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Editors:
Friedemann Pfäfflin,
Ulm University, Germany
 

Walter O. Bockting,
University of Minnesota, USA
 

Eli Coleman,
University of Minnesota, USA
 

Richard Ekins,
University of Ulster at Coleraine, UK
 

Dave King,
University of Liverpool, UK

Managing Editor:
Noelle N Gray,
University of Minnesota, USA

Editorial Assistant:
Erin Pellett,
University of Minnesota, USA

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Published by
Symposion Publishing

  
ISSN 1434-4599



Volume 6, Number 1, January - March 2002



Transgender Individuals' Experiences of Psychotherapy

By Katherine Rachlin

Paper presented at the American Psychological Association 109th Annual Convention, San Francisco, CA. August 24-28, 2001

Citation: Rachlin K (2002) Transgender Individuals' Experiences of Psychotherapy. IJT 6,1, http://www.symposion.com/ijt/ijtvo06no01_03.htm

Abstract

This research examined Transgender and Transsexual individuals' experiences in psychotherapy accross a range of treatment settings. Participants completed a survey that asked why they had sought mental health services and what their experience of treatment had been. The sample consisted of 93 participants (70 Female-to-Male and 23 Male-to-Female) who reported on 150 contacts with various psychotherapists. Results indicated that it was common to have seen a psychotherapist for general personal growth issues earlier in life and to later seek out a therapist who had experience in transgender work in order to focus on gender issues. Provider experience in working with gender issues was associated with a higher number of positive changes, higher patient satisfaction with progress in both general personal growth, and gender related issues. Individuals consistently expressed appreciation for therapists who were flexible in their treatment approach and demonstrated respect for the patient's gender identity.

 

Introduction

Transgender and Transsexual individuals may seek mental health services for a variety of reasons. Psychological assessment and psychotherapy are often suggested, and sometimes required, in the treatment of individuals with gender concerns. The sixth version of the Standards of Care For Gender Identity Disorders (Meyer III. et al. 2001) describes in detail the potential benefits to be had from psychotherapy and outline the role of the psychotherapist in the treatment of Transsexual and Transgender individuals. This research attempted to look at individual experiences in psychotherapy across a range of treatment settings.

Clinicians treating this population are apt to see a wide range of gender identity and expression. Rather than a simple 'opposite sex' identity (most typical of Transsexual individuals), Transgender individuals may have non-traditional and complex experiences of gender. This research is concerned with all people who may seek psychotherapy for gender concerns. The term 'Transgender' is used in this paper to refer to the combined population of Transgender and Transsexual individuals. Being Transgender is not in itself pathological or indicative of a need for psychiatric treatment. However, Transgender individuals do experience a number of unique stressors and are no different from the rest of the population in their potential to experience emotional problems and other concerns which may lead them to seek psychotherapy.

Psychotherapy has a multifaceted role in the gender exploration and transition process. Psychotherapy can provide support for coping with external stressors, treat comorbid conditions, provide increased insight into personal history and motivations, facilitate exploration of the options for living with one's gender identity and enhance decision-making regarding gender transition options. Mental health professionals may see Transgender individuals in formalized gender programs, therapy clinics, or private practice. In every case the therapist will be challenged to provide treatment that is sensitive to the client's unique gender identity and individual circumstances.

Transgender individuals may find ways of living with non-traditional or cross-gendered identities that do not involve altering their bodies. Yet, for some people, there is no substitute for taking actions to create a body that is more truly reflective of their identity. This may include a number of procedures such as electrolysis, hormones, and various surgeries. Hormonal and/or surgical gender-confirming medical interventions have proven to be very satisfactory for a select population. Individuals who undergo hormone therapy may find the effects of hormones sufficiently satisfying so that they need no further medical interventions. Other people will want surgical modification in order to feel personally comfortable and satisfied. Caroll (1999: 128) reviewed "the empirical research on the psychosocial outcomes of treatment for gender dysphoria" and concluded that "The large body of research on the outcome of gender reassignment surgery indicates that, for the majority of those who undergo this process, the outcome is positive." Kuiper and Cohen-Kettenis (1988: 439) also concluded "that there is no reason to doubt the therapeutic effect of sex reassignment surgery."

