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The experiences of transgendered persons in psychotherapy: voices and recommendations.

This study explored the therapeutic alliance and satisfaction between transgender clients and their therapists. The design was qualitative and heuristically based. Seven transgendered participants who had lived full-time as their non-natal gender for at least three months and who had spent at least the majority of a course of therapy discussing their current gender identity were recruited. Interviews were semi-structured, and each was transcribed verbatim. Three levels of coding were used)or analysis: seven individual depictions in narrative form, a single composite depiction bringing together similarities between the experiences of the participants, and a single exemplary depiction of critical themes. Results suggest that the participants did not experience many of the heterosexist, sexist, and pathologizing biases described in previous studies. Rather, they described supportive and affirming relationships with their therapists. Some participants had had negative experiences with previous therapists. Participants called for further training and education for therapists and other helping professionals. Implications for theory, research, practice, and policy are explored.

INTRODUCTION AND LITERATURE REVIEW

This article explores how both transgendered and transsexual persons perceive psychotherapy and the current roles and training of mental health professionals who may work with such clients. Transgender refers to "behavior, appearance, or identity of persons who cross, transcend, or do not conform to culturally defined norms for persons of their biological sex" (American Psychological Association [APA], 2008, p. 29). Transsexual refers to "anyone who lives socially as a member of the opposite sex, regardless of which, if any, medical interventions they have undergone or may desire in the future" (p. 29). It is recommended that those to whom the area is new read recent statements by professional organizations, such as the American Psychological Association's (2008) Report on the Task Force Report on Gender Identity and Gender Variance; the reports of the Gay, Lesbian and Straight Education Network (www.glsen.org); and the American Counseling Association's (2008) sponsored podcast on counseling queer youth by the president of the Association of Lesbian, Gay, Bisexual, and Transgender Issues in Counseling, Dr. Anneliese Singh. Other fundamental writings are Bockting and Coleman (1992); Brown and Rounsely (1996); Califia (1997); Ettner (1999); Gainor (2000); Lev (2004); Lothstein (1983); Pauly (1992); Schaefer and Wheeler (1995); and Seil (1996).

Working with transgender and transsexual clients calls for specialized knowledge. Multicultural counseling guidelines (e.g., APA, 2003) warn of the dangers of therapists not receiving proper training in working with clients who are different from them. According to many authors (Cole, Denny, Eyler, & Samons, 2000; Denny & Green, 1996; Ettner, 1999; Fassinger & Arseneau, 2007; Fontaine, 2002; Gainor, 2000; Perez, 2007; and Ramsey, 1996), graduate students are rarely trained in transgender issues. Lev (2004) notes that current training programs for therapists provide little to no education on gender variance, on the rationale that there are too few gender-variant individuals to justify such attention. If any education is provided at all, it is usually theoretical or tacked on to gay/lesbian/bisexual (GLB) issues. Because of the lack of formal specialized training, therapists wishing for specialized training often have to educate themselves about working with transgendered persons. Few receive the recommended levels of education and supervision for providing care to gender-variant people (Israel & Tarver, 1997; Korrell & Lorah, 2007).

One of the key roles clinicians play with transgender clients is as gatekeepers determining which clients are appropriate for sex reassignment surgery (SRS) or hormone treatment and which are not. Guidelines and recommendations for this decision, called the Standards of Care, were drafted in 1979 by the Harry Benjamin International Gender Dysphoria Association (now the World Professional Association of Transgender Health, WPATH). The current Standards of Care (Meyer et al., 2001) state that anyone desiring SRS or hormone treatment must acquire letters from at least two mental health professionals recommending the individual for the intervention. Previous versions of the Standards of Care specified a certain length of time that the client must be in therapy before the therapist writes the letter, but the most recent version states instead that the length of time is at the discretion of the mental health professionals, putting the onus of responsibility, and power, onto psychiatrists and therapists.

Another area where it is essential for therapists to have specific knowledge and training is diagnosis. Here two concerns are important: differential diagnoses other than gender identity disorder (GID; American Psychiatric Association, 2000), and common comorbid disorders often associated with GID. According to Brown and Rounsley (1996), there are many presenting problems similar to transsexualism for which surgery and hormones are not appropriate, among them confusion and conflict regarding sexual orientation, malingering, and gender dysphoria occurring exclusively during psychotic episodes or dissociative states. Bockting and Coleman (1992) noted other instances in which gender dysphoria is part of another presenting problem, such as psychological pain stemming from a history of abuse, depression, anxiety, or loneliness. Besides determining whether or not a client actually suffers from GID, it is also important to determine what other diagnoses deserve clinical attention. Most authors describe anxiety disorders and depression as being commonly comorbid with GID (Bockting & Coleman, 1992; Gainor, 2000; Israel & Tarver, 1997; Lev, 2004; Ramsey, 1996).

