Shifting paradigms? Making the move to transgender clinical practices.

Transgender Subjectivities: A Clinician's Guide. Edited by Ubaldo Leli & Jack Drescher. New York: Harrington Park Press, 2004, 162 pages. Paper, $19.95.

The relationship between mental health professionals and their transgender/transsexual clients has a long and complicated history--one that has been often characterized in negative terms. Much (though not all) of the service provided to transgender and transsexual populations has been clouded by misunderstandings, misrepresentations, and condescension. Transgender Subjectivities: A Clinician's Guide is part of a growing countercurrent within psychiatry, psychology, and allied disciplines, aimed at redressing the shortcomings of that legacy. It contributes to the trend toward affirmative approaches to understanding and meeting the needs of transgender/ transsexual clients.

Several of the contributors explicitly state their commitment to transpositive approaches. Perhaps this is most clearly seen in the title of the volume itself, where the possibility of true transgender subjectivities--their existence and their plurality--is made manifest. This may seem like a small point. However, the authenticity and complexity of transgender people's lives, both psychic and material, have often been denied or ignored in existing mental health models.

In one sense, then, this volume is part of the larger project of recognizing and valuing transgender and transsexual people. Such a project is often fraught with tensions, and Transgender Subjectivities symptomatically displays some of those tensions. In these kinds of recuperative projects, there is sometimes an impulse to present groups in their best light. Sometimes inclusion within the ranks of "human variation" is bought at the price of capitulating to existing standards of "normal" (or even "optimal"). With a few exceptions, this volume focuses its attention on middle-class White clients, often with an assumption that they will be seen in private-practice clinical settings. It is important to understand the risks of such an approach, especially at the moment that a project of recognition is underway. The mainstreaming of lesbian and gay politics in the U.S. has demonstrated the ways that existing hierarchies of race, class, citizenship, and gender (among others) can become reproduced and reinforced through bids for "normalcy." Such a move, even made unwittingly, within the context of developing clinical practices, runs the risk of ignoring the specific therapeutic needs of entire subpopulations.

Transgender Subjectivities opens with two first-person accounts: one on the subjective effects of testosterone; the other a glimpse into less than supportive therapy. These set the tone of the volume, with its focus on understanding transsexual/transgender people's lives and experiences. Entries that follow include theoretical interventions, research findings, and clinical reports. Data come from autobiographical, survey, interview, and case study materials. Several of the contributors are transgender or transsexual. This range of approaches and perspectives is laudable. However, like many edited volumes, the quality of work is sometimes uneven.

Although Transgender Subjectivities does have an impressive range of approaches and perspectives, its coverage is spotty at best; at a slim 162 pages, this is not surprising. For example, none of the chapters focus on transgender/transsexual youth. Additionally, with a few exceptions, the volume focuses heavily on fully transitioned or transitioning transsexuals, resulting in less attention to gender-variant people who do not fit that model. This would not necessarily be a problem if the book did not make claims to comprehensiveness. However, the copy on the back cover hails Transgender Subjectivities as "a comprehensive guide for understanding the issues and concerns of the emerging transgender phenomenon." The editors take a more modest (and accurate) approach, describing the book as "several snapshots of transgender presentations and subjectivities" (p. 1), for those seeking comprehensiveness this volume will not be satisfied (instead see Ettner, 1999; Israel & Tarver, 1998; and Lev, 2004).

In the introduction, the editors express their hope that the volume will prove useful for clinicians who work with transgender patients but have little training or experience in the area. With that goal in mind, as well as wanting "to be of interest to the general public" (p. 2), they should have provided more tools to help the uninitiated reader get the most out of the essays. Their introduction is probably sufficient for the readership of The Journal of Gay and Lesbian Psychotherapy, where the volume was concurrently published, but not for the more general readership they say they hope to engage.