Though in many cases the most helpful treatment is surgical, there is no reliable diagnostic test that a physician might prescribe to assess the appropriateness of such a patient for surgery. Most of the known correlates of post-surgical success are psychosocial and are best assessed by a trained clinical behavioral scientist. The incidence of postoperative regret is generally extremely low (Pfäfflin (1992) found less than 1% in Female-to-Males and 1-1.5% in Male-to-Females). However, researchers continue to study incidents of regret in an effort to decrease the occurrence even further. A better understanding of the factors which contribute to both postoperative satisfaction and postoperative regret will enable clinicians to improve diagnostic and selection criteria and presurgical preparation.

The substantial body of literature that looks at the outcome of gender confirming surgeries has explored the relationship between measures of post-surgical satisfaction and a number of biopsychosocial factors such as: the quality of surgical results; quality of social and family relationships; quality of professional life; pre-surgical emotional stability; quality of presurgical counseling; and quality of life in preferred gender role prior to surgery (Carroll, 1999; Green and Fleming, 1990; Bodlund and Kullgren, 1996; Brown, 1990; Landen, Walinder, and Lundstrom, 1997; Ross and Need, 1989; Lundstrom, Pauly, and Walinder, 1984; Pfäfflin and Junge, 1998; Pauly, 1981). Kuiper and Cohen-Kettenis (1998: 2) reported that:

More than 20 possible risk factors that influence the result of SRS [sex reassignment surgery] negatively, are mentioned throughout the literature. However, none of them has proved to be an absolute contra-indication for SRS. Negative prognostic factors tend to lie in the area of psychological dysfunction, family background, sexual orientation, disrupted social contacts, insufficient professional support during the 'real life test', and complications in surgery.

It is important that treatment providers be informed about such research when evaluating people for surgery and making treatment decisions.

Psychological evaluation is recommended to assess 'eligibility' and 'readiness' for surgery as defined by the Standards of Care for Gender Disorders (SOC) (Meyer et al. 2001). If factors are present which have been associated with negative outcomes, then psychotherapy may provide an opportunity for the individual to address these issues prior to surgery.

The current SOC (Meyer et al. 2001) are intended to be guidelines for treatment and suggest that physicians obtain a letter from a mental health professional prior to prescribing hormones, and letters from two mental health professionals prior to performing surgery. The first letter for surgery is traditionally written by a psychotherapist who knows the client very well. The second opinion letter is written by a clinician who conducts an evaluation of some briefer duration. It is also possible for two clinicians who are part of a 'gender team' to collaborate on one letter. Such letters generally include a psychosocial assessment, a description of psychotherapeutic treatment, and support of the patient's ability to make decisions regarding gender transition (see SOC for an in-depth discussion of the content of such letters). The physician prescribing hormones or performing surgery may rely on the psychological assessment to inform his or her medical opinion about how best to treat the patient. Patients may not be able to obtain hormones or surgery without such letters. 'Gatekeeping' is a word used to refer to the role of the mental health professional who may control access to medical care through such letters.

Descriptions of the role of the clinician in treating transgender individuals invariably list a large number of tasks. Ettner (1997) provides guidance for clinicians by encouraging them to shift paradigms and approach gender treatment with a different theoretical orientation, and different assumptions and skills than they may use with their other clients. Schaefer, Wheeler, and Futterweit (1995), and more recently, Brown (2001) illustrate how necessary it is for treating professionals to have detailed knowledge of the medical and psychosocial components of the transgender experience. It is also essential for them to be aware of all possible options and treatment strategies. Bockting and Coleman (1992: 134) describe a comprehensive treatment model, which uses a number of treatment modalities, and incorporates the contributions of professionals on an interdisciplinary team. In their comprehensive treatment model, "five treatment tasks can be distinguished: (1) Assessment; (2) Management of comorbid psychiatric disorders; (3) Facilitating identity formation (analysis of biography, family of origin intimacy dysfunction/abuse recovery, sexual identity exploration); (4) Sexual identity management (decision making, sexual functioning, social support); and (5) Aftercare."

