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Amanda B Elder Dissertation Final 2013 (2)

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Amanda Beth Elder, Psy.D.

This document is a dissertation submitted by Amanda Elder to the Wright Institute Graduate School of Psychology in partial fulfillment of the requirements for the degree of Doctor of Psychology. The dissertation sought to enrich the understanding of older transgender individuals' subjective experiences in psychotherapy throughout their lifespan. Elder conducted interviews with 9 transgender-identified participants ages 60-83 to discuss their significant psychotherapy experiences. A qualitative thematic analysis was used to identify themes in the data. The dissertation aimed to offer perspectives on psychotherapy experiences that are often overlooked due to transgender marginalization and to improve psychotherapeutic care for gender variant people.

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OLDER TRANSGENDER EXPERIENCES IN PSYCHOTHERAPY A dissertation submitted to The Wright Institute Graduate School of Psychology in partial fulfillment of the requirements for the degree of Doctor of Psychology By AMANDA BETH ELDER, M.A. MAY 2013 © 2013 AMANDA BETH ELDER ALL RIGHTS RESERVED
ii May 2013 OLDER TRANSGENDER EXPERIENCES IN PSYCHOTHERAPY By AMANDA BETH ELDER, M.A. This study sought to enrich the understanding of transgender individuals’ subjective experiences in psychotherapy throughout their lifespan, both to offer perspectives that are often overlooked due to transgender marginalization, and to improve the quality of psychotherapeutic care for gender variant people. Although many gender variant people have received psychotherapy, only three studies have researched transgender experiences in psychotherapy. This gap in the literature is significant given the amount of harassment, discrimination and violence that transgender people continually deal with when receiving medical and psychotherapeutic services; that psychotherapy has been required and continues to be strongly encouraged in the Standards of Care for transgender people during the process of obtaining gender realignment procedures; and because in order to be multiculturally competent, psychologists must be aware of the needs and experiences of transgender communities. Despite the growing population of older transgender people, and more transgender people transitioning later in life, the few studies on the experiences of psychotherapy have not included the experiences of older transgender people. Therefore, more research is also needed on older transgender people regarding the psychotherapy they received throughout their lifespan.
iii The researcher conducted one-hour interviews with nine transgender-identified participants whose ages ranged between 60-83 years of age. Older transgender-identified people offer historical perspectives that may elaborate on progression of psychotherapeutic services for transgender people in the last several decades. A qualitative research method using thematic analysis was used to identify and analyze themes embedded in the data. The results were organized into ten themes within three categories: 1) Experiences in therapy, including healing and painful moments in therapy, and positive ways that therapy has changed; 2) Life experiences, including transitioning and trans issues, older trans issues, family of origin, discrimination and abuse, resiliency and activism; and 3) Recommendations to other people of transgender experiences and to mental health providers. Overall, participants indicated that they found that therapists are currently more knowledgeable about transgender experiences, are better acquainted with gender fluid language, are less biased and more flexible and resourceful in their approaches. Negative experiences included therapists failing to recognize and affirm their gender as well as overt and covert judgments about gender variance. As in earlier studies on psychotherapy, participants went beyond questions asked, leaving their legacies by relating the challenges and joyful moments of their lives.
iv Dedication I dedicate this dissertation to the brilliant participants. I am so thankful that you bravely stepped forward to get your voices heard. I hope I have done justice to your in- credible life stories and experiences in therapy. Thank you so much for your recommen- dations and contributing to the trans-affirmative psychotherapy literature. This research also belongs to all the fabulous trans, transgender, and gender queer researchers, providers, and activists whom I cited throughout the text. I have had the good fortune to get to know many of you through UCSF’s Transgender Center of Excel- lence, Center for AIDS Prevention Studies, the World Professional Association for Transgender Health, as well as through the Asian & Pacific Islander Wellness Center. I am honored to have presented the preliminary findings of this study at the National Transgender Health Summit this month. I am so grateful for our collaborations and your friendship. In particular, I dedicate this research to Tatiana Kaneholani, my sistah and kumu. Thank you for teaching me how to be graceful and fierce. I also dedicate this to Janetta and Nick.
v Acknowledgements I am eternally grateful to Dr. Ellen Balis, my chair, and to my readers, Dr. Amy Walthall and Dr. Jamison Green. Thank you for believing in me and this work. Thank you for all your hard work and perseverance through four years of a labor of love, sweat, and tears. I am honored to share this with you. A HUGE congrats and thanks goes to my study-buddy in crime who just gradu- ated himself, Dr. John Michael Brown. All the hugs I could give won’t pay back the love you have given me with Huck and Will. I can always count on you to get me to laugh, usually at ourselves and the ridiculousness of the stress we have been under with our hard work. I also attribute my survival and sense of humor from Dr. Susan Guerrero, who’s many words of wisdom she invented, like The D MONSTER. I am ever grateful for our study time together, commiseration, and most of all your friendship. Thank you to Dr. Kaili Moyer, another study buddy and good friend who also did a fabulous gay dissertation that I cited. I want to thank more of my chosen family for all your love and support. Words cannot express, so let’s just keep being family so that I can love you up, ok? I want to thank Ayesha Star Cammaerts, Heather Frank, Shin Yi Tsai, Ronald Pineda, Kaylene Holvenstot, Justine Saunders, Shirin Shoai, and Valeria Velazquez. I want to thank a few more friends and colleagues here who contributed to this work: Maci & the hilarious article she gifted me by Dr. Sehy (Sehy, 1990), Dr. Leon
vi Wann, Cole Moyer, Dr. Greg Gayle, Dr. Annalise Ophelian, Willy Wilkinson, Kelsey Evan Rounds, Carolyn Hunt, Jean Brennan, G. Richard Bellamy, Michelle Cilia, Joseph Nolan, Beanie, Michele Senitzer, and Megan Montgomery. There are many more who I want to include here, so I raise a toast to you in gratitude. I want to thank you, Deborah Dallinger, my editor-in-chief, particularly when you got me through the first pages at my apartment while I was laid up with a healing broken ankle. I want to thank my clients. I am so grateful for our work together. Thank you for helping me become a better person and therapist. I want to thank the staff at the Wright Institute for being so friendly and patient with my constant surprise visits, and fielding all my ridiculous questions. In particular, I want to acknowledge Virginia Morgan, Curtis Lew, Dolores Sullivan, Ais Harvey, Mark Abramowsky, and Jason Strauss. Finally, I have the most to thank to my family of origin. I love you all so much. To my sisters Veronica and Shelly, my brother David, and to Grandma Jean, Nancy, Dan, Jim, Ann, Gale, Steve, and Elizabeth. Especially I want to thank my parents—to you Dad, and to both of you Moms for sending me so much love and strength.
vii Table of Contents Abstract ii Dedication iv Acknowledgements v Table of Contents vii Chapter 1: Introduction 1 Statement of Purpose 1 Background and Significance of Study 1 Historic and Global Gender Variance 1 Prevalence 2 Transgender Discrimination and Resilience 3 Transgender Psychotherapy 4 Need for Study 4 Definition of Terms 5 Research Questions 9 Chapter 2: Review of the Literature 10 History of Psycho-medical Research and Treatment of Gender Variance 10 Sexologists and Early Transgender Conceptualizations 10 Early Medical Advances 14 Mid-20th Century Psychological Perspectives on Gender Variance 17 University-affiliated Gender Identity Clinics 22 Mid-20th Century Transgender Advocates 27
viii Street Queens and Grassroots Activism 29 Development of Standards of Care 32 Gender Diagnoses in the Diagnostic and Statistical Manual for Mental Disorders 36 Gender Diagnoses in the International Classification of Diseases 40 Gender Diagnostic Reform 42 Essentialist and Social Constructionist Trans Identity and Language 46 Trans-affirmative Models of Care 49 Transgender Experiences in Psychotherapy 52 Participants’ Demographics and Study Design 52 Reasons for Seeking Therapy 53 Positive Experiences in Psychotherapy 54 Negative Experiences in Psychotherapy 55 Recommendations for Providers 56 Recommendations for Further Research 58 Issues Facing Older and Aging Transgender People 58 Invisible Minority 59 Diversity within Age Cohort 60 Transitioning Later in Life 60 Discrimination, Violence and Legal Issues 61 Social Support 65 Health Care and Access 66 End of Life Issues 68
ix Areas for Further Research 70 Summary of Current Literature 71 Chapter 3: Methodology 73 Qualitative Research and Thematic Analysis 73 Participant Criteria, Recruitment, and Selection 74 Instruments 75 Procedure and Data Collection 76 Data Analysis 77 Ethical Considerations 78 Bracketing of Potential Bias 79 Chapter 4: Results 81 Research Participants and Therapy Experience 81 Table 1: Self-Reported Demographic Data 81 Table 2: Therapy Experiences 84 Table 3: Transgender Therapists’ Professional Background 85 Themes of Participant Data 86 Table 4: Results of Data Analysis 89 Category I: Experiences in Therapy 90 Theme 1: Trans-Affirmative & Healing Experiences in Therapy 90 Theme 1A: Therapist Affirming Gender and Sexuality 91 Theme 1B: Professional and Respectful Therapists 95 Theme 1C: Range in Theoretical Approach 96 Theme 1D: Range of Issues Addressed in Therapy 97
x Theme 1E: Peer Support Groups 99 Theme 2: Negative or Transphobic Experiences in Therapy 102 Theme 2A: Uninformed Providers 102 Theme 2B: Unhelpful Behaviors by Therapists 103 Theme 2C: Homophobic and Transphobic Experiences 106 Theme 2D: Biased & Derogatory Psychology Literature 107 Theme 3: Positive Changes in the Way Therapy is Conducted 109 Category II: Life Experiences 110 Theme 4: Transition and Trans Issues 111 Theme 4A: Gender Identity Formation 111 Theme 4B: Gender Language 113 Theme 4C: Sex and Sexuality 115 Theme 4D: Waiting to Transition 116 Theme 4E: Passing, Stealth and Living Two Lives 118 Theme 4F: Hormone and Surgery Treatments 121 Theme 4G: Coming Out and Social Relationships 121 Theme 4H: Gender Social Roles 124 Theme 4I: Authenticity 126 Theme 5: Older Trans Issues 126 Theme 5A: Differences in Age Cohorts 127 Theme 5B: Transitioning Later in Life 127 Theme 5C: Health Issues and Disability 128 Theme 5D: Benefits of Older Age 128