In particular, a discussion of terminology would have been helpful. In the introduction, the editors use the terms "transgendered," "transsexual," "gender dysphoria," and "gender-blending," among others, without providing an adequate sense of what these terms mean to them. Even more useful, however, would have been a discussion of the contested nature and multiple uses of these and related terms. This is not simply a matter of helping readers through the text; it is also of real clinical importance. Such a discussion could direct readers, especially clinicians, to the potentially charged nature of applying these labels, and signal the need for a sense of patience, openness, tolerance, and respect concerning their varied uses.

Several chapters do some of the work that is missing from the introduction. For example, Dallas Denny's "Changing Models of Transsexualism" gives the best overview of new approaches to understanding and providing care for gender-variant clients, including a historical grounding for their emergence. The chapter is structured around the rise of a transgender model of care provision, which is in the process of supplanting an earlier transsexual model. The transgender model is premised on (a) defining gender variance as a natural form of human variability, as opposed to a mental illness and (b) allowing for a wide range of transgender embodiments and identities, as opposed to a narrow transition model with a goal of sex reassignment. Denny argues that, for clinical practice, this shift entails a move from "the mutual belief that the purpose of therapy is to determine whether the patient is or is not a candidate for sex reassignment [to] the mutual belief that the purpose of therapy is to help the client make sense of and life plans about his or her feelings about gender" (p. 34). Denny's chapter outlines both the epistemological and practical framework within which the volume's editors and many of its contributors locate themselves. She also includes recommendations to therapists about how to work within the transgender model.

Vernon Rosario's "'Que joto bonita!': Transgender Negotiations of Sex and Ethnicity" takes an even longer historical view, summarizing the nosological history of gender variance in Western medicine. He also touches on current controversies over the continuing inclusion of "Gender Identity Disorder" in the DSM, and in doing so points out the partial and contested nature of the shift to a transgender model that Denny outlines. The heart of Rosario's chapter is a clinical case report on Frances, a transgender Latina sex worker. Rosario's chapter is one of the few places in this volume with a detailed discussion of a transgender subject who is not in the fully transitioning model, and it is one of the only discussions where questions of race and ethnicity are addressed meaningfully. The lack of such a discussion elsewhere in Transgender Subjectivities leaves in place troubling associations of race with only people of color, and leaves an analysis of race in the fives of transgender/transsexual White people unexamined. For example, Aaron Devor's chapter on transsexual identity formation, which includes the disclaimer that it is applicable to people with "mainstream Euro-American values," was the most obvious of several chapters where there is a real missed opportunity for an analysis of Whiteness.

Rosario's case study and discussion demonstrate the failure of transition models to account for the experiences of many transgender people. He also illustrates the impact of race, ethnicity, and culture not only on Frances' gender identity, but also on the salience and shape of various factors (e.g., family, work, relationships) in her life, and hence, for her therapy. Finally, Rosario deftly balances an affirming stance vis-a-vis gender variance while recognizing "the mental health problems of Frances and other transgender individuals" (p. 96).

There is also innovative work in a chapter on guilt and gender variance, and another on children's experiences of a parent's transition. In their chapter on guilt, Schaeffer and Wheeler bring together the strengths of a large sample with qualitative data from individual case studies. They are able to report generally on forms of guilt and to convey a sense of the individual pain that their patients experience. They argue that feelings of guilt are a central feature of the lives of most gender-variant people and must therefore be a central feature in therapeutic contexts. Although not everyone will agree with some of their recommendations (they slip into essentialist ideas about the causes of gender variance as a means of assuaging patients' guilt, and they see "education" as somewhat of a panacea), their chapter opens much-needed discussion on guilt and gender variance.

Likewise, White and Ettner make a valuable addition to the small extant literature on children with transsexual/ transgender parents. Previous work (Green 1978, 1998) showed that children in families with a transsexual parent are not appreciably different from other children (especially concerning their sexuality and gender identity), but White and Ettner look instead at children's adaptation to a parent's transition. They come away with sets of both protective and risk factors that will be useful not only in clinical settings, but perhaps in legal contexts (as Green's previous work has been).

