and its difficulties in cases of acute and chronic gender dysphoria.
B.Sc., R.G.N., Post Grad. Dip. Counselling/Psychology. Psychologist/Counsellor. Nurse. Trustee, Gender Trust and Beaumont Trust. BS Officer. Gendys Conference, 1994
A Chinese proverb says that the beginning of wisdom is giving things the right name.
Before my presentation it will be necessary to give some definitions. I make a basic distinction between sex and gender. Sex is a biological phenomenon, gender is a cultural one.
Sex in its simplest terms, concerning humans, can be defined as being a male or a female. It refers to a set of biological characteristics linked to reproduction.
Intersex is a person whose sex is not clearly defined anatomically. There are chromosomal errors like Turner's Syndrome (where one of the XX or XY sex chromosomes is missing) and Klinefelter's Syndrome (XXY syndrome) or hermaphroditism where the anatomical sex has elements of both sexes.
There are also conditions where there have been developmental variants from the norm; like hypospadias, hypogonadism, gynecomastia, testicular feminization and adrenogenital syndrome. There are even some unfortunates who are born without visible anatomical sexual indicators.
It is now generally recognised that males and females do have vestiges of the other sex and a potential which includes elements of the other sex. Sex is in fact on a continuum. In humans there is actually relatively little sexual dimorphism, but a little bit makes a big difference as to how we see ourselves and others see us.
Sexual Identity is a sense of belonging to one sex or another.
There are seven criteria for establishing sexual identification, based on work by Prof. J. Money 1963)
Gender Identity Differentiation is how we are polarised towards one gender or another and is an psychological and sexual expression of that.
Sexual preference is a person's preferred sex object or object of affection and is to do with sexuality not gender. Like the rest of society transsexuals may be heterosexual, bisexual, asexual or homosexual (transhomosexual in this case).(1)
Gender refers to culturally defined states of masculinity and femininity. It is not directly related to sex or to sexuality. It is a sense of a person being a boy or girl, a man or a woman, and is about an individual's masculine or feminine behaviour and attitudes.
Gender Identity is an individual's sense of being masculine or feminine and their gender role, it is a sense of being of one gender or another.
Gender Role is the public expression of gender identity.
Gender Behaviour is culturally prescribed and often is polarised as masculine or feminine, with boundaries as defined by the society in which an individual lives. One is generally expected to conform to some extent to defined norms. What is 'expected' in 'gender appropriate' behaviour is linked to society and to mating and reproduction. It is partly to do with the individual's sense of self and others' sense of that individual.
Here I depart from the sex/gender distinction I have just offered. In popular and some professional thinking sex and gender are used interchangeably.
Gender Dysphoria (Dissatisfaction) refers to a person's profound sense of unease or discomfort which is in opposition to their physical sex.
Gender Identity Disorder of Childhood(2) "Is an intense and persistent distress in a child about his or her assigned sex and a desire to be, or insistence that he or she is, of the other sex."
Gender stereotyping from a feminist perspective is a product of the patriarchal society in which we live, as indeed is feminism itself.
Whilst there are many who challenge gender stereotyping and the inadequacy of traditional gender roles, there are some who we term gender dysphoric. They are so oppressed by their own sense of incongruent gender identity, that they do not respond to any treatment to reverse that fundamental sense of self.(3)
Transsexualism "is a persistent discomfort and sense of inappropriateness about one's assigned sex in a person who has reached puberty."(4)
It is a condition where a person has such a strong gender dysphoria and conviction that they belong to the other gender than that of their sex at birth, that they seek to live and as far as possible adapt their life and their body, using all means available to be congruent with this fact.
Gender Identity Disorder of Adolescence or Adulthood, non Transsexual type,(5) Here cross dressing is not for the purpose of sexual excitement, it differs from transsexualism in that there is no persistent preoccupation with getting rid of the primary and secondary sex characteristics and acquiring those of the other sex.