xi Theme 6: Family of Origin 129 Theme 6A: Family Acceptance or Non-acceptance 129 Theme 6B: Mental Health Issues in Family 131 Theme 7: Discrimination, Harassment and Abuse 132 Theme 7A: Violence and Abuse 132 Theme 7B: Employment Discrimination 135 Theme 7C: Discrimination by Spiritual Community 135 Theme 8: Resiliency, Community Activism, and Education 136 Theme 8A: Educating and Advocating for Oneself 136 Theme 8B: Teaching Others 137 Theme 8C: Volunteering and Activism 138 Theme 8D: Connecting with Spiritual Community 139 Category III: Recommendations 139 Theme 9: Recommendations to Other Trans People 139 Theme 9A: Advocate for Yourself and Do the Research 140 Theme 9B: Find a Supportive and Informed Therapist 140 Theme 10: Recommendations to Providers 141 Theme 10A: Provide trans-affirmative therapy 142 Theme 10B: Utilize consultation or co-therapy 144 Theme 10C: Research Trans Issues & Language 144 Theme 10D: Attend Community Events 145 Theme 10E: Address Co-occurring Issues in Therapy 146 Theme 10F: Recommendations for Further Research 146
xii Chapter 5: Discussion 147 Discussion of Themes 148 Experiences in Therapy 149 Positive Therapy Experiences 149 Negative Experiences in Therapy 153 Positive Changes in the Way Therapy is Conducted 156 Life experiences 157 Transition and Trans Issues 158 Older Trans Issues 160 Family of Origin 161 Discrimination, Harassment, and Abuse 161 Resiliency, Community Activism, Education, and Celebration 162 Recommendations 163 Clinical Implications 165 Limitations 167 Directions for Future Research 169 Conclusion 170 References 172 Appendices 189 Appendix A: Letter of Introduction 189 Appendix B: Informed Consent 191 Appendix C: General Demographic Information and Therapy Survey 195 Appendix D: Interview Guide 197
xiii Appendix E: Consultation Resources 199 Appendix F: GID Diagnoses with Full Criteria 200 Appendix G: International Bill of Gender Rights 205 Appendix H: Research Committee 208
1 Chapter 1: Introduction Statement of Purpose The purpose of this study is to enrich the understanding of transgender individuals’ subjective experiences in psychotherapy throughout their lifespan, both to offer perspectives that are often overlooked due to transgender marginalization, and to improve the quality of psychotherapeutic care for gender variant people. The researcher conducted one-hour interviews with a diverse sample of 9 transgender-identified people who discussed at least one significant psychotherapeutic experience, regardless of their gender identity at the time of treatment. Participants were between 60-83 years of age. Older transgender participants offered the historical perspectives on how psychotherapeutic services for trans people have progressed over the last several decades. This study may help clinicians question simplistic notions of gender, as well as address clinical competency in service provision, particularly as discrimination towards trans people has become much more widely understood as a civil rights issue (Bendery, 2012; Grant et al, 2011). A qualitative research method using thematic analysis was used to identify and analyze themes embedded in the data (Braun & Clark, 2006). Background and Significance of Study Historic and global gender variance. Gender variance has been found throughout history worldwide. What is sometimes referred to as third gender is revered in many cultures as respected shamans, representatives of goddesses, gods and intersexual deities, or accepted as a diverse population within society which may encompass gender role play to living full-time as another gender. Cross-culturally gender variance has many names, for example: Okule and Agule among the Lugbara people and
2 Isangoma among the Zulu people in Africa; Hijra and Jogappas in India; Baylans or Catalonans in the Philippines; Bissu and Basaja in South Sulawesi, Indonesia; Mudang in Korea; Shih-niang and Wingagu Nati in China; Xanith in Oman; Mahu in Hawaii and other Polynesia societies; Two-Spirit among many Native American tribes; Vestida in Mexico; Guevedoche in the Dominican Republic; and Gallae in Turkey (Feinberg, 1996; Roughgarden, 2004; Wiesner-Hanks, 2011). Prevalence. Minority groups will remain invisible in policy reports on health care disparity and aging until additional research efforts focus on their behalf (Witten & Eyler, 2012, p. 15). Because gender variance is still not recognized in the United States, as an invisible minority, transgender-identified people are not reported in the census data, and their prevalence is difficult to assess. Locating accurate data on the diversity of transgender identity is also more difficult to find, largely due to discrimination and stigma. Thus, it is difficult to determine the prevalence of older and aging transgender people based on the literature. However, the broader lesbian, gay, bisexual, transgender, intersex and queer-identified population in the U.S. aged 65 and older may number three million, perhaps expanding to as many as four million by 2030 (DeVries et al, 2006). According to the World Professional Association for Transgender Health, researchers who have studied prevalence of transgender people have focused predominantly on transsexual individuals who have sought gender transition-related care (Coleman, 2011). Combining most of the research findings in the last 39 years internationally, prevalence ranges from 1 in 11,900 to 1 in 45,000 for male-to-female transwomen (MtF) and 1 in 30,400 to 1 in 200,000 for female-to-male (FtM) transmen (Coleman, 2011).
3 Transgender discrimination and resilience. Transgender and gender non- conforming people face severe harassment, discrimination and violence from numerous aspects of society and are often denied housing, education, employment, health care, legal assistance, and citizenship. In addition to being denied basic human rights due to institutional transphobia, transgender people face discrimination and violence from their partners, family members, friends and communities. As a result, transgender people must often cope with isolation, extreme poverty, and severe health disparities; according to a research study, nearly half of them attempt suicide at some point in their lives (Grant et al, 2011). Despite these formidable challenges, transgender people are resilient, finding their way toward resources and community support, and managing to live full, complete lives. Grant et al (2011) found that 76% of the 6,450 respondents in their study involving the largest amount of trans people ever participated in a study entitled Injustice at every turn: A report of the national transgender discrimination survey by the National Center for Transgender Equality and National Gay and Lesbian Task Force have been able to receive hormone therapy, indicating a determination to endure the abuse or search for sensitive medical providers. In addition to the universal areas of concern associated with aging, such as health care and income disparities, ageism, and end-of-life issues, older and aging transgender- identified people face additional risks. Already marginalized in gay and lesbian communities, transgender-identified people are further discriminated as older adults (Persson, 2009; Witten & Eyler, 2012). Ageism is common in LGBT communities, and in the psychological literature on LGBT aging, older transgender and gender non- conforming experiences continue to be under reported (Witten & Eyler, 2012).
4 Transgender psychotherapy. Given the challenges of discrimination and the inevitable stress that institutional and personal discrimination cause, transgender people have sought psychotherapy to support their coping strategies, strengths, and resilience as well as to address issues that result from stress. The psychotherapeutic literature reveals that transgender-identified peoples' psychotherapy includes self-exploration, relationship and family dynamics, career challenges, and phase of life issues (Bess, 2006; Joy, 2008; Lev, 2004; Witten, 2009, Rachlin, 2002). Need for Study Although many gender variant people have received psychotherapy, only three studies have researched transgender experiences in psychotherapy: Bess, 2006; Joy, 2008; Rachlin, 2002. The dearth in the literature is disturbing given the amount of harassment, discrimination and violence that transgender people continually deal with when receiving medical and psychotherapeutic services, and that psychotherapy has been required and continues to be strongly encouraged during the process of obtaining gender realignment procedures by the Standards of Care for trans people (Coleman et al, 2011). Of the three studies, each examined various aspects of psychotherapy, including the individual reasons for seeking therapy, positive and negative experiences in therapy, and recommendations for mental health providers. In all three studies, researchers pointed out the need for increased training in transgender and gender variance issues. These studies also indicated the need for more psychological research on transgender care from the perspective of transgender people. Many participants in the current studies were middle-aged, but only one was 60 years of age. Although there are is a growing population of older transgender people, and more transgender people transitioning later in life (Witten & Eyler, 2012), the
5 few studies on the experiences of psychotherapy have not included the experiences of older transgender people. Therefore, more research is also needed on older transgender people regarding the psychotherapy they received throughout their lifespan. Definition of Terms The following is a list of terms and definitions used in this study. Many of the definitions are cited by transgender researchers and activists who described themselves and their trans communities. The power to name one’s identity is a critical issue for trans people who face discrimination and violence. Therefore, the terminology will be further discussed within socio-historical context in the following literature review. Throughout the text, trans, transgender, and transgenderism are also used interchangeably with gender variance, to represent the spectrum of gender. Transgender and trans are used as inclusive terms to describe people whose gender identity (subjective experience of themselves as male, female, or other gender designation) or gender expression differs from socially constructed norms associated with the biological sex or gender identity assigned to them at birth (Coleman et al, 2011). Transgender and trans also refers to androgynous, bi-gendered and gender-queer people, who may view traditional concepts of gender as restrictive (Coleman et al, 2011; Green et al, 2011). The terms transgenderist and later transgender were coined by Virginia Prince in the 1970s and 80s to define people who identify and live full-time in the gender opposite to the one assigned at birth, and who may not elect for hormonal or surgical sex realignment procedures (Keatley, 2011; Feinberg, 1996, Lev, 2007). In the 1990s, transgender became used also as an inclusive, politically unifying term for gender variance (Lev, 2007).