According to Denny and Green (1996), clients usually seek out therapists just before transition when they are having trouble functioning in school, work, or social situations; are confused about their sexual orientation; are depressed or experiencing substance abuse problems; or are engaging in fetishistic behaviors. All these difficulties can mask an underlying GID. It should also be noted that there is heated debate about whether or not a diagnostic label of GID is helpful to transgendered individuals (APA, 2008).

Perhaps linked to the diagnostic debates within the mental health field, as well as inaccurate assumptions and stereotypes among counseling and medical professionals, many transsexual persons have historically not felt comfortable trusting therapists (Cole et al., 2000; Gainor, 2000; Israel & Tarver, 1997; Korrell & Lorah, 2007). Transsexual persons have admitted to fabricating or exaggerating experiences so that they would not be denied surgery or to conform to what they believe their therapists' stereotypes might be (Bolin, 1988; Brown & Rounsley, 1996; Ramsey, 1996). In fact, some transgender and transsexual clients may consider their therapists to be adversaries due to the power differentials inherent in the therapist's gatekeeping role (Fontaine, 2002). Such assumptions may be barriers to an effective therapeutic relationship.

In contrast, Bolin (1988) found that not all transsexuals distrusted their therapists. Through communications networks transsexual persons learned which professionals were more likely to recommend them for surgery or which had less stringent criteria for evaluative resources, such as inventories measuring femininity. Bolin's participants also tended to trust clinicians with master's degrees or social workers more than those who had doctoral degrees in psychology or were psychiatrists. They preferred therapists who had no preconceived notions about transsexualism until they themselves began working with transsexual clients. Bolin's participants also trusted female clinicians more than males because they felt females were less likely to endorse stereotypical sexist definitions of femaleness and femininity. Seil (1996) also noted that many transsexual and transgendered clients prefer gay-identified therapists or those who specialize in treating gay, lesbian and bisexual clients. While a number of more current writers (Bockting, Knudson, & Goldberg, 2007; Israel, Gorcheva, Walther, Sulzner, & Cohen, 2008; Korrell & Lorah, 2007) speak to recommended approaches for counseling transgendered clients, the views of transsexual clients themselves are largely unpublished.

Given that heterosexist, sexist, and pathologizing biases have existed among clinicians even in the recent past, the present investigation sought to determine the therapy experiences of transgendered and transsexual individuals today. It has been at least five years since research on this topic has been conducted. Although in 2006 Burckell and Goldfried studied GLB individuals' preferences for counselor characteristics, no transgendered participants were in the study. Given the growing awareness of transgender issues as a result of recent social and political activism, do transgendered individuals still see their therapists as gatekeepers of the status quo, who may render their identities and experiences invisible? Or do they see them as informed advocates for them? How well are therapists meeting the expectations of their transgender clientele? This qualitative study was designed to address these questions by exploring recent experiences of transgender persons in counseling.

METHOD

Participants Seven transgendered individuals were interviewed. A maximum variation sample (Patton, 2002) was sought to identify both unique and similar experiences. If consistency in themes is found across diverse persons, the findings are stronger than if the sample is homogenous. Both male-to-female (MTF) and female-to-male (FTM) individuals were interviewed. Criteria for participation, besides being transgendered, included past or present participation in psychotherapy with a licensed mental health professional in which transgender identity issues were a focus of clinical attention. The present study also limited participation to individuals who had lived full-time as their non-natal sex and gender for at least three months. Their demographics are shown in Table 1.

All seven participants identified themselves as Caucasian/White, were from a large metropolitan area in the Southwest, and were either in therapy or had participated in a course of therapy in the past during which attention was given to transgender identity issues. The mean age of the participants was 46.29 years. The mean income reported by participants, including two who were unemployed, was $28,286. The mean number of therapy sessions reported was 65.17. As can be seen from Table 1, two participants identified themselves as FTM and five as MTF, although they used a variety of terms to describe their gender identity. Among the six participants who reported how long they had identified themselves using the terms they did, the mean amount of time was 4.5 years.

Instruments

Demographic questionnaire. The demographic questions covered age, highest level of education attained, annual income, racial and ethnic background, the term by which participants currently referred to their gender identity, the amount of time they had their current gender identity, the gender and credential or type of licensure of the psychotherapist described in the initial interview, and the number of sessions of the course of psychotherapy that was described in the interview.

