secret”
that carries with it much suppressed fear, guilt, shame, loneliness, and feelings
of futility--that there is no way to resolve the problem. Most transgender people make an attempt at conforming to the culturally designated
sex identity as a way to survive. But this approach is rarely satisfactory or
successful, even with culture’s positive reinforcement. As the years go
by, the transgender person becomes more and more aware of the need to resolve
his or her sex identity incongruity. In Wilson Chung’s study reported in
2002, we learned that the BSTc matures in adulthood. Thus, like turning up the
volume on a radio, the need to understand and achieve homeostasis increasingly
intensifies through the years, forcing the person to pay more and more attention
to the issue of their sex identity incongruity. Indeed, the internal CIS struggle
will never end until homeostasis, is somehow achieved. The details of the internal struggle are individualized for each person, their
environment, experiences, perceptions, and so on. But there are many common
guideposts in the journey. These common points are presented in the “The
Process of Becoming—A General Overview of the Transgender Journey”
section at the end of this paper. The range of coping strategies can go from
emotional ups and downs, to acting out, to substance abuse, to just about anything
else, including an outwardly “normal” adjustment. The relentless internal struggle will eventually lead the person to information,
counseling, support groups, private or public cross-dressing or cross-living,
or a combination of these resources and activities. Tragically, many transgender
persons fall into lives of despair in the margins of culture, often experiencing
physical abuse, emotional abuse, and exploitation. For some who can no longer
go on--- there is suicide. For the survivors who overcame their fears of retribution, the achievement of homeostasis in such a basic, cornerstone reality of sex identity is very empowering. The relief in resolving the intensive and painful internal struggle brings an emotionally moving fulfillment that is described in many ways, such as: ‘for the first time in my life I felt a peaceful feeling inside,’ or ‘I felt a reduction of tension,’ or ‘at last I felt a comfortable feeling inside myself,’ or ‘at last I am me,’ and so on. There is a sense of euphoria, as occurs whenever anyone achieves an incredibly difficult goal. Indeed, the transgender person has achieved an incredibly difficult goal in rising above culture’s error in sex identity designation and courageously proclaiming his or her own true sex identity! In the study by Dr. Reiner et al with intersexed infants described earlier,
a discussion of Kayla, age seven, who had been born without a penis and was
subsequently surgically made into a female, is a powerful example:
Those who were born with a congruent sex identity, where the brain sex identity
and genitals match, have a difficult time understanding what it is like to realize,
at last, what one’s true sex identity really is. To them, all this activity
seems foolish and absurd. After all, they have always known their sex identity
without having to put forth any effort whatsoever. Yet it is important to understand
that for the transgender person, there is an incredibly complex struggle to
overcome strong cultural forces to reach “square one.” External CIS Once homeostasis is achieved and the internal CIS is overcome, the outward expression of that resolution takes a multitude of formats, as seen in a continuum of gender manifestations and behaviors that can include cross-dressing, cross-living, a plethora of other creative expressions, or complete transitioning that surgically confirms the person’s true sex identity. It is incorrect to view genital surgery as a “sex change,” or “sex reassignment,” or “gender reassignment.” These terms reflect the dysphoria of culture. In truth, the genital surgery confirms the true sex identity of the person. It is confirmation surgery (CS). Unfortunately, the transgender person’s joy-filled proclamation in resolving
his or her true sex identity struggle, is all to often met by a world that most
likely will doubt it, and will probably label the transgender person as psychiatrically
disturbed. This is as catastrophic as the wrong sex identity designated at birth,
and initiates what I call the “external” component of Culturally
Induced Stress”(external CIS). Initially, there are various and seemingly relentless activities carried out
by family, friends, and the culture in general, which seem to be a “warning”
designed to force the transgender person to conform to the genitally based
sex identity designation. Implicit in these “warnings” is the threat
of retribution-- that the culture will use punishment, including emotional and
physical abuse, neglect, exploitation, or the outright rejection of family and
friends. Should the behavior reflective of one’s true sex identity continue,
more serious punishments may be undertaken. Cultural marginalization, and economic
impoverishment are extreme forms of rejection experienced by many transgender
persons. The punishments that are designed to force conformity to cultural expectations,
act as a self-fulfilling prophecy. Poverty, brought about by the removal of
economic opportunities from the transgender person, all too often results
in a lifestyle of high risk behaviors that place the transgender person in
situations where many serious problems will develop, including stress related
problems and health issues. These unfortunate outcomes are then weaved into
false cultural myths that look at the status of transgender persons and judge
them as unworthy, even though it was the dysphoric culture that trashed the
transgender persons in the first place! All too often, the punishments are so blatant and cruel that many transgender
people cave in, succumb to depression, and commit suicide. Uncorroborated estimates
are as high as 25% of the transgender population, who successfully kill themselves. There also seems to be a shockingly perverse and implicit “approval” in the culture that a few mindless people interpret as a permission to do whatever they wish to do to the transgender person. Perhaps they believe that severe punishments will serve as an example of what would happen to others who would dare to cross the culture’s rigid binary, genitally focused, sex identity designation lines. Hate crimes are all too frequent. According to statistics compiled by National Transgender Advocacy Coalition and Gwen Smith, there has been a hate filled murder of a transgender person every single month since 1990. Those that survive the social wounding inherent in external CIS must face continuous
instances of discrimination, public humiliation, and attempts at cultural marginalization.