6 Transsexual or transsexualism describes a person who obtains sexual reassignment or realignment surgery (SRS) and hormone treatments. The term was popularized in the American media in 1952 by Christine Jorgensen and her doctor Harry Benjamin who monitored her hormone treatments. Some older trans people who grew up during that time and obtained SRS, identify strongly with transsexual identity and feel than that the term transgender does not adequately represent their experience. Pre-op and post-op refer to before and after sexual reassignment or realignment hormones and surgeries. Transvestite was a medical term initially coined in 1910 by Magnus Hirschfeld, a German sexologist, in his text Transvestites: The Erotic Drive to Cross-Dress (Hirschfeld, 1910). Similar to current usage of trans, Hirschfeld defined transvestite beyond the “erotic urge for disguise” and included those whom he referred to as sexual intermediaries including people who were gay and those with intersex bodies (Hirshfeld, 1910; Stryker, 2008). Since the mid-20th century when psychiatrists defined transvestism as a perversion (APA, 1952, 1968, 1975, 1980, 1987, 1994, 2000), transvestite remains a stigmatizing term. Therefore, many people prefer to use the term crossdresser to describe the practice of presenting as genders different from the one assigned to them at birth (Peters, 2012). Crossdressers associated with performance may identify as drag queens or kings, transgender or trans, or perhaps reclaim transvestite in an empowered, self- actualized political identity. Sex and gender are used interchangeably in the psychological literature and colloquially, but they are not the same (APA, 1994; Stryker, 2008). Sex relates to biological aspects as chromosomes, hormones, and reproductive capacity. Sperm-
7 producing bodies tend to be designated as male, while egg-producing bodies tend to be designated as female (Stryker, 2008). However, those who identify as intersex may have characteristics of male and female biology or morphology or shape of the body. Although there may some biological aspects to gender, gender is largely influenced by culture and socialization, whereby one grows into their subjective sense of their gender identity (Butler, 1990, 2004; Lev, 2004; Stryker, 2008). Gender binary refers to gender identities being categorized as either male/man or female/woman. Although there are people who identify as intersex who may be born with characteristics of male and female biology, morphology or shape of the body, these variances, along with the spectrum of varied cultural and psychological perceptions of gender, are often ignored in favor of the gender binary perspective. The gender binary view conflates biological sex and gender identity, suggesting that individual gender identity, presentation, and performance must be congruent with physical sex characteristics or anatomy (Tilsen et al, 2007). Gender non-conforming or gender-queer describe people whose gender expressions, roles, and identities varies from societal expectations and stereotypes of gender presentation (Grant et al, 2011), or people who defy or do not accept stereotypical gender roles and may choose to live outside expected gender norms (Green et al, 2012). Gender non-conforming and gender-queer people may or may not avail themselves of hormonal or surgical treatments (Green et al, 2011). Similarly, those who identify as androgynous may include those whose appearance and identity do not conform to conventional views of masculinity or femininity, and who may combine both aspects or present in a way that is outside expected gender norms (Grant et al, 2011).
8 Queer refers to a gender inclusive identity that may refer to gender and to sexuality. This term is controversial due to its historical and current use as a derogatory term for gay-identified people. In 1990 the use of queer was reclaimed by activists in New York who called themselves Queer Nation, and would produce actions such as sitting in bars and clubs where primarily heterosexual people were consumers. Queen was a term coined by older grassroots activists who may also identify as drag queen, trans, transsexual or transgender. Self-identified queens may include youth, the homeless, sex workers, prostitutes, husslers, activists or advocates for trans rights who may or may not live on the streets. Lesbian, Gay, Bisexual, Transgender, Intersex, Queer and Questioning (LGBTIQQ), also known as alphabet soup, refers to the spectrum of gender and sexuality (Stryker, 2008). Straight refers to heterosexual- identified people who are cisgendered or who identify with the gender assigned to them at birth. The homosexual identification may be used as a derogatory term due it first being used as a medical diagnosis describing people who are sexually attracted to the same gender as pathological (APA 1952, 1968). Homophobia describes the phenomenon by which people are afraid of LGBTIQ- identified people. Transphobia describes the phenomenon by which people are afraid of gender variance. The above terminology and descriptions are not an exhaustive list. Gender terminology continues to shift and evolve. Rarely do the definitions of these terms remain fixed, and individuals' gender identities may not remain the same throughout their lifespan. Trans-affirmative researchers and providers are continually learning new ways to be more universally-minded in their approach towards inclusivity for all (Lev, 2004).
9 Research Questions By listening to trans peoples’ subjective experiences in psychotherapy, this study hopes to capture a glimpse of the historical gender paradigm shift from a binary one to a more inclusive one, as well as contribute to developing theories of trans-affirmative therapy and improve service provision. Questions were asked to gain experiential information about participant dealings with the topic. The study’s intent was to learn about healing and negative therapy experiences, trends on how therapy is changing, and recognize ways in which therapy can improve and be more trans-affirmative in practice.
10 Chapter 2: Review of the Literature History of Psycho-Medical Research and Treatment of Gender Variance The literature on the psycho-medical concept and clinical approaches to transgenderism is mainly published in Europe and the United States beginning in the 1800s (Meyerowitz, 2002; Stryker, 2008; and Lev, 2004, 2005 & 2007). Most research and theories of gender variance emanated from a pathologizing, reparative perspective (Lev, 2005), although some scientists advocated for human rights and promoted acceptance through their research (Meyerowitz, 2002). The following sections trace the history of the psycho-medical research and treatment of gender variance including: early sexologists and their conceptualizations of transgenderism, the advent of hormonal and sexual realignment or reassignment surgical (SRS) medical treatments in the 1930s, mid- 20th century psychological perspectives on gender variance, and the rise of university affiliated gender clinics, mid-20th century transgender advocates and activism, the development of standards of care for medical and psychological practitioners treating gender variant individuals, the evolution of gender diagnoses and gender diagnostic reform, trans-affirmative models of care, and transgender experiences in psychotherapy. Sexologists and early transgender conceptualizations. In the 19th and early 20th centuries, Western society condemned gender variance. In parts of Europe and the U.S., it was illegal for people to appear in public if they were wearing clothes deemed inappropriate to their gender assigned at birth (Stryker, 2008, p. 33). However, an increasing number of European and American scientists studying human sexuality began to challenge the notion of separate and opposite sexes (Meyerowitz, 2002, p.22). During the 19th century, sexual and gender variance became the focal point of sexologists who
11 were seeking to define sexual behavior within a larger cultural discourse of categorizing madness and deviance (Foucault, 1965; Lev, 2007). While the work of some of the clinicians and researchers described in the following sections supported societal fears with condemnation or cures, others encouraged acceptance of difference. Along the way, scientists developed medical terminology, labels, and criteria; however, the language they used was often ambiguous (Lev, 2007). Biological determinists attempted to describe gender variant people as somewhere between a man or a woman. In 1868, naturalist Charles Darwin described “latent hermaphroditism,” whereby males and females retained latent aspects of each other, ready to express themselves in certain circumstances (Darwin, 1868; Meyerowitz, 2002, p. 23). In the 1860s, Karl Heinrich Ulrichs, a gay German lawyer fought for homosexual rights based on his belief in the “sex of the soul” or psyche (Meyerowitz, 2002). Echoing Ulrichs, U.S. physician William Lee Howard described a type of “sexual inversion” as “psychical hermaphroditism” in his 1897 case study of “a female soul in a male body” (Bullough, 1987). In 1886, Richard von Krafft-Ebing, a prominent Austro-German psychiatrist who wrote the definitive medical compendium, Psychopathia Sexualis, defined “metamorphosis sexualis paranoica” as “the psychotic belief that one’s body is transforming into the other sex” (Stryker, p.38; Krafft-Ebbing, 1886). Conflicting accounts suggest that Krafft-Ebbing was influential in criminalizing homosexuality, arguing that sex drive was meant for procreation, and any other sexual activities were perverse and pathological, and therefore needed to be caught, isolated and cured
12 (Meyerowitz, 2002); while other accounts suggested Krafft-Ebing “reframed sexual deviations as a ‘disease’ and not a sin, a crime, or decadence” (Lev, 2004, p. 70). The Cercle Hermaphroditos was a collective developed in 1895 that proclaimed “to unite for defense against the world’s bitter persecution” against gender variance, promoting self-identity and self-actualization (Stryker, 2008). A member of the collective, Earl Lind, also known as Jennie June, a self-described “androgyne,” “hermaphrodite,” and “fairy,” wrote two autobiographies, Autobiography of an Androgyne (1918) and The Female Impersonators (1922). In 1897, German physician Magnus Hirschfeld cofounded the Scientific Humanitarian Committee, an international organization devoted to social reform on behalf of sexual minorities (Stryker, p. 39). Hirschfeld, a gay, Jewish cross-dresser (Feinberg, 1996), promoted the social acceptance of human sexuality and gender variance, and fought against the criminalization of sexual and gender variance (Stryker, 2008). In 1899 he coined the term “sexual intermediaries” in the first scientific journal on sexual variants, the Yearbook for Sexual Intermediaries, published from 1899 -1923 which described how every human being represents a unique combination of sex characteristics, secondary sex-linked traits, erotic preferences, psychological inclinations, and culturally acquired habits and practices (Stryker, 2008, p. 39). Using this definition, he combined all aspects of a person’s gender presentation and identity. Between 1897 and 1928, British physician Henry Havelock Ellis wrote extensively about sexuality and gender in his highly influential body of work, The Psychology of Sex, Volumes I-VII. In 1913, he coined the term “sexo-aesthetic inversion,” describing the desire to look like the other sex, and in the 1920s, Ellis used