Semistructured interview. Eighteen open-ended questions were drafted regarding one course of therapy in which participants had been involved at some point during the process of developing their current gender identity. They covered how the participant found the therapist; the participant's expectations of the therapist, participant's feelings about the diagnosis and the authority of the therapist to authorize hormonal and surgical intervention, and impressions of the therapist's feelings about diagnosis and transgender issues; the therapeutic alliance and participant trust in the therapist; the impact of the therapist on the participant's gender identity and decision-making about transition; and the participant's impressions of the therapist's credibility.

Procedure

Participants were recruited by distributing flyers, posting them in places such as local coffee houses, and word of mouth. Support groups, therapists, medical professionals, and other agencies or businesses who were likely to work with transgendered individuals (for instance, electrolysis practices) were asked to pass information on to their clients about participation in this study.

Each potential participant contacted the primary author by phone or email and a time was arranged to meet at a private study room in a university library. Before this interview each participant was asked to read and sign an informed consent letter explaining confidentiality and all other relevant aspects of the study. After signing the letter and being given a copy to keep, the participant was asked to choose a pseudonym. The initial interview took 45 to 75 minutes, depending on the breadth and detail provided by the participant. All interviews were tape-recorded. At the end of the interview, the participant was thanked and given a $5 gift certificate. Data collection ceased when all means of recruiting participants were exhausted and no more participants were found. Each participant was contacted about eight months after the interviews by email, phone, or regular mail for consultation during the process of compiling and analyzing the data.

Analysis. During the data analysis each interview was fully transcribed verbatim and then coded descriptively. Moustakas (1990) identified recording and transcribing interviews as an essential step in heuristic inquiry because essences of the experience under investigation emerge directly from the interviews. All participants received a complete transcription of their interviews, allowing for correction and clarification. Once each participant provided feedback as to accuracy, descriptive coding was initiated.

The first level of descriptive coding in heuristic inquiry (Moustakas, 1990) is depicting each participant's experience in the form of a rich and vivid story that may include direct quotations from the interview, examples, analogies, and notes taken before and after the interview. During this process all participants were sent their own depictions and invited to provide feedback on their accuracy and to elaborate if they wished. As primary researcher, I (A. Bess) continued making changes as recommended by each participant and sending them revised drafts until each indicated that the depiction was accurate. Corresponding with each participant during the coding process, according to Moustakas, addresses the issue of validity in heuristic inquiry, which centers on meanings and essences of the experiences of both participants and researchers.

The second step in coding (Moustakas, 1990) is a composite depiction of the experiences of all participants. Composite depictions were constructed for the most part by examining the individual depictions to find common themes. The third and final step of coding, according to Moustakas, is developing exemplary depictions of the themes arising in the interviews. For this level of coding, I chose aspects of participants' experiences in therapy that they had indicated were most important, emphasizing what participants felt was most helpful in therapy in order to illuminate the general experience of transgendered participants in therapy. Each of the three stages of coding involved immersion in the interview and dialogue data and going back and forth between interviews with individuals and the patterns and themes emerging from their experiences as a whole. These processes are also examples of triangulation: according to Miles and Huberman (1994), triangulation refers to demonstrating support for findings in qualitative research by showing agreement between more than one measure, source, or perspective.

RESULTS

Because space limitations do not allow for the cases to be presented in their original detail, only the single composite depiction and the single exemplary depiction are considered here. They serve as summaries of the findings.

Composite Depiction

Typically participants reported finding their therapist through someone else or through community resources. Referrals by friends and attending a talk by a therapist at a support group or gender convention were mentioned as sources, as were listings of medical and mental health professionals in newspapers or magazines for the transgender or GLBT community. For instance, Marc stated he initially sought a therapist who had counseled gay and lesbian people and then later modified his criterion to someone who treated transgender people. Participants typically sought qualities in a therapist like empathy, caring, and expertise, particularly in gender issues. Several mentioned seeking experience working with specific populations, such as gay and lesbian or transgender clients, and several mentioned seeking expertise in specific areas, such as legal matters, sexuality, and identity development.

Most participants (86%) strongly objected to the diagnostic labels listed in the DSM-IV-TR, such as "Gender Identity Disorder" and "transvestic fetishism" (American Psychiatric Association, 2000) and to the implication that having a transgender identity implied a mental disorder, or stated that they viewed their transgender identity as not a symptom of a disorder but instead as one aspect of human diversity, "just part of how God made us," as Melissa said. Participants who disagreed with the use of pathologizing diagnostic labels stated that their therapists also disagreed, although some noted that the therapists used diagnostic terms as needed to facilitate logistical aspects of transition.

