"First a word about the title. Those of you familiar with the history of this subject will be quick to notice that the subtitle refers to Dr. Harry Benjamin’s ground breaking work, The Transsexual Phenomenon, published in 1966. Prior to its publication, very little had been entered into the medical literature about the subject. The few works that were published tended to be about cross dressing (transvestism) in men and gave the impression that the “disorder” was one of perverse sexuality. Benjamin, on the other hand, was one of the first to think in terms of “sex” being the physical manifestation of the body while “gender” and gender expression as being a totally different aspect of what it means to be human. Further more, he writes that he believed that gender was indelibly imprinted on the brain either in utero or shortly after birth. Instead of seeing his patients as being delusional and suffering from a sexual perversion, he saw his patients as suffering from a form of intersexuality; having the body of one sex but the gender of the other. It is this paradigm shift in thinking that makes his work so important.
Benjamin wrote his book based on actual case studies of just under 500 mostly male-to-female patients over a ten year period (1954-1964). He noted that since psychotherapy was useless, transsexuals should instead be treated by hormonal and surgical sex change. Benjamin went on to predict that eventually neuroscience would find that gender identity and expression was hardwired in the brain and not simply a socially constructed aspect of our persona. As we will see in this commentary, that has come to past.
I met my first other gender-variant individual in 1976, when the psychiatrist I was seeing at the U.C. San Diego Medical School set up an appointment for me to meet another patient of his who was dealing with gender issues. With that meeting, a chain of introductions ensued, and I was quickly inducted into the greater San Diego 'gender community'. I met a recently retired nuclear submarine captain, two lawyers, a parole officer, a social worker and four college students. All were in gender-role transition or seriously considering it. Some were going from male to female, others from female to male. Although there were the usual outliers, I was impressed from the very beginning as to the intellect and otherwise normal bearing and conduct most of the members of the community
I was studying for my doctorate at the time. In doing my research for my dissertation on transsexualism I learned that little, if anything, of what I was reading in the professional medical journals about gender issues and transsexualism was in accord with my observations in real life. For some reason, even though Benjamin had opened the door to having an honest discussion about gender issues when he published The Transsexual Phenomenon, a surfeit of subsequent authors tended to consider people presenting with gender identity issues as having serious personality disorders. Their most popular choice out of the DSM pantheon was Borderline Personality Disorder, long considered by psychiatrists and psychologists alike as the worst of the personality disorders. They often described their clients in peer-reviewed professional journals as being narcissistic, delusional and manipulative. The notion that these individuals were not delusional or that there may really be a biological explanation to what these professionals were seeing never seemed to occur to them. To counter these apparent prejudicial characterizations, I wrote a phenomenological dissertation entitled History and Resolution of Sex/Gender Integration Needs in Four Male-to-Female Transsexuals.
Sex and gender. These two words, used interchangeably in society at large, in this work are considered two distinct aspects of what it means to be human. Sex is used to refer to the shape of one’s genitalia and chromosomal composition (generally, but not exclusively, XX for female and XY for males). Gender is used to refer to the hard-wired state of mind associated with one’s innate understanding of being male, female, or inconclusive. Gender is a root factor in one’s identity. As such it plays a leading role in our everyday presentation and interaction with the world around us.
Gender Role: This term is used throughout the book to emphasize the fact that when someone transitions from male to female or vice-versa, they do not actually change their sex nor do they change their gender. Both of those characteristics are an integral physical part of everyone’s being and are unchangeable. Transition does, however, alter permanently an individual’s gender role. People born male first demasculinize and then feminize to a point where they can no longer be recognized as male or function in the male gender role. Similarly, people born female first defeminize and in turn masculinize to a point where they are unable to be recognized as women and accordingly choose to function in the male gender role. It is this hormonal character-logical essence that defines one’s appearance and subsequently one’s gender role.
Transgender: The term “transgender” or “transgendered” has of late emerged as a cover term for anyone who seems to express gender behavior that is counter to what society deems appropriate based on their assigned sex at birth. Transgendered behavior can range from the person who occasionally cross-dresses around the house to individuals who permanently change their gender role through hormonal and/or surgical means. Throughout this book, I refer to this latter group as transsexuals, a term coined by Magnus Hirschfield in 1923. Rather than try to cover the specifics of all the gender variants that are emerging, this book will confine the discourse to transsexualism.
Transsexualism is a state of existence in which one’s sense of gender identity differs markedly from that assigned at birth. As a consequence,transsexual individuals exist, from the very beginning of life, outside the standard male/female binary gendering system. These individuals can more accurately be described as being gender variant. Transsexualism is usually treated by a combination of psychological, hormonal and surgical means. Even though treatment enjoys an exceptionally high success rate in that they adapt successfully to their new gender role assignment, being gender variant is as enduring to transsexuals as being unambiguously male or female is to the general population. Counter to what some people believe, transsexualism, if present, is not just confined to just the actual period of physical transition, it colors every aspect of the individual’s life from the cradle to the grave.