13 the term “eonism” to describe Chevalier D’eon, a member of the court of Louis XVI who, at various stages of life, lived alternately as a man or a woman (Ellis, 1928/1933; Stryker, 2008). In 1905, German psychiatrist Sigmund Freud described inversion or “psychosexual hermaphroditism” as naturally occurring human sexual and gender variance located in the psyche, rather than a biological predisposition. He acknowledged anatomical bisexuality, but believed this did not explain cross gender behavior or same- sex object choice (Freud, 1905; Meyerowitz, 2002). Freud described the transgender experience as a “gender inversion” related to homosexuality (Freud, 1905). Gender inversion was used to characterize men who were attracted to other men as acting like women, and women who desired women as acting like men (Stryker, 2008, p. 34). As founding members of Freud’s Vienna Psychoanalytic Society in 1908-1911, Hirschfeld and Freud influenced each other’s work on gender variance. In 1910, Hirschfeld wrote the first book-length treatise on transgender experience, entitled The Transvestites: The Erotic Drive to Cross-Dress. Other researchers used different terms, but Hirschfeld’s term “transvestite” to describe people who had the urge to wear clothing of the opposite sex survived contemporary usage (Stryker, 2008, p.38). The term “seelischen transsexualismus”or spiritual transsexualism, was articulated by Hirschfeld in his 1923 paper entitled Die Intersexuelle Konstitution as a form of “inversion” (Meyerowitz, 2002, p. 19). In 1949, David O. Cauldwell, an American physician, surgeon, and neuropsychiatrist used Transsexualism to describe those who identified with the opposite sex (Bullough, 1987; Ekins & King, 2001). In his article Psychopathia Transexualis
14 (1949), Cauldwell wrote that the term “transsexual” referred to "individuals who wish to be members of the sex to which they do not properly belong" (Cauldwell, 1949, p. 275). Cauldwell used the spellings "trans-sexual" and "transsexual" interchangeably, and sometimes he used different terms, such as sex transmutationist, gynecomastia, hermaphrodite, intersexual, and transvestite (Ekins & King, 2001). Prominent American biologist and sexologist Alfred C. Kinsey was avidly interested in researching transvestites and transsexuals (Meyerowitz, 2002). Kinsey (1948, 1953) found enormous human diversity in sexual expression and behavior, raising questions of heterosexual “normalcy” (Lev, 2005). Early medical advances. Advances in medical technology in the 1930s and 40s were accompanied by many successful sex reassignment operations and hormone treatments (Meyerowitz, 2002). Operations would include breast removal or enhancement and genital removal, but genital reconstructions, particularly phalloplasty were not available in the early 1900s. Most advances taking place involved hormone treatment by endocrinologists. In 1919, Hirschfeld and his collaborators opened the Institut für Sexualwissenschaft (Institute for Sexology) in Berlin (Meyerowitz, 2002; Stryker, 2008; Wolf, 1986). A research library and archive, the Institute also included medical, psychological, and ethnological divisions, as well as a marriage and sex counseling office (Wolf, 1986). In 1931, Hirschfeld supervised the operation of Dora Richter, who was one of the first documented male-to-female to receive genital transformation surgery. She remained in the Institute as a domestic worker and demonstration patient (Meyerowitz, 2002;
15 Stryker, 2008). Danish artist Einar Wegener, who later became Lili Elbe, was another of the first individuals reported to undergo a sex change operation (Bullough, 1975; Meyerowitz, 2002). Elbe may have been intersex, and may have had Klinefelter's Syndrome, a condition in which human males have an extra X chromosome (Green, 2004). On May 6, 1933, the Nazis raided and burned the Institute’s archive of more than 10,000 books, articles, and magazines (Meyerowitz, 2002; Stryker, 2008). Hirschfeld died in 1935, but many of his colleagues continued related work in the United States. In 1945, Michael Dillon was the first female-to-male to receive phalloplasty surgery in Britain (Green, 2004; Kennedy, 2007). Little was published about men of trans experience and their SRS. This may have been due to sexism in the medical and mental health care fields, and transmen not being able to afford such surgeries as compared to people with male bodies who lived as cisgender men since they had the most social and financial opportunities. One of Hirschfeld’s most notable colleagues was German physician Harry Benjamin who was interested in endocrinology, also supported the right of transgender people to live their lives as they chose (Stryker, 2008). Benjamin first lectured on transsexualism in 1953 (Ekins & King, 1996, 2001), and his most notable publication, The Transsexual Phenomenon (1966), describes his work with 307 gender variant people in his offices in San Francisco and New York. Benjamin felt that medical interventions should be the main focus in working with transsexuals, with psychotherapy available for additional support through the transition process. He stated that gender specialists should determine whether surgery was appropriate for “true transsexuals,” who he defined as
16 people with early age onset of gender dysphoria, lack of comorbid mental health issues, intensity of desire for body modification, as well as ability to “pass” with conservative sexual and gender presentation (Benjamin, 1966; Lev, 2007). Christine Jorgensen was one of Benjamin’s first 10 patients (Benjamin, 1996; Meyerowitz, 2002). Benjamin did not perform her sexual reassignment surgery (SRS), but monitored her hormone treatment, provided emotional support, and credited her with teaching him about the challenges facing transsexuals (Meyerowitz, 2002). In 1952, when Jorgensen became the most widely publicized individual to undergo a “sex change,” making the New York Daily News headlines as the “Ex-GI Blonde Beauty,” awareness of the existence of gender variance increased throughout the broader population (Meyerowitz, 2002; Stryker, 2008). After Jorgensen’s public debut in 1952, U.S. medical journals began to publish articles on sexual reassignment, including discourse about biological, sociological, and psychological perspectives on sex, gender and sexuality (Meyerowitz, 2002). As psychological perspectives emerged, SRS and other medical interventions began to lose legitimacy in favor of social rehabilitation treatment via long-term analysis and behavior modification with the aim of curing patients’ of their gender variance by conforming to their gender assigned at birth (Meyerowitz, 2002). Medical interventions were perceived as extreme and inappropriate treatments for an inherently psychological problem (Meyerowtiz, 2002). Psychiatrist Joost A. M. Meerloo likened SRS with assisted suicide or a means of collaborating with sexual delusions (Meerloo, 1967; Meyerowitz, 2002). Meerloo described his patients as “borderline psychotics with a deep-seated depression and a psychotic denial of self” (Meerloo, 1967; Meyerowitz, 2002, p. 266). Karl
17 Bowman, psychiatrist at the University of California San Francisco’s Langley Porter Clinic theorized that, “[SRS] plays into the patient’s illusions and does not really solve the problem” (Meyerowitz, 2002, p. 110). Bowman and research associate Bernice Engle (1957) debated various theories, including castration anxiety and conflicts over sexual impulses (Meyerowitz, 2002). John K. Meyer, a psychiatrist at Johns Hopkins Gender Identity Clinic, and his co-author Donna J. Reter, concluded that SRS provided no objective advances or social rehabilitation, and he preferred long-term psychoanalysis for treatment (Meyer & Reter, 1979; Meyerowitz, 2002). Despite opposition among clinicians regarding medical treatment, there were more requests for hormones and SRS from gender variant people in the 1950s and 60s (Denny, 1992). Psychiatrist Richard Green and Psychologist John Money, editors of the seminal text Transsexualism and Sex Reassignment (1969), described how SRS interventions should be performed, while emphasizing reparative psychoanalysis throughout the process. Mid-20th century psychological perspectives on gender variance. The psychological theories of sexual and gender variance developed in the mid-20th century were later used to justify diagnostic categorization and “reparative” treatments. Rather than perceiving the diversity of human sexuality and gender (Freud, 1905/1914/1937; Kinsey, 1948, 1953), many of Freud’s contemporaries argued that the etiology of gender identity “problems” stemmed from inappropriate rearing in childhood (Bak, 1968; Green & Money, 1969; Greenson, 1964, 1966; Money, 1971; Stoller, 1964, 1968, 1971; Ovesey & Person, 1973). These mid-20th century psychologists and psychiatrists sought to correct gender and sexual variance through the talking cure and behavioral modification
18 (Meyerowitz, 2002). Eventually, many of these theories took root and justified pathologizing gender variance by psychiatrists, a practice which continues in their criteria (APA, 2000). Mid-century physicians, psychiatrists and psychologists who described themselves as gender specialists were generally white men who never identified with gender variance, and diagnosed “sexual deviations,” including hermaphroditism, pseudohermaphroditism, transvestism, homosexuality, fetishism, and exhibitionism under the category “Sociopathic Personality Disturbance” in the American Psychiatric Association’s first Diagnostic and Statistical Manual for Mental Disorders (DSM) (APA, 1952; Meyerowitz, 2002). This diagnostic category did not adequately address the needs of transsexuals, so psychological theories were devised to distinguish transvestism and homosexuality from transsexuality. At the time, gays and many gender non-conforming people who were diagnosed with homosexuality were being “cured” through institutionalization, castration, sterilization and lobotomies (Davis, 2010). California’s Atascadero State Hospital became known as “the Dachau for queers” (Davis, 2010). The California Sex Deviates Research Act of 1950 was created to discover the causes and cures of homosexuality, including administering hormones and castrating male sex offenders in CA prisons to see whether this altered their sexual behavior (Stryker, 2008). These reparative treatments towards gay and transvestite-identified people set the precedent for further psychological theories and treatments for all sexual and gender variant individuals. Transsexualism was described by mid-20th century psychologists as a mental illness, suggesting that the desire to change sex was caused by repressed or denied
