Notes on Gender Role Transition

By Anne Vitale Ph.D. Author, Editor



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T-Note #1

Dances With Therapists

....or hard time getting to the first appointment with a gender specialist


by Anne Vitale Ph.D.

Originally posted on February 15, 1996

Rev 1-- October 7, 2000

Rev 2 -- May 22, 2011

Asking for help in coping with crossdressing, gender dysphoria and other related issues is often difficult. Making that first call to a therapist is especially hard. Even when the call is completed and an appointment made, getting to the therapist's office is often several degrees of difficulty harder. In fact, most gender therapists expect only one out of every two people who call and make an appointment to show up. Since this "no show ratio" for potential gender clients exceeds the "no show ratio" in the general population, it probably has some significance. Let's look at some variations on what I have come to call "first visit avoidance".

One frustrating variation for me personally occurs when I return a call and the caller denies having called me. Did my answering service take down the wrong number? Did I dial the wrong number? The answer to both these questions is... Perhaps. However, because this scenario happens so frequently and because I usually have the right name and hear an ominous hesitation and tinge of anxiety in the voice that answers, I have come to believe that this person is, for some reason, having second thoughts about talking to me. All I can do at this point is apologize and hang up.

Another, far too common dance occurs when an individual comes to the first appointment, appears to have a positive intake experience, agrees to work with me, and makes a follow up appointment. The problem and the dance starts when the client waits until the last minute and takes advantage of my free, 24 hour minimum cancel period before calling and canceling. This person tends to continue this pattern, sometimes for months, coming every second or third time he or she calls.

Another frustrating call comes from a person who goes to extreme lengths to reach me (i.e., leaves a pager number, etc.), asks a lot of questions regarding gender identity issues and my qualifications for dealing with the issues, makes an appointment, doesn't show, and claims he or she forgot they had the appointment and requests a second appointment. And yes, you guessed it, she or he doesn't show for the second appointment either. A quick check with a couple of other gender specialists in the Bay Area shows that someone with the same initials as my caller has called them as well, made two appointments, and did not show for either of them.

I believe there are several reasons for these behaviors. Some are pathological and probably only peripherally related to gender issues. In other cases the individual may be very serious about working out their gender issues and is carefully shopping for a therapist. Shopping for a therapist is laudable and most therapists have no difficulty with the concept. What bothers the therapist, however, is when the client makes a return appointment that he or she has no intention of keeping.

The reason many clients choose to change their mind about seeing a therapist appears to be directly related to fear. It is not unusual for clients to come to my office, after several false starts, and admit that I am the first person they have ever told about their gender issue. Even when they do speak, it is in very general terms. It is as if the very words will alter their life forever or worse yet, that I will find them revolting. It is only after I have completely assured them that I am at ease with cross dressing and crossgender behaviors and guaranteed their confidentiality that the self imposed silence is broken.

Perhaps a little information about what actually happens on that first visit might help to ease the anxiety of actually attending that first appointment with a therapist. For those of you who have never seen a therapist, the first appointment is called an Intake Appointment. It is an anxious experience for every client no matter what issues are involved. In fact, it is even difficult for the psychotherapist. The therapist's issues revolve around having to decide to accept or reject a committed responsibility for providing professional psychological help to an individual they barely know but is obvious in distress. Once a therapist agrees to work with the individual and the client has given his or her consent, the therapist has both a legal and ethical responsibility to see that commitment to its, hopefully, positive end. The client's issues are mainly a matter of trust in the good will and abilities of the therapist. Although the therapist must make the decision whether or not to work with the individual in that intake hour, the client is, of course, free to take his or her time in deciding. This latter fact may explain the false starts a client sometimes makes before settling down to a committed relationship with the therapist.

So what actually happens during the Intake Appointment? The therapist must work on two levels simultaneously. One level is the content of the presenting concern of the client. The other is with the client's presentation itself. There are no hard and fast rules about this interchange but much of what happens depends on how much the client already knows about the therapist.

Usually the client has received the referral from someone who is either a past or present client of the therapist. Another source is this very web site. In such a situation, the client usually knows far more about the therapist than the therapist knows about the client. In that first hour, the client should be busy confirming or modifying his or her expectations of the therapist. The therapist, on the other hand, starts from the beginning, using her professional training to sort out any potential difficulties inherent in the client that she is either unwilling or unqualified to handle.

The therapist makes her decision by giving the client an informal mental status exam. Lest you become too concerned with being covertly examined, consider it to be very much like what any two strangers do when they meet for the first time. The therapist evaluates the client for verbal expression, and appearance. She also looks for simple comprehension and the client's orientation as to time and place. More subtle concerns to the therapist relate to her compatibility with the client's race, ethnicity, and social economic status. This is done as unobtrusively as possible while she is gathering biographical data and encouraging the client to speak freely. An hour or two is usually enough time for any therapist to decide if the client's concerns fall within her scope of professional competence and if she has enough information to offer a therapeutic commitment. If not, the therapist must make a referral and the relationship is ended.

(A substantial portion of this Note originally appeared in issue Number 74 of Cross-Talk)


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Disclaimer: Nothing on this site should be viewed as providing therapeutic advice. No formation of a client/therapist relationship with Dr. Vitale is intended or to be implied or inferred. The information provided in this site is for educational purposes only. I attempt to keep the information current but make no representation or warranties in that regard. You should not rely upon this information as a substitute for consul with a qualified mental health professional.