There are three stages to a transsexual’s life. In the first stage, the person is either openly or secretly experiencing generalized feelings of anxiety due largely because they are deprived of a sociological outlet for their inner sense of being male or female. Here in the book, I refer to this anxiousness as gender expression deprivation anxiety. This period may start as early as age 3 or 4 and lasts until it must be addressed in a meaningful manner. The second stage is triggered when the gender expression deprivation anxiety rises to a point where the individual can no longer function productively in his or her daily life and decides to enter treatment. The third stage begins when the individual completes a course of psychological and medical treatment and begins living partly or fully in a new gender role. This gender role transition and its aftermath is covered extensively in this book.
When I opened my psychotherapy practice in 1984, I had just completed my internship and had no idea my career would lead to specializing in working with people with gender identity issues. Even though I had written my dissertation on the subject and had gone through gender role transition myself five years earlier, it seemed then too rare a condition to even consider earning a living working exclusively with this population. Besides, I was very concerned that my own transsexuality would have a possible adverse influence on how I conducted therapy with this (my) population. Countertransference issues can be very destructive to a vulnerable population. Despite my initial concerns, and because there seemed to be no one else available, I agreed to start seeing a few indigent clients referred to me by a clinic in San Francisco that had considerable experience in treating sexual minorities but lacked experience in treating individuals
with serious gender identity issues.
By 1984, I had been a member of the Harry Benjamin International Gender Dysphoria Association (now known as the World Professional Association for Transgendered Health, WPATH) for five years and had made contact with other therapists interested in gender issues in the San Francisco Bay Area, where I live. Most notable among them were Paul Walker PhD, Lin Fraser EdD, Rebecca Auge PhD, Alice Webb DHS and Mildred Brown PhD. Together, we formed a peer supervision group that eventually became the Bay Area Gender Associates (BAGA). It is from this base that I began to work in earnest with the gender variant population.
The role of the therapist in working with individuals struggling with gender identity issues is somewhat unique in the profession of psychotherapy. This is due to the elusive nature of gender identity, the still deeply entrenched social stigma attached to gender variance, and what is often construed by the clients as the "gatekeeper role" of the therapist. (The "gatekeeper role" refers to the client's need for referral letters from the therapist for hormone therapy and sex reassignment surgery.) Even the very notion of calling a gender issue a "psychological disorder" has been seriously questioned, and there is a strong movement to change that designation in the forthcoming DSM-V.9.10
Gender variant individuals are typically voracious readers of all things pertinent to their dilemma. They are aware of the contentious history between the gender community and the therapists who purport to treat them. The animosity between these two groups has eased somewhat over the last ten years, as new authors and a new generation of more enlightened therapists replace the old guard. However, one still reads negative echoes of therapists as “gatekeepers” on some of the gender-related internet forums.
It is my hope here to share my experience in working with more than 500 gender variant clients over the last 26 years—covering everything from intake to long-term outcomes. Far from being a medical treatise, this book is about otherwise normal people with a special existential problem that has and will continue to color their entire lives. It has been a privilege to have worked with these outstanding individuals. Despite their almost overwhelming handicap, the vast majority of people I have worked with have shown themselves to be highly intelligent, motivated and courageous. My practice has also taught me a great deal about the willingness of many of the people around my clients to give up long-held preconceived notions of who they thought gender-variant individuals were and open up to the new and more accurate life-affirming reality. Unfortunately, that is not always the case. Far too often I have seen the very notion of gender role transition bring out hatred and spite in once-close families, resulting in abandonment by spouses, divorce and loss of one’s children, as well as loss of long-term
friendships, driving the gender dysphoric individual deeper and deeper into despair and far too often to suicide.
A second objective is to pass on to other therapists my philosophy and style of working with gender-variant clients. My approach is simple: I take every individual seriously, no matter how male or female they appear on presentation, how old or young they are, or what social circumstance they are in. I tell each client during our very first session that I have no agenda other than to help them find a way to make their life work. Reaching that goal can vary from finding a minor way to satisfy their need for cross-gender role expression to, if necessary, complete gender role transition. I tell them that I will share everything I know about gender role transition but that ultimately each individual must be ready to accept full responsibility for decisions made along the way.
Finally, this book is about the people who, for no reason of their own making, find themselves intellectually and emotionally separated from living fulfilled lives by the sex of their physical body. It is the story of what it means for thousands of men, women and children who suffer gender expression deprivation anxiety but find a way to go on to live
full and successful lives"