The treatment of Transgender individuals provides an opportunity for a multifaceted and potentially non-traditional role for the psychotherapist. The SOC describe the potential for psychotherapy to educate, clarify options in Transgendered living, facilitate transition, improve personal familial, social and working relationships, provide information about medical, legal, and community support resources, provide support for family and significant others, and even suggest that the therapist be available to advocate and educate in the workplace. So much is expected of the therapist that it is clear why a high level of specialized expertise is needed. The SOC provide suggested criteria for professional competence in this area and Israel and Tarver (1997) also propose criteria for the designations 'Gender Specialist' and 'Senior Gender Specialist' in their 'Recommended Guidelines.' Qualification for 'Gender Specialist' includes, but is not limited to "a minimum of two years of direct supervision or consultation with a practicing 'Senior Gender Specialist' who is recognized as having advanced experience in providing consultation to peer practitioners," (Israel and Tarver, 1997: 12). Schaefer, Wheeler, and Futterweit, (1995: 2047) in describing the basic requirements for good treatment, state:

Essential to an effective psychotherapeutic relationship is that psychotherapists be informed about all aspects of gender identity disorders and conditions, be knowledgeable about all known options available for learning how to live with this condition, be completely versed and educated about the unique challenges on working with all levels and intensities of gender identity ideation and expression in patients.

Because there are comparatively few therapists with such expertise, individuals often search out other sources of support such as peer support groups, internet contacts, and therapists who have no experience with Transgender issues.

The requirement that individuals see a mental health professional prior to medical intervention presents some challenges. Individuals who want psychotherapy may not be able to afford or locate an appropriately trained therapist. The suggestion in the SOC that individuals see a therapist is especially burdensome for those people who do not want therapy at all. Some Transgender people do not believe that they have a need for psychological services and oppose the recommendation that they meet with a mental health provider. Individuals may resent having to spend time and money for psychological services in order to obtain medical services. They may also have fears concerning speaking with someone who holds the power to grant or deny them access to the interventions they feel they need. This fear and resentment creates a dynamic between therapist and client which may have an impact on the process and outcome of treatment. A number of therapists have explored the ethical dilemmas raised by the dual roles of gatekeeper and therapist. Vitale (1997: 254) emphasized that the ethical issues become more treacherous when professionals do not have the training and expertise and sensitivity to competently assess and treat Transgender clients. In response to the fractured relationship and long time mistrust between the Transgender and professional communities she proposed:

As the first step in resolving our difficulties, I suggest we start with a more clearly defined idea of what constitutes a qualified gender therapist. ...a licensed professional with sufficient training and supervision to handle this extremely debilitating disorder. The individual should be ready to accept crossdressing and sex or gender incongruity as a psychologically unalterable, congenitally attributed, natural phenomenon.

Anderson (1997: 189) offered a solution to the dual role raised by evaluator and therapist by suggesting that

The therapist's singular role would be to counsel, support, interpret unconscious material, and educate and encourage the client in the interest of exploring all possibilities that promise growth and change in a desired direction. At the end of the period of therapy the client could meet with a second clinical behavioral scientist who, furnished with records of the process and outcome of therapy, would evaluate the applicant and ultimately recommend or withhold endorsement.

Bockting and Coleman's (1992) 'comprehensive treatment model' takes some of the gatekeeping power away from the primary therapist by utilizing a multidisciplinary treatment team to make that final recommendation for surgery.

All of these approaches assume that it is necessary for a transgender person to undergo an evaluation prior to medical treatment. Hale (2001) proposes a different approach. He advocates taking the responsibility for treatment decisions away from behavioral clinicians. He argues in favor of an informed consent procedure which would eliminate the universal need for a psychological evaluation and which would transfer the task of evaluation and diagnosis from the psychotherapist to the physician. He also suggests that the relationship created when a psychotherapists acts as a gatekeeper is both unethical and may prevent transgender individuals from benefiting from psychotherapy. These issues continue to be debated as interested practitioners attempt to provide the best care possible.

Though the exact numbers are not available, it is reasonable to assume that a large portion of the people who consider or undergo gender transition engage in some form of psychotherapy. What are they seeking when they enter into psychotherapy and what do they get out of it? Are they there because of a medical mandate or because they want increased insight and personal growth? This research attempted to look at how Transgender people approach psychotherapy and what their experiences of treatment have been. Ultimately such information may suggest direction for training and practice in psychotherapy and assessment, so that professionals can provide Transgender clients with services that will be most valuable and satisfying.