Participants also reported that instead of having diagnostic labels or courses of action imposed on them, their therapists presented them with several options regarding identity and transition. For instance, many (57%) stated that their therapists explicitly supported their decision to have or forego SRS, or to take or not take hormones. Participants also reported that the therapists either provided support, options, or both regarding decisions related to transitioning and body modification. Two participants also mentioned that their therapists helped them address issues that came up after transition: Lil described receiving support and feedback about dating, and Tamara described receiving support about integrating her transgender identity into the rest of her personality and identity.

Three participants expressed appreciation for the fact that their therapists were not rigid about the degree to which they incorporated masculinity or femininity into their gender identity, and showed comfort with a certain amount of flexibility within their own male or female identities. For instance, Marc expressed appreciation for his "male and female side," Drew decided to continue dressing in female "drag" despite identifying as male, and Tamara did not let her female gender identity dictate how "girly" she should be. Many participants (71%) stated that they had already decided whether or not to transition or take hormones before beginning therapy. According to Melissa, "I knew what direction I wanted to go, and I just knew I needed to find somebody to help me get there." Although over half the participants (57%) reported that their therapists supported their own decisions about transition, some stated that the therapists did not recommend all clients indiscriminately for transition, which would be in keeping with the Standards of Care to which the therapists adhere. Lori described her therapist as being "selective" in determining which clients would benefit from surgery, hormones, or both.

Participants endorsed a variety of opinions about how much of a role therapists should have in determining who should receive hormonal or surgical intervention. The participants who supported the Standards of Care stated that the Standards protected medical and mental health professionals from lawsuits and ensured that transgender clients who wanted to transition knew the risks, such as the possibility that many loved ones might be unsupportive. For instance, Tamara said, "I think if you don't think you have to live full-time for a year, you're only kidding yourself, because it's a tough world out there." The participants who disagreed with the Standards of Care stated that clients themselves are most knowledgeable about what is right for them, and they did not like having access to hormonal or surgical treatment limited in this way. The high cost of surgery and difficulties with name changes were other aspects of transition cited as objectionable.

The two aspects of the therapeutic relationship most often mentioned by all participants were support and empathy. Three said that their therapists specifically assisted them with disclosure and coming-out issues. For instance, Lil mentioned her difficulty coming out to her Lion's Club chapter, Tamara mentioned her therapist's assistance in coming out to her grown sons, and Melissa described facing discrimination at her workplace after she came out. Instances where a therapist's support contrasted with a notable lack of support from others were also described. For example, Drew's therapist's validation contrasted sharply with criticism from others in the transgender community about transitioning at such a young age; he said they questioned whether or not he was "trans" enough.

All participants explained how their current therapists helped them tremendously with self-acceptance, self-definition, validation, and normalization, as articulated by Drew: "I would say she changed my life .... I'm a much better person, I think. Just like.., even if I didn't talk to her about anything trans, I think she still helped me a lot." Participants also expressed appreciation for the expertise and experience of their therapists. Overall, except for Marc, who said he was his therapist's first FTM client, most participants did not mention any sense of having to teach their therapists about transgender issues, although a few mentioned that they thought they taught their therapists about their own unique situations.

Participants mentioned specific aspects of their therapists' backgrounds that made them more comfortable. For all, the therapists were female, and both MTF and FTM participants stated that they felt more comfortable with a female therapist. Three expressed appreciation for their therapist being an open lesbian; as Lil said, "She's got this point of view where's she's been looked down on by parts of society, too." Three participants mentioned specific characteristics or experiences they shared with their therapists.

Asked if they trusted their therapists, all participants answered emphatically in the affirmative. Several, like Brenda, gave examples of their therapists maintaining confidentiality as a rationale for trusting them: "She's real strict in her ethics and everything, and if I see her on the street I have to approach her first. She's totally ethical about everything. So I trust her. Yeah." All participants also stated emphatically that they felt they could be completely honest with their therapists, and that they thought it was in their best interests to do so. As Drew said,: "What are you going to get if you are sitting there lying to her, paying her but lying to her?"

More than half the participants (57%) noted that they had participated in group as well as individual therapy and had found group to be particularly beneficial. Those who said that they initially had difficulties socializing stated that the support and sharing they experienced among other group members were particularly beneficial. The mutuality of both offering and accepting support was also brought up as a unique benefit of group therapy, as described by Melissa: "It's a good way to socialize, to form groups, and to get to know our own patterns and participate in activities to educate the general public." Also, participants said that they often received very helpful information about resources from other group members.