19 homosexuality, perversion, masochism, neurosis, psychosis, character or personality disorder, or by brain trauma (Denny, 2004). Physician Robert Bak (1968) argued that most transsexuals “showed a preponderance of obsessional symptoms, impulsive character structures, and borderline personalities.” Bak, and his colleague Robert J. Stoller, connected the concept of perversion with psychotic process, suggesting that a mentally stable person would not identify with a gender other than the one they were assigned to at birth (Bak, 1968; Stoller, 1971). However they also noted that a transsexual is as likely to be psychotic as anyone in the general population (Bak, 1968; Stoller, 1971). In differentiating transvestites from transsexuals, sexologists claimed that transvestites were sexually aroused by cross-dressing using women’s clothing as sexual fetishes, while transsexuals were perceived to be asexual (Green & Money, 1969; Stoller, 1971). Most gender specialists struggled to understand transsexualism with little data from a few patients who identified as transsexual, and most, if not all of whom were male-to-female (MTF) transsexual women or trans women. Transsexual women were thought to be asexual, a perception stemming from the sexist stereotypes that good girls and women were shy and sexually immature, if not virginal (Green & Money, 1969; Stoller, 1971). Psychiatrist Mortimer Ostow described Jorgensen as having “a neurotic aversion” to sexual contact; psychiatrist George H. Wiedeman suggested that she had “features of fetishism, homosexuality, exhibitionism and masochism,” and perhaps an “underlying schizophrenic process” (Meyerowitz, 2002, p. 106). In 1957, psychiatrist Karl M. Bowman and research associate Bernice Engle at the University of California
20 San Francisco’s Langley Porter Clinic defined a transsexual as “the person who hates his own sex organs and craves sexual metamorphosis” (Meyerowitz, 2002, p. 110). The etiology of transsexual developmental stages and psychodynamic relationships with caregivers was explored in 1971 by Robert J. Stoller, psychiatrist and professor at the University of California at Los Angeles. Stoller refers to gender identity as “…one’s self-image as regards to belonging to a specific sex” (Stoller, 1964, p. 220). He theorized that children know their core gender identity by the time they are 2 or 3 years of age, and the remaining gender role development comes from parental reinforcement of their perception of the child’s gender identity (Stoller, 1971). Stoller considered Benjamin’s theories that gender identity was biologically driven (Benjamin, 1966), but he suggested that gender identity was predominantly shaped by child rearing (Stoller, 1964/1968). For most transsexual males, Stoller noted that child rearing typically included a “pathologically intense symbiosis” with a mother who was masculine or bisexual, and a father who was weak or absent (Stoller, 1964/1968). In this context, “bisexual” refers to embodying both the physical masculine and feminine gender traits, as well as playing roles deemed to belong to men and women (Money, 1971; Stoller, 1971). Stoller (1971) emphasized that the inappropriate playing out of these gender roles by the parents produced gender ambiguity in children. The case example provided by Stoller (1968) showed the bisexual mother behaving like a man or the child’s father, which Stoller proposes is what caused the child’s transvestism or transsexuality. Ralph R. Greenson (1964, 1966) suggested the importance of identifying and addressing the
21 issue of transsexualism during childhood if only to prevent homosexuality, which was considered an even more serious problem. Physician Robert Bak (1968) argued that the etiology and defensive positioning of transsexuals stemmed from the childhood identification with the phallic mother who was masculine or bisexual, and represented a perverted denial of the castration complex. He added that the psychological core of a mother’s bisexual identification was the revival of the her primal fantasy of having a penis (Bak, 1968). Bak goes on to explain that her children would become perverted by their “… mother’s ‘uncertain’ sexual identity- ‘penis or no penis’” and thus producing the child’s paraphilia (Bak, 1968, p. 21). American psychoanalysts Lionel Ovesey and Ethel S. Person (1973) attempted to distinguish between core gender identity, whereby a child begins to identify with their gender at approximately three years of age; and their gender role identity, whereby the individual identifies more with their masculinity or femininity into adulthood and throughout life. They stated that dependency is the “nuclear conflict” or central issue in the major gender disorders, again emphasizing unhealthy development and improper rearing (Ovesey & Person, 1973). These developmental theories were the basis of a research-practitioner model used in U.S. and Canadian gender identity clinics. Because the research designs were based upon the theories that incorporated assumptions about the genetic causes and pathological nature of transsexualism, the results were often devastating for gender variant participants, many of whom were turned away without access to hormones or surgery (Denny, 1992).
22 University-affiliated gender identity clinics. More than 40 gender identity research clinics, predominantly university-based, opened in the 1960s in the U.S. and Canada. The first three were located at Johns Hopkins University, the University of Minnesota, and the University of California at Los Angeles, with clinics subsequently opened at Vanderbilt University, the University of Virginia, Stanford University, and Duke University, among others (for a critical examination of the clinics, see Denny, 1992). These clinics assessed patients, and depending on the outcome, offered hormones and SRS. Within a few years of opening, all but one of the clinics closed, due in large part to the mistreatment of participants by untrained clinicians producing flawed research (Denny, 1992). Despite their many flaws, the clinics legitimized the surgical treatment of transsexual people (Denny, 1992). The successful clinic at the University of Minnesota continues to provide ethically sound research, education, and advocacy for transgender and gender non-conforming people (Bockting et al, 2004). The gender identity clinics’ research involved extensive case-by-case analysis by a treatment team that reviewed participants’ results from the admission criteria and procedures. The Case Western Reserve Gender Identity Clinic provided a typical admissions criteria for most clinics, which included at least one full battery of psychological testing, extensive clinical interviews of patients, their partners and family, payment of evaluation fees (based on a sliding scale), and long-term individual and group psychotherapy (Denny, 1992). If all the requirements were met, the treatment team would decide whether the participant was eligible for hormones and surgery; if so, the participant would be required to complete extensive follow-up tests, procedures and psychotherapy (Denny, 1992).
23 Most “experts” in the field were inexperienced and untrained in transsexualism, yet they were instrumental in designing and implementing the research based on arbitrary selection criteria (Denny, 1992). Most applicants were rejected for a variety of reasons, including age, sexual orientation, marital status, occupational choice, and inability to pass well enough in their new gender role (Denny, 1992). For example, Kessler and McKenna (1978) reported that a colleague admitted that his selection process for SRS was based on sexual feelings evoked in him by his transsexual patients who were subsequently described to be “attractive” and “passing well” (Denny, 2004; Kessler & McKenna, 1978). Applicants were expected to become well-adjusted, attractive, heterosexual graduates (Denny, 2004). In alignment with gender conservatism at the time (Broverman et al, 1972), clinicians sought to instill in their clients the notion of a rigid gender male- female binary that adhered only to heterosexual practices (Stryker, 2008); only the most extreme masculine and feminine presentations were acceptable (Bolin, 1988; Denny, 1992). Candidates for SRS were savvy in reading the medical literature which described clinicians’ criteria of expected responses, behavior, and presentation (Denny, 1992 & 2004; Ophelian, 2009). These criteria were initially outlined in Benjamin’s compendium (1966) regarding the “true transsexual” who was deemed appropriate for SRS (Denny, 1992 & 2004). The criteria included the typical story of the origin of their transsexualism from childhood, with feelings of having been “trapped in the wrong body,” and experiencing a psychic pain that could only be treated by body modification (Denny, 1992 & 2004).
24 The case of David Reimer illustrates the harm and suffering these clinics and their presumed experts had on many participants. The case serves as a reminder of the potentially damaging effects of clinicians’ cultural and moral biases on practice and research (Bess, 2006; Colapinto, 2000, 2004; Denny, 1992), and how crucial it is for providers to de-emphasize passing, and support clients’ needs over that of the researchers’ objectives. In 1966, Reimer’s penis was irreparably damaged in a botched circumcision procedure conducted in a hospital when he was 8-months old. In 1967, his parents sought the help of psycho-biologist John Money and his team at the Johns Hopkins Clinic, and were told that nothing could be done to restore their son’s penis (Green, 2004). Reimer’s parents were told he could not possibly live a satisfying life as a man without a penis, but that he could be made into a girl and still be able to have heterosexual sex, though would not be able to bear children. The case study of Bruce and Brian Reimer began in their first year of life and continued through puberty (Colapinto, 2000). Brian continued to be raised as a boy, while Bruce was surgically castrated and raised as Brenda (Colapinto, 2000). Throughout her development, however, Brenda rejected anything feminine and did not adjust to her social role and had terrible problems in school. During her adolescence, Brenda became depressed and refused further surgical procedures, hormones and psychotherapy. The family refused to continue treatment in 1979, after the children were reportedly encouraged by Money to masturbate in front of the doctors to demonstrate their psychosexual development (Colapinto, 2000). Later that same year, the clinic stopped providing SRS treatment services. In 1980, at 15 years of age, after being told the truth about his birth, Brenda changed her name to David and decided to live as male.