This relentless level of culturally dysphoric behavior sends a message to the
transgender person that he or she is not fit to be in the cultural mainstream.
For many, the only alternative becomes a marginal lifestyle that is very different
from the world that the transgender person knew before he or she “came
out.” The Role of Counseling The internal stress experienced from having to deal with the sex identity incongruity
is indeed monumental. That, combined with the constant external cultural pressures
to conform to a sex identity and gender role expectations that are genitally
focused, accompanied by the guilt and a fear of retribution by others, and there
will ultimately be various stress related symptoms exhibited by the transgender
person, It is crucial that the counselor understands the physical origins of transgender
and be comfortable in working with a transgender person. It is not a psychiatric
problem. It is a physical issue that has placed the transgender person at
the mercy of a culture that not only refuses to understand, but one that ostracizes
and punishes the transgender person relentlessly. Individual supportive
approaches and later adding group sessions with other transgender persons,
appear to be the state of the art in counseling, and generally work well. Many counselors follow the Harry Benjamin International Gender Dysphoria Association’s
Standards of Care. The standards are helpful but must never be used as
a rigid procedure or used to prolong counseling to satisfy the counselor’s
need for power as a gatekeeper, or to the benefit of the counselor’s income.
The Standards of Care have always been accepted as guidelines for working with
transgender persons. Rigid adherence to these standards usually reflects a
counselor who is not competent in working with transgender persons. In some instances there may be other diagnostic conditions concurrent with, but separate from, the presence of transgender related CIS, which can make the treatment process more complex. But whatever the presenting problem(s) described, the appropriate tasks for
the counselor in these cases include: 1. defining the problems, including the
history of these problems; 2. taking a detailed history of the person; 3. the
understanding and exploration of the current bio-psycho-social issues
experienced by the person; 4. assisting in the management of stress related
issues; and, if applicable, 5. the exploration and confirmation of the true
sex identity as reflected in the brain. Basic counseling skills are necessary,
as always. A good counselor knows that he or she must develop rapport that earns
the right to respectfully discuss the information shared by the person. Along with the ongoing assessment, diagnostic, and intervention work, there
are a number of other important roles that the counselor will need to assume
in working with transgender persons. These include, but are not limited to:
family counselor, civil rights advocate, and resource mentor. The fact of transgender is not an issue for employing so called “reparative
therapy” strategies that attempt to force the person to accept the gender
roles of the “culturally induced” sex identity designation made at
birth. If attempted, “reparative strategies” will succeed only briefly,
most likely as a way for the person to show compliance with the counselor. But
over time, the relentless sex identity incongruity struggle will reassert itself.
The person will then become aware that he or she has been seriously wounded
by the process of “reparative therapy,” and will undoubtedly feel
betrayed by the counselor. Confidence in the counselor, as well as the process
of helping and support will be seriously compromised, if not destroyed. Tragically,
this cruel abuse of trust by the counselor quite often results in the person
stopping counseling altogether. Many conclude that the process is useless, thus
rejecting a crucial support system that can assist them in the successful working
through of the many issues related to the transgender journey. The primacy of the brain in determining sex identity cannot be overridden
or ignored. It must be respected as the true sex identity of the person. In Conclusion: It is a profound human tragedy that the transgender person is consistently
viewed as the dysphoric one--the one with the problem. The research seems clear
that transgender is a physical incongruity of sex identity where the brain,
now seen as the origination of sex identity, is not matched by the genitals.
This biological fact continues to be ignored, resulting in an the ongoing error
of sex identity designation that is genitally based. The primordial error is
then compounded by cultural socialization that relentlessly pressures the transgender
person to conform to gender roles that are not congruent to the person’s
true sex identity. The induction of stress, that I call CIS, needs to be identified
as a predominant exacerbating factor in the internal and external suffering
of transgender persons. The stark reality is that the culture itself commits
a serious crime against the true and courageous spirit of the transgender
person, who is only trying to correct a tragic mistake of a wrong birth sex
identity designation, and a wrong gender socialization. In the final analysis,
it is the culture that suffers from dysphoria, in that it refuses to understand
and accept the transgender person. It seems to me, then, that the culture
must stop the wounding of transgender persons, resolve their dysphoria, and
reach out to assist them medically, legally, in housing and employment, and
in the process of public policy making. Along with the cultural institutions,
everyone in the culture needs to reach out with acceptance and compassion toward
transgender people. Then, a tragic mistake would be corrected. The Process of Becoming—A General Overview of the Transgender Journey
Stage Two: Primary Socialization
Stage Three: The “Awakening”*----the sex identity quandary
is realized---
Stage Four: The Internal Struggle to Understand (Internal CIS)
Stage Five: The Victory---The conflict is resolved within and homeostasis
(balance) is achieved!
