Text of talk given at National Transgender Health Summit 2011

Notes on Gender Role Transition


Anne Vitale Ph.D.

Text of talk given at National Transgender Health Summit, Univ. of California San Francisco April 9, 2011

PDF file of slides available upon request. Please put SLIDES in the subject field

Slide 1 ----Title slide on screen prior to starting

potential Therapeutic Errors When Using Binary Based Terminology to Explain the Gender Variant Condition.

Introduction:

My talk today is based on portions of my recently published book. "THE GENDERED SELF Further commentary on the transsexual phenomenon." I have a few copies with me today so please see me after the talk if you are interested in purchasing a copy. It is also available on Amazon.com and Lulu.com

Today I am going to talk about the way my work with gender variant clients has changed over the last 28 years.

I opened my private practice in 1984. Being only 4 years post-op myself I started out with a strict adherence to the common sociological notions of the male/female binary. Work with my clients, work with my peer supervision group, the Bay Area Gender Associates and my own personal --in the real world experience, now as a long term post-op--has changed all of that.

Much of what I will be offering here is what I have learned from working with over 500 gender variant individuals.


Slide 2

To start I am going to ask you to rethink the absoluteness generally associated with five of the most commonly used phrases in the "gender lexicon"

The Common words and phrases are:

  • Dysphoria
  • Gender Identity Disorder
  • Male-to-Female
  • Female-to-Male
  • Sex change

  • Slide 3 Lets look at "Dysphoria" first

    Marriam-Webster Dictionary defines dysphoria as a state of feeling unwell or unhappy.

    --I am not sure who thought this one up but it is obvious that who ever did did not take the problem seriously. Given the degree of chronic gender related anxiety some clients --mostly genetic males in midlife --present with, I have come to think of the term as being an insult.
    Slide 4

    In contrast...Depending on the direction the individual is transitioning, the age of presentation, and the extent of the investment the client has made in trying to function in their birth assigned sex, these individuals often report that they are:

  • racked with guilt and shame over their condition
  • They are paralyzed with anxiety...some report even having panic attacks
  • They are living in fear of even if the knowledge of their gender variant condition was to become known they would loose all that they cherish and be ostracized from family, friends and the ability to support themselves.
  • Many are depressed and suicidal ... feeling as if their lives are in ruin.
  • These individuals are not simply "unhappy" they are miserable.


    Slide 5 Gender identity disorder or GID

    This may be the most hated and misleading term that has ever been forced upon this population.

    Grouped with the Sexual Disorders and paraphilias in DSM IV, alongside Transvestic Fetishism, Exhibitionism, and Pedophilia GID upset everyone from the very onset of its introduction in 1994 when it replaced the DSM III designator: "Transsexualism"

    If taken literally, as the authors apparently meant it to be, GID describes a person with a very serious mental disorder. To be uncertain of one's identity takes one into the territory of psychosis and extreme pathology. It also implies that if one can not make the obvious correct association between one's physical sex and the gender they have been assigned they must be delusional. Thereby encouraging Reparative therapist and theological councillors to try to fix the so called delusion despite there being no evidence based history of that being possible.

    Even the American Psychiatric Association realizes their error. Preliminary reports show that this term will probably be changed in DSM V to Gender Incongruity.


    Slide 6--Male-to-Female and Female-to-Male---Since one is the mirror image of the other, I'll take them together.

    My concern here is a little more tempered. I continue to find these two terms useful but with a strict caveat. I use them only to describe the aspirational direction of a clients preferred gender expression. I do not take them literally. I hope it is not news to anyone here, but in my opinion it is impossible to take a male as most cisgendered males understand themselves to be and turn them into the woman most cisgendered females understand themselves to be. The same is true in reverse with female bodied people.

    At best, a successful outcome occurs when we take genetic males with a weak sense of being male and a strong desire to be female into a close approximation of being a cisgendered woman. The same phenomenon applies for FTMs. Fortunately there is a livable alternative. I will get to that shortly.


    Slide 7- SEX CHANGE ?....Well....not exactly.

    This is a pop-culture, shorthand term describing only what this all looks like. Sex is defined chromosomally at the moment of conception. No amount of cross-sex hormones or surgery can change one's sex. As I said...this is what transition looks like but it is not what actually happens. Fortunately, with transition, something more life affirming and profound occurs. Again...I will elaborate more on that in a minute.


    Slide 8 So if we are not treating ...

  • Someone who is merely unhappy
  • or someone who is self aware and not psychotic
  • or someone who is not literally going from male to female or female to male
  • and since Sex Change is impossible....

  • Slide 9 Who and what are we treating?

    And what should we be looking for relative to a successful outcome? To aid in that, let’s look at some alternative concepts.


    Slide 10.... As an alternative to the five binary terms and their inherent implications, please consider...

    Instead of DYSPHORIA or that you are treating someone who is merely unhappy, think in terms of repairing the damage caused by living under the burden of unrelenting feelings of forced existential displacement from a gendered world openly alloted to others but explicitly denied your client. Someone who has been living --often for decades-- trying to live a normal life under the burden of chronic gender expression deprivation related anxiety. Some one who is now burdened even further by their well intentioned efforts to live a nomal life concruent to their assigned sex at birth.