25 Green (2004) examined and reflected on how Reimer’s case is often conflated with intersex issues and experience. This may be because Money published research on intersex conditions and the impact of parental and social influence on gender identity development, and was considered an expert on intersex conditions and gender reassignment. Money studied the Reimer twins in order to prove the theory that a person’s gender identity, or sense of their own gender is primarily socialized and not necessarily related to biological aspects. In 1997, Milton Diamond and Keith Sigmundson published the John/Joan case based on the case of Bruce/Brenda to promote socialization without SRS for intersex children. David was not intersexed, nor did he identify as transgender, but there are parallels between his story and the issues people with trans and intersex identities face, including the ethical right to informed consent, medical status and history, the right to be free of surgeries imposed by others, and that their anatomy not be discussed as abnormal or “inadequate” as compared to bodies that have reproductive capabilities (Green, 2004). However, some providers regard intersex- related surgeries as “corrective,” and transgender-related gender affirming surgeries as “mutilation” (Green, 2004). Once David Reimer was allowed to express his gender, similarities arose between his treatment and that of men of trans experiences, including being treated with testosterone, offered phalloplasty for penis construction, and living his life continually aware that his body was different than those of other men. (Green, 2004). Similar to the mistreatment trans people have had to face by psychological and medical providers, David “had to deal with the collective family stress of the slowly unraveling social experiment of which they were all victims” (Green, 2004, p.204). In 2000, David Reimer
26 collaborated with John Colapinto in their widely publicized book about David’s life, As Nature Made Him: The Boy Who was Raised as a Girl. In 2004, David committed suicide following his divorce from his wife and his brother’s death two years earlier (Colapinto, 2004). The hardship that may have led to David’s eventual suicide was due to having to endure unethical treatment by physicians and psychologists who sexually harassed him, lied to him, and treated him as an experiment rather than respectfully regard his right to self-determine his gender identity and body presentation. In a more recent study of over 6,000 transgender and gender non-conforming participants, 41% reported that they had attempted suicide (Grant et al, 2011). Many researchers and advocates recognize that transgender patients are among the most socially stigmatized of sexual minorities who face discrimination in health care coverage and insensitivity from ill-informed health providers (Bockting et al, 2004). In an effort to remedy the sordid past of many of the gender clinics, and the transphobia in treatment centers and hospitals, the University of Minnesota has incorporated quality controls, including direct accounts of patient satisfaction with services (Bockting et al, 2004). Psychologist Walter Bockting and his research team in the Program in Human Sexuality, Department of Family Practice and Community Health, University of Minnesota reported on patient satisfaction surveys conducted from 1993- 2003 of 180 transgender and 837 other sexual health patients (Bockting et al, 2004). Bockting recognized the difficulty in achieving patient satisfaction when mental health professionals are the primary gatekeepers regarding access to sex reassignment procedures. They found that in the face of this barrier, satisfaction was achieved when
27 providers were non-judgmental and open to honest responses. Transgender and gender non-conforming participants appreciated providers who de-emphasized passing, and supported clients’ needs over that of the researchers’ objectives. While completing the survey and during service delivery in general, Bockting (2004) found that many of the clinic’s transgender patients strongly advocated for self-determination and challenged the traditionally passive patient role. Bockting (2004) reported that a shift in patient care occurred in the 1980s with attention to the treatment of co-existing psychological problems often compounded by living with a stigmatized identity. “In the 1990s,” Bockting noted, “…the paradigm shifted between helping individuals to adjust within the two binary options of male versus female toward fostering coming out as a transgender person as patients more openly affirmed their unique gender identities in the context of a gender-diverse, increasingly visible transgender community.” Mid-20th century transgender advocates. In the mid- 20th century, a few prominent transsexual and transgender advocates created social networks with doctors and other professionals in order to advocate for issues of profound importance to transgender people (Stryker, 2008). These networks provided doctor and patient referrals, as well as participant recruitment and funding for research programs. In the 1940s, Louise Lawrence, a transgender community organizer in San Francisco, formed a worldwide network of transgender people, and frequently lectured on transgender topics at the University of California at San Francisco (UCSF) (Stryker, 2008). She corresponded with biologist and sexologist Alfred C. Kinsey regarding her extensive knowledge of transsexual medical history, and Kinsey introduced her to
28 Benjamin (Meyerowitz, 2002). Through Lawrence, Kinsey and psychiatrist Karl Bowman met in 1949 to discuss Benjamin’s work (Stryker, 2008). Lawrence met with Jorgensen, and hosted many transgender friends and acquaintances who sought her counsel and referrals for treating doctors (Meyerowitz, 2002). In 1942, she met and mentored Virginia Prince, another transgender advocate who was studying pharmacology at UCSF. In the 1940s and 50s, Virginia Prince, a transgender woman with a Ph.D. in biochemistry based in Los Angeles, began to advocate on behalf of herself and other transgender people who were not interested in pursuing SRS (Meyerowitz, 2002; Stryker, 2008). In the 1960s, Prince opened the Hose and Heels Club and was founder and editor of Transvestia magazine (Lev, 2007). In the late 1960s, she began living full time as a woman (Stryker, 2008). Prince was influential in Benjamin’s treatise, The Transsexual Phenomenon, particularly regarding the affirmation of transvestitism as a legitimate gender presentation and downplaying the overt sexualization of transvestites (Benjamin, 1966; Lev, 2007). Prince is most noted, however, for coining the term “transgenderist” which distinguished transvestites from transsexuals; she later modified the word to “transgender” (JoAnne Keatley, UCSF Transgender Health Conference, April 2011; Feinberg, 1996, Lev, 2007). Decades following her 1952 public debut, Christine Jorgensen continued to promote herself and advocate for transsexual people through her autobiography, Christine Jorgensen: A Personal Autobiography (1967), book signings, live stage shows, and the film The Christine Jorgenson Story (1970) (Jorgensen, 1967; Meyerowitz, 2002; Stryker, 2008). Although she never considered herself a political activist, Jorgenson’s life and
29 work educated the general public and provided hope for many struggling transsexuals (Meyerowitz, 2002; Stryker, 2008). Reed Erickson, a wealthy FTM transsexual, founded the Erickson Educational Foundation in 1964, an organization promoting research and education on transsexuality (Meyerowitz, 2002). Erickson funded three years of Benjamin’s research (Benjamin, 1966; Meyerowitz, 2002), which was critical because Benjamin struggled to secure grants to fund SRS research, considered a taboo medical intervention (Meyerowitz, 2002). The Erickson Education Foundation also funded research at the Johns Hopkins Gender Identity Clinic (Lev, 2007). These transgender advocates and their networks laid the groundwork for many transgender organizations including Conversion Our Goal, the National Gender-Sexual Identification Council, Street Transvestite Action Revolutionaries or STAR House, the Queen’s Liberation Front, Transsexual Activist Organization, and the Transexual Counseling Service which used one “s” to distinguish from the medical term transsexual (Lev, 2007; Stryker, 2008). Their connections with gender specialists provided support for research and medical care, as well as efforts to de-pathologize gender variance (Lev, 2007; Meyerowitz, 2002; Stryker, 2008). Street queens and grassroots activism. While middle class transgender advocates wielded their influence to effect change in the medical establishment, uprisings in the streets by transgender youth protested police brutality, and legally sanctioned racism and transphobia in all areas of service provision, including access to health care and other basic human rights (for historical accounts, see Feinberg, 1996; Meyerowitz, 2002; Stryker, 2008). Often targeted and brutalized by the police, street queens have
30 been on the front lines and the first to rise up against the paradigm of the gender binary and fight for basic human rights of housing, employment, medical treatment and the right to live free of discrimination, harassment, violence and stigmatizing diagnoses. Access to proper health care, job equality, and diagnostic reform would not exist had street queens not demanded recognition and fair treatment. Their direct actions inspired collaborations among transgender activists, their health care providers, and police. The first transgender organizations united to provide social support and share resources, as well as to demand civil rights for transsexuals, transvestites, and gender non-conforming people nationally and internationally. The following section describes the uprisings and the transgender activists who formed the first transgender organizations. Spontaneous protests erupted following brutal treatment of transgender people by police who routinely raided bars and diners to humiliate, harass, and incarcerate trans patrons on suspicion of prostitution, vagrancy, or loitering (Stryker, 2008). The first collective resistance occurred in May 1959 at Cooper’s Donuts in Los Angeles when police entered the coffee shop to arbitrarily arrest drag queen patrons, and the other customers decided to resist en masse (Stryker, 2008). Fighting extended into the streets, and many people who were arrested escaped being loaded into the police paddy wagons (Stryker, 2008). The first organized civil disobedience took place in Philadelphia on April 25, 1965 at Dewey’s lunch counter where more than 150 patrons staged a sit-in, but were turned away by the management and three teenagers refused to leave (Stryker, 2008). Activists picketed and arranged a sit-in on May 2 and police were called in, but no arrests were made, and indiscriminate denials of service ceased (Stryker, 2008).