Stage Six: “Coming Out*”---The formal Courageous fear-filled
Step and the experience of External CIS
Stage Seven: Living with CIS---Making a Life
*Copyright 2001 (revised 9/03) by Lisa M. Hartley, ACSW-DCSW---all rights reserved [reprinted here with kind permission of the author] REFERENCED BIBLIOGRAPHY Zhou, J.-N., Hofman, M.A., Gooren, L.J., and Swaab, D.F., A Sex Difference
in the Human Brain and it’s Relation to Transsexuality, Nature Magazine,
#378: pp. 68-70, November 1995. Kruijver, Frank P.M., Zhou, J.-N., Pool, Chris W., Hofman, Michel A., Gooren,
Louis J.G., and Swaab, Dick, Male to Female Transsexuals Have Female Neuron
Numbers in a Limbic Nucleus, The Journal of Clinical Endocrinology and Metabolism,
Vol. 85, No 5, pp. 2034-2041, 2000. Chung, Wilson C.J, DeVries, Geert J., and Swaab, Dick F., Sexual Differentiation
of the Bed Nucleus of the Stria Terminalis in Humans May Extend into Adulthood,
The Journal of Neuroscience, February 1, 2002, 22,(3): 1027-1033. Cannon, Walter B. The Wisdom of the Body, Second Edition, WW Norton, New York,
1939. Ettner, Randi, Confessions of a Gender Defender: A Psychologists Reflections on Life Among the transgender, Chicago, Spectrum Press, 1996. ADDITIONAL RECOMMENDED BIBLIOGRAPHY --Colapinto, John, As Nature Made Him: The Boy Who was Raised as a Girl, HarperCollins
publishing, 2000. --Kotula, Dean, “A Conversation with Dr. Milton Diamond,” an internet
document found at http://health.ftmaustralia.org/library/02/0100.html, created
April 26, 2003, Revised May 3, 2003, Copyright 1999-2003, prepared by Craig
Andrews for FTM Australia, all rights reserved. --Ettner, Randi, Gender Loving Care: A Guide to Counseling Gender Variant Clients,
New York, WW Norton & Company, 1999. --Bockting, W. and Coleman, E. editors, Gender Dysphoria: Interdisciplinary
Approaches in Clinical Management, New York, Haworth Press, 1993. --Walworth, Janice, Transsexual Workers: An Employer’s Guide, Center for
Gender Sanity, P.O. Box 10616, Westchester, California, 97296-0616, 1998. --Feinberg, Leslie, Transgender Warriors, Boston, Beacon Press, 1996. 20. --Boenke, Mary, Our Trans Children, Washington, DC, PFLAG, 1998 (Booklet). --Boenke, Mary, Transforming Our Families: Real Stories About transgender
Loved Ones, Imperial Beach, California, Walter Trook Publishing, 1999. --Stuart, Kim Elizabeth The Uninvited Dilemma, Metamorphous Press, P.O. Box
10616, Portland, Oregon, 97296-0616, 1991. --Benjamin, Harry, The Transsexual Phenomenon, New York, Julian Press, 1966.
Last reprinted in 1989 by the Outreach Institute and Renaissance. Can also be
reviewed on the internet in the International Journal of Transgenderism, electronic
books published by Symposion. --Sullivan, Louis, From Female to Male, The Life of Jack Bee Garland, Alyson
Publications, Inc. 1990. --Kirk, Sheila and Martine Aliana Rothblatt, Medical, Legal and Workplace Issues
for the Transsexual, Together Lifeworks, P.O. Box 93, Watertown, MA, 02272-0093,
1995. --Devor, Holly, FTM: Female to Male Transsexuals in Society, Indiana University
Press, 1997. --Evelyn, Just, “Mom I Need To Be A Girl”, Imperial Beach, California,
Walter Trook Publishing, 1998. --Bohjalian, Chris, Trans-Sister Radio, (A novel), New York, Harmony Books,
2000. --Morris, Jan Conundrum, New York, Henry Holt and Company, 1987. Web Site Information
The above websites have been helpful for me. One of the best starting points
in getting to Transgender websites, and there are hundreds of them, is to use
a drive engine. I use ‘YAHOO’—at the home page click on ‘Society
and Culture’—when that page opens, click on gender—when that
page opens click on ‘transgender.’ This will get you to many good
sites from which more can be accessed, especially if you are in the mood to
surf the net. Chat rooms are generally not the best areas for information. They
are wonderfully supportive to many struggling with the many issues of transgender.
Most find others who have ‘been there--done that.’ There are the usual
pitfalls, e.g. Porn, which, in my opinion, shouldn’t be accessed anyway.
I have found that the IFGE (International Foundation of Gender Education) website
has access to a number of excellent websites. |
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