Two participants described previous negative experiences with therapists other than the ones on whom they focused during their interviews. Lori said she had recently spoken to a group of therapists who did not specialize in gender issues, and she received a generally negative and hostile response. She also described previous courses with therapists who did not specialize in gender issues, although one specialized in human sexuality, and they had generally either disregarded her gender issues or rejected them. It is worth noting that when Lori was previously receiving treatment, she sought therapy for presenting problems other than gender dysphoria. Other participants mentioned seeking therapy before making the decision to transition. For instance, Brenda initially saw her therapist for grief regarding the deaths of her father and former girlfriend, and when Lil began seeing her therapist, she struggled to determine whether she wanted to simply crossdress or transition full-time. Participants also mentioned focusing on other problems in therapy besides gender issues. For instance, Marc alluded to a history of trauma.

Specific criticisms of therapy by participants included a lack of competency, overt expressions of hostility, and approaching therapy with an attitude of eliminating pathology rather than facilitating wholeness. At least two explicitly stated that mere textbook knowledge by itself is not sufficient training for aspiring transgender-sensitive therapists, although helpful resources do indeed exist. For instance, Lil recommended that potential gender therapists sit in on some sessions with transgender people, if possible. The participants who emphasized going beyond books and didactic knowledge stated the importance above all else of making connections with transgender people, so that they are seen for their humanity rather than their novelty--"so it's not quite so exotic and negative," as Drew said.

Participant recommendations for helping professionals to receive specialized training in transgender issues did not apply solely to aspiring therapists. Marc described extreme difficulty in finding services with homeless shelters, rehabilitation specialists, and other helping professionals and social service agencies due to being transgendered. (During the data analysis phase of this study, a close friend informed the primary researcher that Marc had died by suicide.)

Exemplary Depiction

According to participants, the ideal therapist is a mixture of many characteristics: caring, empathy, sensitivity, flexibility, expertise, experience, and straightforwardness. Caring and empathy are needed to help transgender clients learn to love and accept themselves and cope with painful experiences, such as rejection by loved ones and discrimination. Expertise and experience are needed to help these clients find resources, such as legal assistance for name changes, medical professionals to prescribe hormones and perform surgery, and support groups. Therapists also need to possess broad knowledge to present a wide variety of options related to transition, so that transgender clients are empowered and equipped to make informed decisions. However, it is essential that therapists not presume to make decisions for clients.

According to participants, the ideal therapist should challenge transgender clients to reach beyond their grasp and not become stagnant in pursuing their true wishes related to transition and identity expression. Transgender clients need to be challenged to explore the painful feelings that often accompany the deep and transformative process of developing gender identity. On the other hand, it is also important that they not be pushed into decisions or behaviors that may conflict with who they really are. Therapists should continuously be aware of where clients are in their own development, and the personal obstacles that may be present. The therapist's job is to uncover, rather than shape, the true identity of gender-variant clients. For some gender-variant clients this process is more complex than others, given the extremely wide variety of identifies and expressions that are possible, especially those that challenge the status quo. An equally wide variety of sexual orientations is also possible. Some transgender clients require more guidance than others in discovering where they fit and what feels comfortable to them.

The support, guidance, and empowerment transgender clients need does not have to come from therapists alone. Group therapy and support groups are an ideal environment for transgender clients to realize that they do not have to be isolated, and to receive specific information. However, as with any group of people or any community, norms or expectations may form that may cause discomfort or confusion for an individual client, and therapists need to be able to provide a safe place for expressing and exploring those concerns.

In creating a safe atmosphere for transgender clients, another important issue is confidentiality. While confidentiality is of the utmost importance for any therapist, it is exceptionally so when working with transgender clients, especially those considering coming out. Trans-sensitive therapists often play many roles: advocating within the transgender community, raising consciousness of transgender issues outside the community, and networking to find the resources clients need. Because transgender communities are small even in large metropolitan areas, several transgender clients may see the same therapist. It is both challenging and absolutely necessary to always maintain client confidentiality.

The ideal therapist must also be aware of the rationale for the Standards of Care and carry out their intention in making sure that transgender clients are fully aware of the risks and responsibilities involved in life-altering hormonal and surgical interventions. At the same time, therapists must be sensitive to the frustrations faced by transgender clients who desire such interventions. Many gender-variant clients feel that they have already had to wait an unbearable amount of time to transform their bodies to be congruent with who they are inside.

Above all, transgender clients want to be seen as real people, not as diagnoses or clinical terms in textbooks. They want their stories, feelings, and experiences known. Required training for any therapists, whether or not they aspire to be gender therapists, must include basic information about gender variance and constructive ideas about how to avoid discriminating against and dehumanizing transgender clients. Specifics of such training could include sitting in on therapy sessions with gender-variant clients, required reading about the variations in transgender experience, and experience talking to transgender individuals in person.

The bottom line is that transgender people do not want to be fixed, they want to be whole; they are risking a tremendous amount to confront the pain and life-changing transformative aspects of their journeys. Seeking wholeness is not for the faint of heart. Nor can it be accomplished with brief therapy.