 

Method

Survey

A survey was designed to ask Transgender people why they had sought mental health services, what they looked for in a psychotherapist, their opinion of their therapist's level of competence in working with gender issues, and the outcome of treatment. Each participant was allowed to describe their experiences with two therapists.

Surveys were distributed at a Transgender conference in Baltimore Maryland, USA in February 1999. They were also distributed by individuals who had heard about the survey and wanted to participate. People also learned about the survey via Transgender newsgroups on the Internet.

Subjects

Thirty-one percent (n=29) of the surveys were completed and collected at the conference. Fifty-two percent (n=48) of the respondents obtained surveys at the conference, through the Internet, or through another person and mailed in their surveys with an identifiable return address on their envelope. Seventeen percent (n=16) obtained the survey on the Internet and responded via e-mail. The response rate is unknown as individuals accessed the survey through a number of channels and researchers did not keep track of the number of copies distributed.

Demographic and identifying data

The sample consisted of 93 subjects (70 assigned female at birth and 23 assigned male at birth) who reported on 150 contacts with various psychotherapists. Participants represented 28 of the 50 states of the USA and ranged in age from 17 to 57 years with a median age of 37. Twenty-eight percent of the respondents reported that they had some college education: 36% reported that they held a Bachelors Degree, 15% a Masters Degree, and 15% a Doctoral degree. Forty-six percent reported that they lived in an urban area, 32% in a suburban area, and 19% in a rural area. Eighty-five percent of the sample identified themselves as Caucasian, 8% as African American, 3% as Mixed Heritage, 2% as Native American, and 1% as Hispanic.

Gender identity

Participants were given a check list of gender designations such as 'Male', 'Male-to-Female', 'Transgendered', 'Transsexual', etc. and were invited to check the words that they used to identify themselves. Many individuals identified with more than one label.

Among those assigned female at birth: 91% identified with the term Female-to-Male or FtM, 77% identified as Male, 34% as Transgender, 31% as Transsexual, 3 % as both Male and Female, 1% as Female, and 1 % identified as other. These numbers add up to more than 100%, which reflects the fact that individuals often found that no single term was adequate to describe them. For the sake of simplicity this group of female-bodied masculine-identified individuals will be referred to in this paper as FtM (Female-to-Male).

Among those assigned male at birth: 87% identified as Male-to-Female or MtF; 83% as Female; 70 % as Transgendered, 17 % as Transsexual, 13 % as both Male and Female; 9% as other, 4% as cross-dresser; and 4% as Male. Again, may individuals identified with more than one term. For the sake of simplicity this group of male-bodied female-identified individuals will be referred to in this paper as MtF (Male-to-Female).

Gender confirmation choices and physical status

The majority of subjects had undergone hormone therapy (64% of MtFs and 80% of FtMs) and/or a name change (45% MtF, 71% FtM). (See Table 1)

 

Table 1. Gender Transition Choices and Physical Status

 

 

Number of respondents who made this choice

Gender Confirming Action

Definitely Not

Considering

Actively Planning

Have Had

 

 

n

%

n

%

n

%

n

%

Hormones

 

 

 

 

 

 

 

 

 

MtF

1

5

1

5

6

27

14

64

 

FtM

2

3

5

7

7

10

55

80

Name Change

 

 

 

 

 

 

 

 

 

MtF

0

0

6

27

6

27

10

45

 

FtM

2

3

9

13

9

13

49

71

Top Surgery

 

 

 

 

 

 

 

 

 

MtF

7

33

10

48

4

19

0

0

 

FtM

4

6

6

9

23

33

36

52

Genital Surgery

 

 

 

 

 

 

 

 

 

MtF

2

9

7

32

8

35

5

23

 

FtM

20

29

35

51

11

16

2

3

 