Transgenderism occurs where an individual chooses to live as the other gender. Increasingly this has come to mean without recourse to gender reassignment surgery.
Transvestism is where a person, usually male in Western society, has a compulsion to dress in the clothes of the other sex. It consists of cross-dressing and to an extent role playing, and may be gender motivated (expeditions into their often stereotypical concept of a woman's life), or sexually motivated (often connected with fetishism).
Transvestism may be gender motivated, or may also progress from fetishism. Other forms of cross dressing might be in connection with humiliation (where the forcing into the 'weaker sex's' clothes is involved).
Cross-dressing also occurs in connection with drag (homosexual), with theatre, or with early sexual experimentation or fancy dress.(6)
It can be seen that there is a gender continuum, as there is with sex; that this is part of the natural variation in humans. Each individual responds to his or her sexual and gender identity and sexual preference with different amounts of pragmatism or guilt.
The medical and psychiatric, psychological, health and social welfare professionals respond with varying appropriateness or ineffectiveness to this range of people. There is a range of personal prejudices and degrees of empathy. Society and the law do not clearly recognise this variety of people with their particular behaviours and difficulties, which reinforces their sense of isolation, inequality and guilt.
Whether gender dysphoria is a response to nature or nurture or both is open to debate,(7) but modern research suggests that brain sex is a reality and that gender programming occurs in the sixth week of gestation. There is now a strong case for saying that the foundations of a sense as to belonging to one sex (or one gender) or another, is first established in utero and is absolutely fundamental in brain development.
Developmental psychologists place more emphasis on the nurture aspects of gender reinforcements and programming.
Whatever the aetiology of this group of clients, a number of difficulties have been experienced in counselling the group who are most challenged by their gender dysphoria.
Counselling gender dysphoric clients.
My experience with gender dysphoric sufferers commenced many years ago. My aim was to help people in chronic, or acute crisis, situations; who were challenged by their belief that they might be transsexual.
Questions concerning their gender identity, their core personality, consumed many of my clients.
The client tended to regard me as the expert, the person with authority. The initial transferences largely work with the counsellor as the expert in this way. (Berne on transactional therapy(8)) Because clients wanted to be 'Told what to do,' there could be a great temptation to be overly pragmatic.
Caution is the name of the game.
Options were always, so far as possible, highlighted for the client, so that he or she could make important choices. They were helped with cognitive problem solving techniques and provided, as far as possible in advance, with all the information possible. Ignorance has always been a problem with not only the clients, but also many professionals.
The numbers of distressed persons coming to us via the Beaumont Trust was so great that we founded the Gender Trust in 1990, as a registered charity. It has limited resources of time, helpers or money, and unfortunately no premises. It faced large numbers of clients whose needs were not, in most senses, being met by the Gender Identity Clinics; or by other professionals who were either ignorant of this field or hostile to it.
General practitioners, local psychiatrists and psychologists were not addressing this problem. Almost no counselling which was geared for the particular difficulties of clients with gender identity difficulties, was available on the NHS.
The sessions had to be limited in number because of limited resources. They included a preliminary history and assessment prior to counselling, and a clear contract to address a particular difficulty. Also the Gender Trust provides clients with information, practical help and advice.
The counselling the Trust provided had to be a form of crisis management, with brief counselling support, backed up with peer group support, information and advice in other contexts (conferences, information provision, workshops and seminars, involving inputs from myself and other professionals in the field).
I worked from a multi-disciplinary theoretical base, using specialised knowledge derived from Freud, Jung, Ellis, Hirschfeld, Benjamin, Stoller, Green, Money and others.
Much of the work was undertaken with a clear contract to address particular issues, using Windy Dryden's Rational Emotive Therapy(9,10,11) as the main model. This involves using an eclectic, largely cognitive, approach to bring about change, based on the hypothesis that humans have a tendency towards irrationality; but, optimistically, that we also have a great potential to work to change our biologically-based irrationalities. By identifying goals, setting a contract to address a particular difficulty and actively pursuing these goals, using a cognitive approach to reach these insights, therapy enables a client to change.