DISCUSSION

Implications for Theory

The present study focused on the current state of mental health treatment of gender-variant individuals, rather than the historical context of this treatment. However, as Schaefer and Wheeler (1995) noted, Harry Benjamin pioneered the compassionate involvement of medical and mental health professionals in helping gender-variant individuals resolve gender dysphoria, an involvement that continues today, according to the accounts of this study's participants about their therapists. Some participants mentioned that their therapist was selective in determining who was recommended for hormonal or surgical intervention, and the fact that selectivity is mentioned at all is reminiscent of the precedent set by Benjamin and his colleagues.

Many authors have described how the current transgender movement developed in reaction to stigma and oppression from mainstream culture, to exclusion from and marginalization by feminist and GLB communities, and to misunderstanding by medical and mental health professionals (Bornstein, 1994; Brown and Rounsley, 1996; Califia, 1997; Cole et al., 2000; Cromwell, 1999; Ettner, 1999; Lev, 2004). One theme that emerged from most of these accounts was the importance of self-realized and self-determined identity, achieved primarily through challenging the binary gender norms imposed by the medical model. One notable exception was Namaste (2005), who sharply criticized the focus of the American transgender movement on identity for being irrelevant to the daily lives and problems faced by many transgender and transsexual people, many of whom she said continue to see themselves as men or women rather than questioning the gender system.

The views expressed by the participants of the present study fell somewhere between the polarities of the transgender movement's critique of gender and Namaste's (2005) critique of the movement. Participants described expressing and receiving validation for a broad spectrum of gender diversity while at the same time using terms to describe themselves that fell within the traditional binary two-gender system of male and female.

Participants provided a great deal of support for the stages of Lev's (2004) transgender emergence model. The first stage, awareness, is noteworthy because up to that point gender-variant clients may have a sense that something is amiss but may not understand fully the nature of their distress. The participants in the present study stated that they became fully aware of gender dysphoria or gender variance before rather than during treatment with the therapist on whom they primarily focused in their interviews. However, several who mentioned seeing other therapists for reasons such as depression or grief before exploring their gender issues stated that these therapists either ignored any gender issues that were brought up or reacted negatively. The report of these experiences is consistent with previous findings (Ettner, 1999; Fontaine, 2002; Gainor, 2000; Israel & Tarver, 1997; Korrell & Lorah, 2007; Lev, 2004, 2007; Martin & Yonkin, 2006).

In all the participants' stories, seeking information and reaching out played a prominent role, which is Lev's (2004) second stage of transgender emergence. Several participants emphasized the benefits of support or therapy groups with other transgender people. However, Drew's story also illustrates that the transgender community sometimes has norms of its own and can exclude people for being too young, not "trans" enough, or otherwise diverging from whatever is considered to be the "typical" experience.

Several participants mentioned that their therapists helped them with disclosure and coming-out issues, which is Lev's third stage. The challenge of such disclosures is consistent with the difficulty described previously (Bockting & Coleman, 1992; Boenke, 1999; Fassinger & Arseneau, 2007; Howey 2002; Israel, 2004; Israel & Tarver, 1997; Korrell & Lorah, 2007).

All seven participants mentioned that their therapists helped them explore their identities and find labels that fit them, which Lev (2004) listed as the fourth stage of transgender emergence. They also reported that their therapists either provided support, options, or both about decisions related to transitioning and body modification, the fifth stage of Lev's model. Finally, two participants mentioned that their therapists helped them address post-transition issues, which are related to Lev's sixth stage, integration. This confirms the importance of addressing post-transition concerns (see Bockting and Coleman, 1992; Ramsey, 1996).

Implications for Research

Suggestions for further research include investigating a larger sample of transgender clients, exploring the experiences of gender-variant individuals other than transgender persons, and interviewing therapists about their experiences, including how their perspectives on gender diversity have evolved over time. For example, Israel et al. (2008) recently interviewed 14 therapists regarding their perceptions of helpful and unhelpful situations with LGBT clients. Assessment of how much gender diversity training therapists have had is needed, along with identification of areas for further professional development. Any new training programs should also be evaluated for effectiveness.

Other possibilities for future research include assessing the needs of underserved minorities within the transgender populations. For instance, Namaste (2005) reiterates that transgender and transsexual prostitutes are ignored and marginalized. Further studies could combine outreach and assessing the needs of this community. Research could also be conducted assessing the needs and presenting problems of gender-variant individuals who are people of color, who participate in inpatient or outpatient mental health treatment, who are in correctional facilities, or who receive substance abuse treatment services.