31 Historian Susan Stryker directed and produced the documentary Screaming Queens (2005), based on the protest in 1966 when patrons of Compton’s Cafeteria in San Francisco rioted against police and destroyed a squad car (Stryker, 2005 & 2008). Tamara Ching, a transgender activist involved in the riot, reported that after the protest, police stopped harassing transgender people on the streets of the Tenderloin District where Compton’s was located (Stryker, 2005). After transgender activist Louis Ergestrasse introduced police sergeant Elliot Blackstone to Harry Benjamin’s Transsexual Phenomenon, Blackstone took a leading role in changing police treatment of transgender people (Stryker, 2008, p. 75). He asked Dr. Joel Fort at the Center for Special Problems, a radical enclave of the San Francisco Department of Public Health, to provide services for transsexuals (Meyerowitz, 2002). Dr. Joel Fort worked with Benjamin and his patient transgender activist Wendy Kohler, who formed the first transgender support group, “Conversion Our Goal,” and the National Gender-Sexual Identification Council (Meyerowtiz, 2002; Stryker, 2008). Blackstone supported Kohler and her group which met in Glide Memorial Church, an organization dedicated to providing social services and health care for transient and diverse populations. Kate Davis and David Heilbroner directed the documentary film Stonewall Uprising (2010) which describes the three days of rioting against police at the Stonewall Inn bar in New York City’s Greenwich Village in June 1969. This action resulted in increased community organizing. A shift occurred in gay activism in which it veered away from attempts to mainstream with straight, gender binary dominant culture. Drag queens, hustlers, gender non-conformists, gay men, lesbians and counterculture youth started to collaborate with the provision of food, clothing and shelter, as well as to
32 advocate for civil rights for transgender people. In 1970, veterans of the Stonewall Uprising, Sylvia Rivera and Marsha P. Johnson, established Street Transvestite Action Revolutionaries or STAR House, providing care for African American and Latino transgender youth. Lee Brewster and Bunny Eisenhower founded the Queen’s Liberation Front which instituted the commemoration of the Stonewall Uprising each June, now known as Pride celebrations for LGBTIQQ people. In 1970 Angela K. Douglas formed the first international transgender organization, Transsexual Activist Organization, with chapters in seven cities across the U.S. as well as in Canada, England, and Northern Ireland. Douglas deplored the pathologization of gender variance and fought for institutional reform. In 1973, the Transexual Counseling Service was formed and used one “s” to distinguish from the medical term transsexual. The uprisings at Cooper’s Donuts, Dewey’s, Compton’s Cafeteria, and the Stonewall Inn paved the way for street queens and other transgender activists to organize and effect a reduction in police harassment and brutality, eventual policy change, as well as improved quality of health care. Although more medical doctors began advocating for their clients, others were still inclined to hold firmly to the medicalization and pathologization of transgender people. Development of standards of care. In 1979 the Harry Benjamin International Gender Dysphoria Association (HBIGDA), a group of therapists and physicians, designed guidelines for hormonal and surgical sex assignment procedures and psychotherapeutic interventions described in their Standards of Care (SOC). These guidelines were developed in order to improve health services for transsexual and transgender people (Fraser, 2009). Throughout the next three decades, six additional versions of the
33 guidelines were published with the seventh most recent version released in 2011. The name of the HBIGDA changed to the World Professional Association for Transgender Health (WPATH) in 2006, and was ratified by the members in 2009. The original HBIGDA SOC for Gender Identity Disorders were approved at the 6th International Gender Dysphoria Symposium in San Diego, California (1979). Although the guidelines referred to hormonal and sex reassignment, psychotherapeutic interventions were also included in SRS service provision. The first four versions of the SOC (1979, 1980, 1981, and 1990) focused treatment on behavioral intervention, with the possibility of referrals for hormones and surgery. Psychotherapy was required for approval of hormones and surgery, and thus interventions focused primarily on evaluation and referral. Psychotherapy was required throughout the process and following SRS. Although the SOC were intended to respond to the needs of transsexual clients, controversy about the Standards focused on the role of psychotherapists as gatekeepers providing access to SRS via letters of recommendation with a diagnosis (Bockting et al, 2004; Denny, 2004; Fraser, 2009; Lev, 2005). After the American Psychiatric Association developed an official diagnostic nomenclature for gender variance distinct from transvestitism in the third edition of the DSM published in 1980 (APA, 1980; Meyer et al, 2001), subsequent versions of the SOC included diagnoses in recommendation letters written by mental health providers for SRS. Although the diagnosis and letter were (and still are) advised in the SOC, the HBIGDA recognized that assigning a specified amount of psychotherapy negatively impacted the therapeutic alliance. Thus, the HBIGDA removed psychotherapy as a requirement, but highly recommended it in the 5th and 6th versions (1998 and 2001,
34 respectively) (Fraser, 2009; Levine et al, 1998; Meyer et al, 2001). Psychotherapy guidelines included in the 5th and 6th SOC emphasize the importance of a strong therapeutic alliance, recognition of patients’ autonomy, and support of multiple options for gender adaptation (Fraser, 2009; Levine et al, 1998; Meyer et al, 2001). The SOC began to acknowledge that a person can never completely eradicate aspects of their original sex assignment (Fraser, 2009). Rather than emphasize passing as male or female, transgender people were, in this way, understood with “…the whole of the person’s complexity… the goals of therapy are to help the person live more comfortably within a gender identity and to deal effectively with non-gender issues” (Meyer et al., 2001, p.12). The HBIGDA changed its name to the World Professional Association for Transgender Health (WPATH) in 2006 at a board retreat (Fraser, 2009). According to the 2006 board minutes, the new name incorporated the new vision and mission statements: “As an international multidisciplinary professional association, the mission of HBIGDA, (now WPATH), is to promote evidence-based care, education, research, advocacy, public policy and respect in transgender health” (Meyer et al, 2001). With this name change, WPATH began to acknowledge shifting cultural gender paradigms in international medical and psychotherapeutic practice (Fraser, 2009). Eli Coleman, former HBIGDA president, addressed this issue with the HBIGDA in 2003: “…there has been a significant paradigm shift in how we have treated transgendered persons…” (Fraser, 2009). He presented his Ten Steps to Promote Transgender Health: 1) Promote sexual health including elimination of the barriers to sexual health, 2) Learn from other cultures, 3) Let old paradigms die and new ones emerge, 4) Provide access to
35 optimal care, 5) Provide training to allied health professionals, 6) Provide sound and ethical research, 7) End discrimination and stigma, 8) Change laws and public policies, 9) Change religious views, and 10) Promote social tolerance for diversity. WPATH included transgender in the title for “a better representation of our membership and to confirm that full membership is for professionally trained people who work with trans-patients or clients” (Fraser, 2009). WPATH’s new vision incorporated Coleman’s Ten Steps, and sought to ally with the World Health Organization definition of health as stated in the preamble to their constitution (1949): “…a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (Fraser, 2009).” Intending to steer away from pathologizing gender variance, WPATH presented the new vision of a multidisciplinary approach to care that promoted “…education, advocacy, training, research, quality health care and best practice standards for service providers and policy makers regarding gender variant individuals” (WPATH, board minutes, 2006 as cited by Fraser, 2009). The 7th version of the SOC in press ten years later in September 2011 was a departure from subsequent versions, particularly with regard to respecting gender fluidity. The new SOC states that gender variance is “…a common and cultural-diverse phenomenon that should not be judged as inherently pathological or negative” (Coleman, et al, 2011, p. 4), and that discrimination and stigmatization are directly associated with pathologization. Mental health care providers are urged “… to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment” (Coleman et al, 2011, p. 1).
36 The SOC emphasizes that providers should not impose a binary view of gender, and that the practice of trying to change a person’s gender to become more congruent with the sex assigned at birth is no longer ethical. Despite the proclamations against pathologization, the SOC continue to promote diagnostic nomenclature in the DSM-5. WPATH proposed the term “Gender Dysphoria” to replace “Gender Identity Disorder” in the 5th version (Coleman et al, 2011). Rather than using the terms intersex or intersexuality, WPATH suggests using the term “Disorder of Sex Development (DSD),” which is controversial to intersex individuals who strongly object to the naming of their identity as a disorder (Coleman et al, 2011). There are still some contributors to the SOC and the DSM who continue to resist the de-pathologization of gender variance. However, WPATH and updated versions of the SOC for transsexual, transgender and gender-nonconforming people continue to shift in positive ways, particularly as more transgender people and their allies direct the course of health care. Gender diagnoses in the Diagnostic and Statistical Manual of Mental Disorders. There are four versions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), with three revisions (APA, 1952, 1968, 1975, 1980, 1987, 1994, 2000). Between versions and revisions, gender diagnoses were listed under different categories with varied numeric coding. In the first edition of the DSM (1952), under the diagnostic category of Sociopathic Personality Disturbance (000-x60) a diagnosis of Sexual Deviations (000- x63) included:
37 … Most of the cases formerly classed as ‘psychopathic personality with pathologic sexuality.’ This diagnosis will specify the type of pathologic behavior, such as homosexuality, transvestism, pedophilia, fetishism, and sexual sadism (including rape, sexual assault, mutilation). (APA, 1952, p. 39) In the second edition of the DSM (1968), the category Personality Disorders and Certain Other Non-Psychotic Mental Disorders maintained the same subcategory of Sexual Deviations, which includes 302.3 Transvestitism, with a change of spelling, 302.8 Other sexual deviation, and 302.9 Unspecified sexual deviation. This subcategory was described as: For individuals whose sexual interests [were] directed primarily towards objects other than people of the opposite sex, toward sexual acts not usually associated with coitus, or toward coitus performed under bizarre circumstances as in necrophilia, pedophilia, sexual sadism, and fetishism. Even though many [found] their practices distasteful, they remain unable to substitute normal sexual behavior for them. (APA, 1952, p.44) Transsexuals and intersex individuals were presumably subsumed in the Other or Unspecifed sexual deviation diagnoses, however, no clarifications were made regarding diagnoses for gender variance. Homosexuality was listed as a disorder, but removed in the DSM nosology in 1973 by the APA, and replaced with Sexual Orientation Disturbance. In the third edition of the DSM (1980), the category Psychosexual Disorders included three new diagnoses: 302.5x Transsexualism, 302.60 Gender Identity Disorder of Childhood, and 302.85 Atypical Gender Identity Disorder. Transsexualism was defined as “a persistent sense of discomfort and inappropriateness about one’s anatomic sex and a persistent wish to be rid of one’s genitals and to live as a member of the other sex” (APA, 1980, p. 261-2). Transsexualism also included sexual orientation subtypes: 0= unspecified, 1= asexual, 2= homosexual, and 3= heterosexual. Doctors would refer
38 these designations based on patients’ sex assigned at birth, not on the gender with which they identified. In the revised third edition of the DSM (1987), three new diagnoses were added, as well as a new diagnostic category. Two of the new diagnoses—302.85 Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type (GIDAANT), and 302.85 Gender Identity Disorder Not Otherwise Specified (GID NOS) – shared the same coding, and were included in Disorders Usually First Evident in Infancy, Childhood, or Adolescence. The third new diagnosis, 302.30 Transvestic Fetishism, was the only remaining gender-related diagnosis in the Psychosexual Disorders category, and listed in the Paraphilia subcategory. Diagnostic criteria for GID NOS included people with intersex conditions. The essential feature of Transvestic Fetishism was described as “recurrent, intense, sexual urges and sexually arousing fantasies, of at least six months’ duration, involving cross-dressing” (APA, 1987, p. 288). This disorder was used primarily to describe heterosexual males who may have engaged in homosexual activities. In the fourth edition of the DSM (1994), a new category of Sexual and Gender Identity Disorders included two subcategories: Gender Identity Disorders and Paraphilias. GID NOS is listed under Gender Identity Disorders, in addition to the two revised diagnoses of 302.xx GID in 302.85 Adults and Adolescents, and 302.6 GID in Children. Transvestic Fetishism continued to be listed under the Paraphilia subcategory, and specify if With Gender Dysphoria. DSM-IV also described the possibility for a concurrent diagnosis of GID and Transvestic Fetishism.