The BAC Code of Ethics was applied, as were The Standards of Care in Treatment of Transsexuals.(12) Counselling was often in my home or the client's. Sessions were from one to two hours.
Client's difficulties and themes which have recurred are:
Clarification, helping the client to clarify whether he/she is genuinely gender dysphoric; or, for example, a guilty transvestite convincing himself he is transsexual to escape that guilt.
Motivation. The client who sees himself as a failed man and (foolishly) believed that life as a woman is easier.
Poor self esteem and self hate.
Poor ego development.
Self restriction, Unrealistic views about what a woman or a man are "supposed to be," a self-imposed stereotypicality.
Inferiority, Being a little man with no penis (in the case of the female to male transsexuals). Being an unconvincing woman in the case of many male to female transsexuals. Also an 'inappropriate' education and life history.
Practicality, Not passing as a member of the gender role chosen (in the case of the male to females).
Guilt because of family disruption or religious difficulties.
Divorce and the effect on children and partners.
Relationships. Sexuality, friendships, partners, parents etc.
Loneliness and isolation.
Employment and Housing.
Unrealistic expectations of surgery and postoperative complications; surgery junkies.
Medication, including hormone-induced mood swings.
Depression and suicide.
Alcoholism, drug abuse.
Bereavement (mourning a past life, and to an extent adjusting to the negative implications of surgery. Lost fertility, lost libido etc.) And a plethora of other difficulties.
It left me as a counsellor with a feeling rather like the little Dutch girl with her finger in the dyke . . . or was it a boy?
The politics of the last thirty years have been rather like the earlier attitude of many professionals to homosexuals. The professional's script has been to somehow 'cure' the person and to 'make him/her 'normal'.
Often the attitude of professionals has been very far removed from the humanistic core conditions of Carl Rogers, with his use of empathy warmth and genuineness. Ignorance or prejudice were rife. There were also self-styled counsellors who did actual damage to clients by telling clients what to do, instead of listening.
I encouraged clients to participate in the process by their working at home, as well as in the consultation room, with lists and homework and self appraisals.
Much of my work was intuitive and based on experience with these clients, working around evidence and clues in a diagnostic sense, to some extent looking at practical realities. It was largely successful, but felt a bit like triage at a battle front.
I was attracted to Rogers's "Way of being" with a client. Though I knew my theoretical background and practice had not harmed a client and had helped many, I reacted against the very directive self-styled 'counsellors' who were actually harming their clients, many of whom had subsequently come to us for help.
To illustrate two of the problems faced by transsexuals and the range of counselling skills required I shall describe the experience of two clients.
I recall a client who had attended a Gender Identity Clinic and had been told that he was transsexual by the Consultant Psychiatrist. He was in deep depression and suicidal, and felt like "a nothing." I adopted an entirely Rogerian approach with this client, working with the process and with unlimited positive regard. I saw him on a weekly basis.
After a year he was saying that this was the first time in his life anyone had ever listened to him. This was an issue for him.
It also transpired that he was, apparently, not transsexual.
He was operating the mind set "If I dress as a woman sometimes, I must be one." His mother had also unmanned then mocked him, with "boys don't do that" when he had cried. There were many strong retroflexions in which he enacted his mother's problems (she seems to have had a classic Freudian penis envy).
In fact he had two fantasy persona, one a Lee Marvin type, a loner, a very masculine cowboy type; the other a Debbie Reynolds sixties girl. He would dress up as either of these and watch videos of his hero or his heroine. But they had been as he put it "at war with each other in his head" and it made him miserable. 'She' was there because he rejected masculinity, 'he' was there because he felt guilty about 'her'.
He was depressed and had a very low libido and couldn't cope without his fantasy "safety valves." His long suffering wife accepted all versions of him. He eventually accepted himself and his "eccentricity." It is a clear case where surgery would have made things very much worse. Above all this case convinces me of the value of a client based, person centred, empathetic approach. His defensive boundaries had been so strong he had never before admitted the facts to himself or others. Nobody had before walked in his moccasins, or his high heels.