The FtM and MtF groups showed very different patterns in decisions regarding surgery. While none of the MtFs had top surgery (breast augmentation), 52% FtMs had undergone top surgery (mastectomy and reconstruction) and another 33% were actively planning it. Twenty-three percent of the MtFs had undergone genital surgery and another 35% were actively planning it. Only 3% of the FtMs had genital surgery, 16% were planning it and 29% had decided definitely not to have it. Only 9% (n=2) of the MtFs had decided definitely not to have genital surgery. These results speak to the reality of FtM surgical options. While MtF genital surgery is relatively accessible and offers a potentially satisfying outcome (cosmetically and functionally), FtM procedures are regarded by many people as requiring an unreasonable degree of cost, risk, and compromise. (Though it should be noted that many FtMs are more than satisfied with their choices post-surgery.) In contrast, FtM hormones and chest surgery deliver impressive results and are seen as generally desirable and usually necessary.

Gender presentation

Sixty-eight percent of those male-identified (FtM) and 48% of the female-identified (MtF) were living full-time in their preferred gender (defined as presenting in that gender at least 90% of the time) (See Table 2). The rest of the subjects were at various earlier stages of transition or had, for the moment, found ways of expressing their gender that did not involve a full-time social commitment to one gender.

Table 2. Gender Presentation

Gender Presentation

% of Time Presenting

 

 

0

<50

50-89

90-100

 

 

n

%*

n

%

n

%

n

%

FtM

 

 

 

 

 

 

 

 

 

Male

6

9

8

12

8

12

47

68

 

TG**

44

64

13

19

 7

10

45

 7

 

Female

54

78

11

16

2

3

2

3

MtF

 

 

 

 

 

 

 

 

 

Female

3

13

3

13

6

26

11

48

 

TG**

16

70

6

26

0

0

1

4

 

Male

12

52

4

17

2

9

5

22

Each person's responses added up to 100% of the time.

*Percentage of the total number of FtM (70) or MtF (23)

* *Presenting as ambiguous or Transgender

 

Results

Experiences in psychotherapy - Most Recent therapist and Former therapist

Each participant was given the option of reporting on their experience with two therapists. 57 participants chose to report on two therapists and another 13 indicated that they had seen more than one therapist but only reported on the most recent. The Former, or earlier therapist, and Most Recent therapist, did not always represent two equivalent therapy experiences. Either therapist may have been someone the person saw primarily for an evaluation and/or a letter for hormones or surgery. In some of those cases a second therapist was consulted while therapy with the primary therapist was ongoing and the primary therapy continued during and after the evaluation. This was a rare occurrence (only nine individuals indicated that they were there for a 'second opinion' letter). In most cases there appeared to be two temporally distinct experiences with psychotherapists.

Reasons for seeking therapy

Survey items which asked about the reasons for seeking therapy were submitted to a principal components analysis and two factors emerged: Factor I - General Psychotherapy/Personal Growth, and Factor II - Gender Exploration/Transition. People rated the Former therapist higher on Factor I and rated the Most Recent therapist higher on Factor II (see Table 3). This suggested that earlier experiences were more likely motivated by general concerns and more recent experiences were more likely motivated by gender concerns.

Table 3. Reasons for Seeking Therapy

Reason

Former Therapist**

Most Recent Therapist**

Both***

 

n

%

n

%

n

%

Factor I: Help with Personal Growth

Improve relationships

32

56

44

47

76

51

To reduce emotional discomfort

38

67

46

49

84

56

Personal growth

33

58

43

46

76

51

Work or school Conflicts

19

33

26

28

45

30

Helped make other decisions

10

18

23

25

33

22

Gain comfort with gender

17

30

27

29

44

29

Other reasons

1

2

1

1

2

1

Factor II: Help with Gender Exploration/Transition

Help make decisions regarding gender transition

21

37

50

54

71

47

Support during transition

12

21

42

45

54

36

Support after transition

3

5

14

15

17

11

Letter for hormones or surgery

19

33

54

58

73

49

(First opinion)

18

32

46

49

64

43

(Second opinion)

1

2

8

9

9

6

*n=93 people reported experience with Most Recent Therapist

**n=57 people reported experience with Former Therapist

***n=150 total experiences reported

Outcomes of therapy

Twelve items representing potential outcomes of treatment were submitted to a principal components analysis. Three factors were found to account for 60% of the variance in outcome: Factor I - Progress in Gender Exploration/Transition, Factor II - Progress in General Personal Growth/Life Enhancement, and Factor III - Overall Satisfaction with the Treatment (see Table 4).

