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 T NOTE #3

April 11, 1996

Revised October 7, 2000

As you might expect, the first couple of meetings in any therapeutic relationship are extremely critical. This is especially true if the presenting problem is a gender identity issue. People come in at varying stages of dealing with their gender issues and the work must proceed accordingly. A minority of people enter the work expressing a clear desire to change their sex and want me to monitor their transition. I am, of course, open to doing exactly that if all of the criteria have been met. Others are far less anxious to think that far ahead. Crossdressing is usually the most some MTFs will openly discuss. However, in this Note, I want to concentrate on those people who present at the outset declaring to be clear and ready to enter transition.

The first level of transition is psychological evaluation for hormonal therapy. In that regard, paragraph 5.1.2 of the HBIGDA Standards of Care states The patient must be known to a clinical behavioral scientist for at least 3 months and that clinical behavioral scientist must endorse the patient's request for hormone therapy. This is such an important and useful period, responsible gender therapists have come to interpret the 3 months to mean twelve weekly, one hour sessions. I have at times, varied this schedule for individuals who must travel considerable distance, In such a case I suggest that we meet in six double sessions. Although it is not ideal, where money is of special concern, I have spread the 12 sessions out to every other week over 24 weeks.

The first two or three hours are used to establish a therapeutic alliance. I realize that what is transpiring for my client is life changing therapy. It is extremely important for them to have as much confidence in me as I can possibly endow. This is done by clearly defining the ground rules under which we will be working. I also assure the client that nothing drastic is going to happen immediately. The two of us will take all the time necessary to work out what is right and take appropriate and controlled action as the therapy evolves. I find it useful to slowly reveal my in-depth knowledge and expertise in the field of gender transition while being very attentive and authentic in my listening. This is also a good time to take careful notes that can be reviewed and annotated between sessions.

When a safe, secure environment has been established and as we move on in the series of interviews, the depth of the gender dysphoria and its ramifications begin to emerge. Family, friend, and workplace issues are examined. Often a joint session with the client's parents or a significant other will be called for now. Questions about what the client might expect if he or she was to decide to transition are encouraged and answered as honestly as possible.

I also make certain to keep the client aware of the pacing of our interviews. Even though we start with my being in charge (i.e., insisting on following the Standards of Care, asking direct questions, and strict adherence to a regular meeting schedule), I slowly shift the burden of responsibility for the client's work in therapy directly onto the client. I make it very clear that although I am there to help, it is he or she who will decide to enter and, if he or she chooses, complete transition. The pacing, of course, is dependent on the individual's ability to handle his or her particular situation. If additional time is necessary for any reason whatsoever, then we simply schedule in more time.

I've said it before and I will undoubtedly say it again: Transition is hard. Very hard! The first twelve weeks should be the time when fantasies and misconceptions are tempered by reality. The range of transition that can be expected from the hormones and potential plans for surgery should be clear in the individual's mind before hormone therapy starts. Meeting others who have already started or gone through transition is usually the best way for the client to gain these insights. I also arrange for the individual to meet, by mutual consent, others who are either dealing with common special problems, or have the individual participate in one of my gender issues groups.

At some point, usually after the first two months of therapy, both the client and I have a good idea where we are going and at what pace to proceed. If we are still dealing with fundamental fears and uncertainty, then there is naturally no talk of moving on in transition. If on the other hand all appears to be in order, I make a concerted effort to be very specific about what the client can expect physically and psychologically. To aid in empowering the client, I have him or her start thinking about what internist or endocrinologist they will want to work with. Here in the San Francisco Bay Area, we are lucky to have several physicians who specialize in hormone therapy. Each has a specific style and idea as to how fast transition should occur. Eventually the time comes when we both feel the time is right to try hormone replacement therapy. It may have taken twelve weeks or it may have taken twelve months. Either way the time must be right.

In essence then, the first twelve sessions are used to authenticate the transition, establish a bond between the therapist and the client, set the pace for the rest of transition, and importantly, empower the client by giving him or her control over an element of his or her life that, until now, may have appeared nearly impossible to attain.

(A substantial portion of this Note originally appeared in issue Number 76 of Cross Talk)