He did not fit the categories of diagnosis held by the NHS.
There seems to be an expectation that once a patient is labelled (diagnosed) they only have one dimension.
His problem really seems to have been his own very rigid, sexist, view of male and female identity, with two strongly stereotypical extremes in his personality, which brought about an extreme sense of conflict and guilt about his fantasy or eccentricity, and subsequent isolation.
Using Rogers's Core conditions in counselling him enabled this shy person to be liberated, and he became more functional as a whole person since he was able to accept himself and to integrate his harmless eccentricity into his life. The therapeutic relationship we had has enabled him. He became as Rogers puts it, "a person."
Earlier work using only a cognitive approach by another counsellor had "tried to stop him dressing up," in his words, which only made him feel more guilty and suicidal.
A client presents with a problem or series of difficulties. It is the counsellor's task to help unravel the knots, to enable a client to recognise personal constructs (beliefs) which are damaging, and to be in touch with his or her feelings.
Rogers's model has demonstrated that the client is the expert. A less directive and more adult to adult mode of process was actually more helpful with this client than a need to 'cure him' might have been in the past. He still retains his 'eccentricity,' but it is not damaging him now, and his depression has gone. He is coping.
I have one client who was genitally abused as a boy, who actually had surgery and sexual reassignment, reasoning that if the hurt member was removed it could not be hurt again.
Her present displacement is that she had her surgery because she was unable to bear the guilt of being a homosexual man, but that she is not a woman because she does not have a woman's past. She is also alcoholic and a sadomasochist, and would like to abuse her abusers, other men.
This, often sad, complex client has often planned her suicide, "the ultimate existential act", as she puts it.
She has at times regressed in a Freudian sense to infantile states of mind and behaviour, and a psychodynamic Freudian approach might in Michael Jacobs words "be too limited for this client." However an Egan (person based) approach has helped this client tell her story, see where her problems have come from and to grieve about her mistakes. I do not know how her story will end.
I felt that this client was very much on the edge of risk of suicide, or complete breakdown.
Gestalt work was very powerful with her. She has written the unsent letter "to her now dead parents," expressing her hate and anger, and another to her abuser. This method of enabling a client to express repressed feelings is one I have used before and will continue to use. Our work with dreams, and her dream diary gave her a reason "to keep coming to counselling and not to kill herself yet" as she said.
Cognitive work helped her to stop drinking, she has realised it was not a solution but a poor escape.
She sees herself as an "it" now, but at least she is less negative about that and is a "proud it" as she puts it.
This client now has chosen a gender neutral mode of dress and name and her latest bandwagon is to become androgynous.
This means that the stress she had in maintaining a female persona which she did not believe in, or a male one she hated, is removed. Interestingly she in no way regrets her surgery. She has now returned to her traditionally all-male job and has largely, as she puts it escaped from the tyranny of gender.
While these two clients are unusual and extreme they demonstrate that nothing is as straightforward as it first may seem. It is vital not to attempt to make the client fit the labels.
The majority of gender Dysphoric clients appear to genuinely benefit from counselling, even on a brief counselling basis. Once the core identity issue is addressed many of the other difficulties seem to be less distressing and depressing. Gender distress seems to be at its most acute at times of choice. "What am I?" as well as "Who am I?" is the question.
Once identity is established, then the issue becomes "how shall I live my life." The counsellor's task is to enable the client to deal with his or her own decisions and the consequences of these decisions.
It sometimes feels like an almost impossible task, but it is worthwhile. What we need is resources and trained people to develop the work.
Purnell, A., (1994),Gender counselling, and its difficulties in cases of acute and chronic gender dysphoria. GENDYS '94, The Third International Gender Dysphoria Conference, Manchester England. London: Gendys Conferences.
Web page copyright GENDYS Network. Text copyright of the author. Last amended 27.11.98