Table 4. Therapy Outcome

Outcome Factor I

Progress in Gender Exploration/Transition

 

Clarified gender issues

Clarified possible transition options

Helped make transition decisions

Felt supported during transition

Outcome Factor II

Progress in General Personal Growth/Life Enhancement

 

Improved relationships

Improved emotional stability

Increased comfort with self

Helped make other decisions

Outcome Factor III

Overall Satisfaction with the Treatment

Would you recommend this therapist?

How helpful was the experience?

Nothing changed as the result of treatment (negative loading)

People who scored high on seeking therapy for gender exploration/transition issues scored high on reported benefits in that area. Similarly, those seeking therapy for general personal growth issues reported benefits in those areas. Conversely, there were low cross-correlation scores. Degree of seeking help for gender exploration/transition was not highly correlated with benefits in general personal growth, and progress in gender exploration/transition was not likely to happen when one sought therapy for general personal growth issues. People who were there primarily for general personal-growth oriented therapy remained in treatment longer than those there primarily for gender exploration/transition.

The therapists were rated significantly differently on two of the three outcome factors. The Most Recent therapist was associated with higher ratings on both Factor I (Gender Exploration) (t=4.10 p<.05) and Factor II (Personal Growth) (t=3.02 p<.05). There was no significant difference between the two therapists on Factor III (Overall Satisfaction). Factor I and Factor II are concrete accomplishments in treatment, while Factor III represents a measure of the goodness of the service. It appears that while the Former therapist was satisfactory, more was accomplished with the Most Recent therapist. There are many possible reasons for these higher ratings of their most recent therapist. In some cases people continued to look for help until they found a therapist who could give them what they needed. There may also be a bias towards one's current or more recent therapist and a need to see the therapist as competent. Another central reason for increased progress may be the more recent therapist's significantly greater level of perceived experience with gender issues (see below). Perhaps the relief of addressing gender issues with the second therapist outweighed the successes of non-gender oriented therapy with the first therapist. Perhaps the ability to discuss gender issues productively facilitated work in other areas of treatment as well.

Perceived provider experience with gender issues

A composite variable was created to assess the effect of perceived provider experience with gender issues. The 'Gender Experience' variable combined the following items which were dispersed throughout the questionnaire and used a variety of scales:

  • Provider specialty area ('gender identity' or 'other')
  • How connected was the therapist to the TG/TS community?
  • How up-to-date was s/he on Trans-issues and resources?
  • Approximately how many TS/TG individuals would you estimate this provider had seen before you?
  • To your knowledge, did s/he follow the Harry Benjamin International Gender Dysphoria Association's Standards of Care?
  • Do you believe that the therapist had adequate experience and expertise to serve your unique needs concerning gender?
  • What made him/her either competent or not competent? (Written answers often mentioned gender experience/experience or lack of it.)

Table 5 shows the significant correlations between treatment variables and level of perceived provider experience with gender issues.

Table 5. Treatment Variables Related to Psychotherapist's Perceived Level of Gender Experience

Treatment Variable

Correlation with Psychotherapist 
Gender Experience (composite variable)

Reasons for seeking services:

 

Presenting Factor I (non-gender reasons)

-.149

Presenting Factor II (gender reasons)

.658*

 

 

Outcome of Treatment:

 

Factor I Progress in gender exploration/transition

.596*

Factor II. Progress in Personal Growth

.031

Factor III Satisfaction With Treatment

.470*

 

 

Rapport

.342*

Harm from therapy

-.259*

* p= <0.05

When a person went to see a therapist who was rated highly in gender experience the person was likely to have gone to therapy with the goal of gender exploration or transition. Degree of gender experience was significantly correlated with better rapport: progress regarding gender exploration/transition, and higher levels of overall satisfaction. Gender experience was negatively correlated with number of sessions, indicating that the treatment was briefer or more recently begun (often therapy with less experienced therapists was in the past and therapy with gender specialists was current and ongoing). Gender experience was negatively correlated with a variable called 'harm done'. This variable arose from the written comments of 14 subjects who described how they felt they had been harmed by therapists (written in the general "other comments" section at the end of the survey). The harm usually took the form of belittling, challenging, or judgmental behaviors regarding the patient's gender, which in some cases resulted in increased despair.