The volume does not shy away from controversial material, as evidenced by Anne Lawrence's "Autogynephilia: A Paraphilic Model of Gender Identity Disorder." Lawrence's chapter offers an overview of Ray Blanchard's controversial concept of autogynephilia, which she defines (using Blanchard's words) as "a male's propensity to be sexually aroused by the thought or image of himself as a female" (p. 71). Lawrence, who has published in this area, provides a detailed and much-needed overview of the literature, concluding that the concept "provides a powerful model for understanding the phenomenology of male-to-female transsexualism" (p. 84). Her discussion productively complicates the relationship between gender, gender identity, and sexuality. To Lawrence's credit, she also includes a section that addresses the controversies surrounding autogynephilia; however, she characterizes these critiques in overly narrow terms. Lawrence's reading of the critiques is that some transsexuals feel misrepresented by the concept of autogynephilia. This is certainly one aspect of the critiques, but it does not tap into their full scope.

Lawrence ends her section on controversies with recommendations to clinicians about how to help their patients see beyond the critiques to the value of the concept of autogynephilia. However, she might have also included some discussion of the concept's possible pitfalls for clinicians. For example, at a recent conference for professionals who specialize in Gender Identity Disorder, I was talking with some young psychologists at a reception. Mid-conversation, one of them pointed to a transsexual woman looking at herself in a mirror adjusting her makeup, and said, "Look at that! And some people don't think autogynephilia is real." Although anecdotal and outside of a clinical context, this points to the ways in which concepts like autogynephilia can take on a life of their own, becoming both reductive and reified, and may be too easily applied. This is a danger that comes in part from explanations wherein there are a limited number of transgender/transsexual "types" and part of the clinician's task is to determine which type applies in a given case.

The overriding tenor of this volume stays generally within a transpositive epistemological framework, yet there are other pockets of potentially pathologizing work. For example, Seil's chapter delineating four subgroups of transgendered patients felt especially out of place. Without making the basis for his assertions clear, he argues "GID varies little in substance from one person to another within each subgroup of patients" (p. 102), something with which many transgendered people (and I suspect some experienced clinicians) might take issue. He also sometimes relies on simplistic and pathologizing explanations for aspects of his patients' behaviors and identities; for example, he explains drug and alcohol use with vague references to "lifestyle." And while the editors and some of the authors mention the social pressures and hostile culture within which transgender/transsexual people live (see especially Rosario's concluding remarks, p. 96), more attention was needed to the effects of these factors on this population's mental health presentations and therapeutic needs.

Even with the shortcomings that I have mentioned, taken as a whole Transgender Subjectivities can be placed among the ranks of a new breed of clinical handbooks that avoid pathology models of gender variance. The volume introduces the reader to a significant range of transgender subjects, using a wide array of data, from several compelling perspectives. The "snapshots" that it shows us will be useful for both the seasoned clinician and for the less experienced reader.

REFERENCES

Ettner, R. (1999). Gender loving care: A guide to counseling gender-variant clients. New York: W.W. Norton.

Green, R. (1978). Sexual Identity of 37 raised by homosexual or transsexual parents. American Journal of Psychiatry, 135, 692-697.

Green, R. (1998). Transsexuals' children. International Journal of Transgenderism, http://www.symposion.com/ijt/ijtc0601.htm.

Israel, G. E. & Tarver, D. E. (1998). Transgender care: Recommended guidelines, practical information, and personal accounts. Philadelphia: Temple University Press.

Lev, A. I. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. Binghamton, NY: Haworth Medical Press.

Reviewed by Karl Bryant, Ph.D. Candidate, University of California Santa Barbara, Department of Sociology, Ellison Hall, Santa Barbara, CA, 93106-9430; e-mail: [e-mail].