    Slide 11 Instead of Gender Identity Disorder...

    Think in terms of Gender Expression Deprivation Anxiety.


    Slide 12 ... Instead of Male-to-Female, Female-to-Male or Sex Change

    Consider helping the individual undergo a far more doable and realistic, Gender Role Transition.


    Slide 13 ---Instead of a Successful Outcome being an all or nothing, start to finish transition

    Think in terms of simply helping your client find a way to make their life work. What gendered form that ends up taking is your client's concern not yours.


    Slide 14 Let's look at these alternatives separately and in more depth...
    Slide 15 Dysphoria---

    As they say...sometimes it is hard to see the forrest for the trees. The presenting issue may be gender related but do your client a favor and think of them first and foremost as a person caught in the paradox of trying to live a normal life under abnormal circumstances.

    Unless you have overwhelming evidence to the contrary, think of any comorbidities encountered upon examination as being secondary to the gender expression deprivation.


    Slide 16 This brings us to my primary proposal.

    I propose here as I have else where, we think of the problem not as an exotic identity disorder but as an anxiety disorder... Specifically--------Gender Expression Deprivation Anxiety Disorder or GEDAD

    There are Two Components to GEDAD --Biological and Sociological

    Biological component--We know with considerable confidence that gender expression deprived individuals routinely respond favorably to the exogenous administration of cross-sex hormones. We also know that cisgendered individuals do not.

    Quoting from the WPATH Standards of Care Version 6 (page 16)

    "Satisfaction with the hormone's effects consolidates the person's identity as a member of the preferred sex and gender and further adds to the conviction to proceed. Dissatisfaction with hormonal effects may signal ambivalence about proceeding to surgical interventions."
    Reading further in the same paragraph--and I think this is important... we find:
    "Hormones themselves are often enough to allow the individual to experience relief from the gender related anxiety. "

    Sociological component. --Resolved by making it sociologically possible for the individual to live fully -- or even part time if applicable-- in the preferred gender role. The bulk of the psychotherapy once transition is under way should center on support and education.


    Slide 17...Gender Role

    Without closing doors to a possible favorable outcome, I think it is important that the treating therapist make it clear to the client what is physically possible and what is not. Too often clients come into therapy with over blown dreams of becoming a normal man or a normal woman.

    Transsexuals who have been through transition and are now 20, 30 and even 40 years into their post-op/post treatment lives, report that although they have no regret having transitioned they know now that although something profound happened they never really changed their sex.

    They have, however, attained something far more important. / What they routinely report is that without the burden of chronic gender related anxiety, time and space to live has opened up for them. They know now and accept that they will never get to where cisgendered people start in understanding their gendered self. But that for most transsexuals is enough. How well one makes that adjustment is the stuff of a longer philosophical discussion.


    Slide 18...Successful Outcomes

    The most important key to a successful outcome in working with gender variant individuals is to keep it real.

    Other more specific practices include..

  • Keep the work client centered. I mean this in the Existential sense rather than the Rogerian sense. Remember with gender we are dealing with a core existential element in the human psyche.
  • Therapist should have no other agenda other than to help make their client's life work.
  • Gender issues often overlap a whole hosts of comorbidities. Rather than isolate and treat only the comorbidities or only the gender issues, the whole of the person must be worked with.
  • Avoid countertransference issues. It can be very tempting to discourage clients from full exploration of gender role transition based on negative projected cross sex appearance or the therapist's discomfort with the potential sociological disruption such a transition will cause for not only the client but for his or her family. If any if this makes you uncomfortable, please consider referring the individual to someone who has more experience with gender issues.
  • Avoid the GateKeeper role--Although the therapist plays a major role in the enterprise, Ultimately it is the client's choice as to which gender role they will chose to live in.
  • and lastly...his may seem obvious but I am going to say it anyway. Follow the WPATH Standards of Care. The SOC has served as the cornerstone in helping gender variant individuals since 1979. I follow them because they work.

  • Slide 19 In closing...let me review

    I have suggested that we avoid thinking in binary terms regarding our work with gender variant clients. The world of the gender variant is not the world of the cisgendered. They should not be held to some imagined sterotypical standard of gender related behavior.

    Remember, you are treating Gender Expression Deprivation not some sort of exotic identity disorder.

    Remember, you are not changing someone's sex, your are helping the client change their gender role.

    Trust the client. The goal of the treatment should be to help the client sort out for themselves what for them is the most comfortable level and quality of gender expression.

    The administration of cross sex hormones goes a long way to providing the space necessary for the resolution of other problems. It may take a few months, but give them time to do their magic.

    ....and most importantly....Avoid letting the big idea of being male or female get in the way of the therapist's primary job, which is simply to help the client make their life work. What gendered form that takes should be immaterial to the therapist.
    Slide 20 ---Thank you for your attention.

    Copyright (c) 2011 Anne Vitale PhD, all rights reserved.

    email-- Contact Dr. Vitale ----Please use the word INQUIRY in the Subject Line!