Gatekeeping

In order to isolate those treatment experiences in which patients were most likely to be affected by gatekeeping, we looked at how "there for a letter" as a reason for seeking services, was related to other variables. Eighteen people indicated 'there for a letter' was their only reason for seeing a therapist. Another 55 listed 'there for a letter' as one reason among others. Seventy-seven people did not check 'there for a letter' among their reasons for seeing a therapist. Information was compared for the three groups: 'letter only', 'letter plus other reasons', and 'no letter'. Individuals who checked 'there for a letter' only or with other reasons, were more likely than 'no letter' individuals to be in therapy for gender-related reasons and significantly less likely to have come to therapy to work on general personal growth issues. Individuals who listed 'there for a letter' only, or with other reasons, were significantly more likely to chose therapists who scored higher on gender experience (t=5.91, p<.05) and who were likely to follow the Standards of Care to some degree.

The 18 individuals who were in the 'letter only' group differed from the other two groups in a number of ways. 'Letter only' individuals scored significantly lower on progress on Factor I (Gender Exploration) and Factor II (Personal Growth), but their scores for Factor III (Overall Satisfaction) were identical to the other groups. Written comments indicated that individuals who went for a letter and got a letter felt that they accomplished something and received the service they wanted. There was also a significant difference in the number of sessions for those there only for a letter (mean number of sessions was ten) and individuals there for other reasons (mean number of sessions was 52). Of the 150 therapy experiences reported there were only 13 cases in which patients said that 'nothing changed' as the result of the treatment; five of those were in the 'letter only' group and six were there for a letter plus other reasons. Table 6 shows the overall correlations between 'there for a letter' and other variables.

Table 6. Variables Correlated with 'There for a Letter'

 

Correlations with 'There for a Letter'
for Therapist A, Therapist B, and Both

 

Most Recent 
Therapist

Former 
Therapist

Both

Outcome Factor III (Satisfaction)

-.004

.315*

.192*

Experience with TG individuals

.412**

.578**

.507**

Follow the HBIGDA standards?

.302**

.528**

.407**

Have undergone some transition

.296**

.384**

.310**

Number of sessions

-.243*

-.173

-.211*

n=150

*p=<0.05

** p=<0.01

Limitations of this study

This non-random sample of convenience was limited geographically, economically, and socially. All individuals had contact with the Transgender community either through a conference, a counselor, a peer group, or through the Internet. The sample was limited to those willing to volunteer to participate. Unrepresented are the large numbers of Transgender individuals who mistrust researchers and therapists and would decline an invitation to participate. The survey was limited in length to encourage participation, which limited the number of demographic questions that could be asked. In addition to unanswered questions there is bias caused by the fact that all information about the participants was gathered through self-report. Furthermore, all information about the therapists was filtered through the clients. We do not so much have data about therapists and therapy, but about clients' impressions of their therapists and therapy. Much of the data refers to things that happened in the past, such as why one went into therapy and how one felt regarded by the therapist. It would have been ideal to gather such data in the moment to avoid some of the effects of time and the forces of memory. In this survey we treated all contacts with psychotherapists as psychotherapy. This is not always the case as there are occasions when psychotherapists are providing assessment and not psychotherapy. In future research those distinctions should be made more explicit.

When looking at the results of this study one may be struck by the large percentage of FtM individuals who responded. Of course this was influenced by how the sample was obtained: subjects were solicited at an FtM-oriented conference and the project posted on FtM-oriented Internet newsgroups. The number of responses demonstrates that FtM individuals are accessible and willing to participate in research. This is important to note because there has been a tradition of focusing Transgender-oriented research on MtFs. When FtMs are included at all they are usually the minority. Hopefully this research is part of a trend towards equal inclusion and greater representation and understanding for FtMs.

 

Discussion

More than 87% of respondents reported that positive change occurred in their lives as the result of psychotherapy. This was often true even when they felt that the therapist did not have adequate experience in gender issues and when they would not recommend the therapist to a peer. However, negative experiences in therapy were more often associated with perceived lack of provider experience with gender issues. Subjects also reported that treatment was compromised when providers who had some expertise in gender were not adequately up-to-date on current queer, Transgender, or FtM issues. Many people also indicated that the experience was not as worthwhile when the provider was extremely passive or distant.