Implications for Therapy

The generally positive experiences of participants in this study give direct guidance to therapists about what is important in clinical work with transgender individuals. Expertise, empathy, and trustworthiness are critical, as is avoiding pathologizing diagnoses and heterosexist bias. It is impossible to determine for certain why the experiences of participants in the present study differed so greatly from the more negative experiences that have been reported (Bolin, 1988; Califia, 1997; Cole et al., 2000; Cromwell, 1999; Fontaine, 2002; Gainor, 2000; Israel & Tarver, 1997; Wilchins, 1997). Possible explanations are that therapists are better informed than in the past, or that transgender people are more visible in the general public and in the mental health profession than before. A third possibility, related to the impact of transgender activism and increased access to information on transgender issues, is that a different kind of clinician has been drawn to working with gender-variant individuals than previously, a clinician more invested in serving underserved populations than in maintaining the status quo.

It is important that therapists be constantly vigilant in monitoring bias that could potentially rupture therapeutic relationships and interfere with the goal of providing affirmative therapy to gender-variant clients (Bockting, Knudson, & Goldberg, 2007). The need for such vigilance supports Israel and Tarver's (1997) recommendation for informed supervision and consultation in gender-specialized work.

The power differential inherent in requiring therapists to authorize hormonal and surgical intervention, as the Standards of Care require, did appear to affect the therapeutic relationship of the participants in the present study, which echoes the concerns of prominent clinicians and researchers (Bolin, 1988; Brown & Rounsley, 1996; Cromwell, 1999; Denny & Green, 1996; Fontaine, 2002; Gainor, 2000; Israel & Tarver, 1997; Lev, 2004). Some participants expressed appreciation for their therapists' thoroughness and expertise in assessing the appropriateness of surgical and hormonal intervention. Others objected to their therapists having that much power. Most, however, acknowledged for better or worse that they saw the legal necessity of the Standards of Care in protecting medical and mental health professionals from lawsuits (see Bockting & Coleman, 1992; Satterfield, 1988; Seil, 1996).

As in previous studies (Bolin, 1988), participants stated that they were more comfortable with a female therapist. However, whether therapists were licensed on the master's level or doctoral level did not appear to be related to the comfort level of participants with their therapists, which contradicted Bolin's findings. The results of the present study suggest more relevant concerns to be that a clinician be licensed or otherwise qualified to meet specific needs of gender-variant clients, such as writing letters authorizing medical intervention, assisting in coming-out issues, overtly demonstrating confidentiality, sharing experiences, and being straightforward and empathic. Some of these therapist variables have not been specified in previous research, but because they made a difference in the present study, they warrant further investigation (Beutler, Machado, & Neufeldt, 1994).

Consistent with previous studies (Fontaine, 2002; Lev, 2004; Martin & Yonkin, 2006), participants' therapists played multiple roles. All participants also emphasized the necessity for every therapist to receive at least a minimum amount of training in gender issues, a recommendation clearly supported by professional organizations (American Counseling Association, 2008; APA, 2008) and authors (Cole et al., 2000; Denny & Green, 1996; Ettner, 1999; Fassinger & Arseneau, 2007; Fontaine, 2002; Gainor, 2000; Israel & Tarver, 1997; Korrell & Lorah, 2007; Ramsey, 1996).

Another notable clinical finding of this study is that the average number of therapy sessions reported by participants was 65--a much higher number than is typical for therapy clients in the present age of brief therapy and managed care (Garfield, 1994). Facilitating gender identity development is clearly a lengthy and involved process, one for which a brief therapy model is not appropriate.

Therapists should also consider comorbid diagnoses when working with transgender individuals--several participants had sought treatment for depression, stress, or trauma. These findings support the commonly seen comorbid diagnoses listed in the clinical literature (Bockting & Coleman, 1992; Israel & Tarver, 1997; Lev, 2004).

The clinical and academic literature cites numerous issues relevant to many gender-variant individuals that both clinicians and public policy have overlooked, such as HIV prevalence (Israel & Tarver, 1997), health care (Bockting, Robinson, et al., 2004; Lombardi & Davis, 2006), substance abuse, and difficulties in correctional facilities and with inpatient populations (Israel & Tarver, 1996; Lombardi & Davis, 2006; Namaste, 2005). The experiences of transgender people of color also are often overlooked (Fontaine, 2002; Gainor, 2000; Israel & Tarver, 1997; Lev, 2004), as are the vocational concerns of transgendered persons (O'Neil, McWhirter, & Cerezo, 2008). Unfortunately, the present study did not shed any light on most of these areas, since none of the participants described any such experiences. However, Marc's story and suicide highlight the urgent need for in-service training on gender variance in social service agencies such as homeless shelters. All social service agencies, in fact, desperately need training on gender variance so that they do not exclude transgender people.