Overall, provider experience in working with the gender issues was associated with: better rapport with the therapist, greater progress in gender exploration/transition, and higher client satisfaction. Respondents were in agreement regarding what was most helpful in treatment. When asked what had been most helpful people listed four things: acceptance, respect for the person's gender identity, flexibility in the treatment approach, and connection to the Transgender community.

The outcome research indicates that satisfaction with life after gender transition is more likely when individuals have solid professional lives, good family relationships, good social support networks, and are emotionally stable (Carroll, 1999; Green and Fleming 1990; Landen, Walinder, Lundstrom, 1997; Kuiper and Cohen-Kettenis, 1988; Lundstrom, Pauly, Walinder, 1984; Pfäfflin, and Junge, 1998; Pauly, 1981; Ross and Need, 1989). The Standards of Care suggest that these issues be addressed prior to gender reassignment. It would seem that in many cases individuals follow this path quite naturally. The participants in this study saw earlier therapists for those 'personal growth' issues such as emotional stability, school, work, and relationships, and later in life a gender specialist was sought for concentrated and practical work on gender issues and possible gender transition.

These results reflect a common circumstance in working with Transgendered individuals. It is not unusual in gender-specialized practice to see individuals who have already had psychotherapy. Many clients have benefited from previous therapy and enter gender therapy at a point when they have achieved a great deal of insight and stability. Such people may present to the gender specialist having benefited from the earlier therapy and ready to tackle the gender issues, which the earlier therapy could not fully address. These individuals may need a therapeutic experience which can maximally incorporate gender issues. The Standards of Care (Meyer et al. 2001) offer a general description of what the content and direction of such treatment may be as do several other authors including Bockting and Coleman (1992), Brown (2001), Ettner (1999), Israel and Tarver (1997), and Schaefer et al. (1994). Among the respondents in this study, the earlier therapist was often not experienced in working with gender. In treatment with a less experienced therapist gender is less likely to be a focus. This may be because the client does not bring it up as much or because the therapist does not have the experience to know what to do with this material. Greater satisfaction with the more recent therapist in this study may indicate that if a person is not working on gender issues they will be less satisfied with psychotherapy.

Another common circumstance in working with Transgender clients is that of serving as a consultant or second therapist to a client who is already in treatment. This may arise because the client is in need of a second opinion letter for surgery; because the primary therapist is not familiar with gender issues and they may want back up from a specialist; or because the client feels that their primary therapist's knowledge of gender issues is not sufficient and the client wants some additional work with a specialist. In such cases the two providers must be careful to coordinate services and address the complex treatment issues raised in this dynamic.

Psychological evaluation should be distinguished from psychotherapy and should not be a substitute for therapy when needed. It may be important to distinguish between psychological assessment and psychotherapy and make sure that the client has realistic expectations. People were satisfied when they came for a letter and left with a letter. They did not necessarily experience personal growth, increased insight, or help with life decisions. Individuals do not usually expect to get personal benefit from diagnostic tests, beyond their diagnostic capabilities. It might be realistic to have similar expectations of psychiatric assessment prior to gender reassignment.

In the present study, when gatekeeping (as defined by request for a letter) was a focus of treatment it served to influence the choice of therapist and was associated with shorter length of treatment. Gatekeeping was not necessarily detrimental to the therapeutic alliance and individuals who were in treatment for the sole purpose of getting a letter usually reported satisfaction with treatment. It is apparent from the results of this study that large numbers of individuals who were 'there for a letter' also wanted help with other aspects of transition and a variety of personal problems. This illustrates why it is important that the professional who writes the letter be a competent psychotherapist.

In summary, results demonstrate that Transgender individuals go to therapy for many reasons, some of which have nothing to do with gender. When they do seek help for gender-related concerns, the expertise of a gender specialist is appreciated and beneficial.

 

References

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Correspondence and requests for materials to Katherine Rachlin, Ph.D. 153 Waverly Place, Suite 10, New York, NY 10014 (KRachlin@aol.com)