Another policy suggestion, based on the results of this study, is to incorporate a mandatory gender variance component in all graduate training programs for therapists. As one example, as of January 2008 the APA's Commission on Accreditation now requires that gender identity be included as an aspect of diversity in the curricula of accredited programs. This requirement came 10 years after Phillips and Fischer (1998) emphasized the need for students in graduate training programs to be trained in GLB issues, and the same need exists for a deeper, more experiential level of multicultural training (Fischer, Jome, & Atkinson, 1998; Kiselica, 1998). Affirmative training in transgender issues would fit very well with these components of therapist training. Clinicians already licensed could also be required to participate in some sort of continuing education on gender diversity as well as cultural, ethnic, and sexual orientation diversity, so that all practitioners would be qualified to affirm diversity of all kinds and to make referrals when needed.

Limitations

The most obvious limitation in this study was the small number of participants. While a small sample size is characteristic of many qualitative research studies, it nevertheless makes the findings less generalizable. Moreover, all seven participants were Caucasian, and it is impossible to say for certain the extent to which the experiences of transgender clients who are racial, ethnic, or cultural minorities would resemble those reported by these participants.

Another limitation was that participants may have thought of the primary researcher as a medical/mental health "expert" who would be in the gatekeeper role herself someday and might therefore have felt a power differential similar to what they might have felt with their therapists. When all seven participants emphasized their honesty and the degree to which they trusted their therapists, they may have been telling her what they thought she wanted to hear as well. Because the participants did provide some penetrating critiques of other aspects of therapy, this seems tmlikely.

My (A. Bess's) nonobjective position about my experience as an openly bisexual woman, a feminist, a clinician, a close friend or acquaintance of a number of transgender and transsexual individuals, and an activist personally invested in minimizing power differences and questioning the status quo most likely also affected my interpretation of the results of this study. It is my belief that this subjecivity is both a blessing and a liability. While it may have blinded me to some implications or interpretations, it also contributed to the passionate intensity, energy, and perspective necessary to see such a project through.

CONCLUSION

The participants interviewed in this study described an overall positive experience with their therapists, although many reported less positive experiences with previous therapists and others in social service agencies that did not specialize in gender diversity. Participants reported that the therapists on whom they focused primarily in their interviews accepted and supported a wide variety of gender identities, expressions of gender, and sexual orientations. They expressed mixed feelings about the therapist gatekeeper role, but nevertheless stated that their therapists were trustworthy and they felt they could be honest with them. Their therapists' demonstrated commitment to client confidentiality helped to reassure transgender clients that the therapists were trustworthy. Participants reported that their therapists helped them with identity development, coming-out issues, exploring options, finding support for surgical and hormonal intervention, advocacy and legal issues, and networking with the transgender community through therapy groups and other resources.

Therapists need to continue to evaluate how they can better serve transgender clients and bring about changes in therapy training. They are called upon to continually examine how to make the world a far safer and more affirmative place for gender-variant people to live.

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J. Alison Bess is affiliated with Barksdale Air Force Base Mental Health Clinic. Sally D. Stabb is affiliated with Texas Women's University. Correspondence concerning this article should be addressed to: Dr. J. Alison Bess, 2MDS/SGOW--Mental Health Clinic, 243 Curtiss Road, Suite 100, Barksdale AFB, LA 71110. E-mail: Jennifer.Bess@barksdale.af mi.
Table 1. Participant Demographics

Pseudonym     Age             Education        Income

Marc          36              HS               25
Lori          60              PhD              31
Lil           56              BA               50
Tamara        50              AA               60
Drew          19              Some college      0
Melissa       48              Some college     32
Brenda        55              HS                0

              Identity        Therapist        Number of
Pseudonym     Term            Credentials      Sessions

Marc          FTM             MA/LPC           192
Lori          F               MA/Sexology       36
Lil           MTF             MA/LPC            36
Tamara        F               PhD               --
Drew          FTM             --                48
Melissa       Transsexual     PhD               15
Brenda        F               MA/LPC            64

Note. Age is in years. HS = High school diploma;
AA = Associates' degree; BA = Bachelor's degree;
PhD = Doctoral degree. Income is reported in thousands
of dollars per year and rounded to the nearest thousand;
FTM = Female-to-male, F = Female; MTF = Male-to-female;
Identity terms were those preferred by each participant.
MA/LPC = Masters Level Licensed Professional Counselor.
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Title Annotation:RESEARCH
Author:Bess, J. Alison; Stabb, Sally D.
Publication:Journal of Mental Health Counseling
Article Type:Report
Geographic Code:1USA
Date:Jul 1, 2009
Words:8334
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