39 There were no changes in categorizations or diagnoses in the revised edition of the DSM-IV (2000) [see Appendix F for full diagnostic criteria]. Autogynephilia was included as an associated feature of Transvestic Fetishism, with subtypes based on sexual orientation and arousal. Autogynephilia is described as a phenomenon in males “who experience sexual arousal produced by the accompanying thought or image of themselves as females” (APA, 2000, p.574). DSM-V proposes that the GID diagnosis change to Gender Dysphoria, defined as “a marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration” (APA, www.DSM5.org). This includes the subtypes with or without the “Disorder of Sex Development,” which may indicate the person’s intersexuality. Also specified is “Post-transition,” indicating whether the person “… has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is undergoing) at least one cross-sex medical procedure or treatment regimen, namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in a natal male, mastectomy, phalloplasty in a natal female)” (APA, 2012). In the Paraphilia subcategory, Transvestic Fetishism may be revised in DSM-V to Transvestic Disorder, defined as a “…recurrent and intense sexual arousal from cross- dressing, as manifested by fantasies, urges, or behaviors.” Clinicians can subsequently, specify “With Fetishism (Sexually Aroused by Fabrics, Materials, or Garments),” or “With Autogynephilia (Sexually Aroused by Thought or Image of Self as Female),” or “With Autoandrophilia (Sexually Aroused by Thought or Image of Self as Male). Final specifiers include “In Remission (No Distress, Impairment, or Recurring Behavior and in
40 an Uncontrolled Environment)” with time of duration, and “In a Controlled Environment.” The diagnostic rationale in the DSM neglects to explain the final specifiers. The American Psychiatric Association’s DSM criteria including gender diagnoses are used by most mental health providers in the United States. Often diagnoses are necessary in order for patients to receive medical benefits including gender realignment surgeries (Green & Wilson, 2012), but providers are urging other providers to use caution when using diagnoses, and avoid pathologizing gender and sexual variance (Coleman et al, 2011). Internationally, gender and sexual variance has been classified in the International Classification of Diseases discussed in the next section. Gender diagnoses in the International Classification of Diseases. WHO assumed leadership of the ICD in 1948 (Jette et al, 2010). The DSM was influenced by the World Health Organization’s diagnostic nomenclature in the International Classification of Diseases (ICD) (APA, 1968). In conjunction with the DSM, the U.S. National Center for Health Statistics (NCHS) developed its own clinical modification (CM) to the ICD (NCHS, 1999; WHO, 1992). The Sexual Deviation classification was introduced to the ICD-6 (1948), and was later included in the DSM-I in 1952 (APA, 1952; Reiersøl & Skeid , 2006). In the fifth chapter of the ICD-10 “Mental and Behavioral Disorders” the classification of Gender Identity Disorders, (coded as F64) is listed under the Disorders of Adult Personality and Behavior, (F60-69). This subcategory includes Transsexualism (F64) described as:
41 A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one's anatomic sex, and a wish to have surgery and hormonal treatment to make one's body as congruent as possible with one's preferred sex. (WHO, 1992, p.215) The diagnosis Dual-role Transvestism (F64.1) is described as: The wearing of clothes of the opposite sex for part of the individual's existence in order to enjoy the temporary experience of membership of the opposite sex, but without any desire for a more permanent sex change or associated surgical reassignment, and without sexual excitement accompanying the cross-dressing. (WHO, 1992, p.215) The diagnosis Gender Identity Disorder of Childhood (F64.2) is described as: A disorder, usually first manifest during early childhood (and always well before puberty), characterized by a persistent and intense distress about assigned sex, together with a desire to be (or insistence that one is) of the other sex. There is a persistent preoccupation with the dress and activities of the opposite sex and repudiation of the individual's own sex. The diagnosis requires a profound disturbance of the normal gender identity; mere tomboyishness in girls or girlish behaviour in boys is not sufficient. Gender identity disorders in individuals who have reached or are entering puberty should not be classified here but in F66. (WHO, 1992, p. 215-216) The diagnosis Sexual Maturation Disorder (F66) is described as: The patient suffers from uncertainty about his or her gender identity or sexual orientation, which causes anxiety or depression. Most commonly this occurs in adolescents who are not certain whether they are homosexual, heterosexual or bisexual in orientation, or in individuals who, after a period of apparently stable sexual orientation (often within a longstanding relationship), find that their sexual orientation is changing. (WHO, 1992, p. 221) The Gender Identity Disorders subcatory includes (without description) Other gender Identity Disorders (F64.8), and Gender Identity Disorder Unspecified (F64.9). Listed under the subcategory Disorders of Sexual Preference (F65) is the diagnosis Fetishistic Transvestism (F65.1) described as:
42 The wearing of clothes of the opposite sex principally to obtain sexual excitement. Fetishistic transvestism is distinguished from transsexual transvestism by its clear association with sexual arousal and the strong desire to remove the clothing once orgasm occurs and sexual arousal declines. A history of fetishistic transvestism is commonly reported as an earlier phase by transsexuals and probably represents a stage in the development of transsexualism in such cases. (WHO, 1992, p.218) The classification of diseases and disorders in the World Health Organization’s ICD mirrors much of the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders. Although there have been suggestions to universalize a diagnostic manual internationally, other countries have come up with their own classifications which incorporate the nuances of their cultural experiences of psychopathology (Paoin et al, 2009). Gender diagnostic reform. For more than three decades, medical and psychological practitioners have worked with the gender diagnoses in the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM). The controversy related to Gender Identity Disorder (GID) reform in both texts involves multifaceted viewpoints from within the transgender human rights movement, and psycho-medical communities. Arguments focus on whether to include or remove the gender diagnoses. Physicians, psychiatrists, psychologists, and legal reform advocates of the World Professional Association for Transgender Health (WPATH) who are in favor of including GID in the ICD and DSM, maintain that the diagnosis serves those who suffer from gender dyphoria, and legitimizes hormones and SRS for legal and policy reform including insurance coverage (Coleman et al, 2011). Insurance companies rarely cover SRS or hormone treatments (Stryker, 2008); however some state and national health
43 programs provide coverage for individuals diagnosed with GID (Green & Wilson, 2012). Ironically, health providers will continue to be untrained in schools until insurance will reimburse for it (Green, 2012, personal communication). Discussions regarding the DSM-V suggested revisions, include changing the terminology to be less stigmatizing of gender variance, or changing the diagnosis to a medical condition. Suggested terminology include: gender dysphoria (Coleman et al, 2011); gender dissonance (Winters, 2005); gender incongruity (Rochman, 2007); and Gender Expression Deprivation Anxiety Disorder, or GEDAD (Vitale, 2005). Vitale (2005) suggests removing GID listing GEDAD under Anxiety Disorders. Lev (2005) suggests removing GID from the DSM and using the ICD-10 codes for Transsexuality under Axis III medical conditions. Lev’s proposal would enable insurance companies to reimburse the medical condition “similar to pregnancy” thereby avoiding the stigmatization of an Axis I mental health diagnosis (Lev, 2005). However, Bockting points out that “there is no physical marker that a person has gender dysphoria” unless a person has begun hormone treatment, “it would be possible to physically assess if a person’s chromosomes don’t match their genitalia. Perhaps an ICD classification could be used for people who have transitioned and continue to need hormone therapy” (Rochman, 2007). Accessing hormones on the street or online can be a health risk without a doctor’s prescription and well-trained, careful observation particularly for individuals with hormonal conditions, as well as the potential for Hepatitis C and HIV infection for those who share injection equipment (Bockting, 2008; Coleman et al, 2011; Grant et al, 2011).
44 Some advocates urge for the complete removal of the diagnoses, due to the medical and societal discrimination transgender people face as a result of institutionalized transphobia inherent in the diagnosis (Bolin, 1988). Gender identity pathology assumes that the problem resides within the person, and fails to account for societal stigma from which the person suffers. Because of discrimination, harassment and violence faced by transgender people on a daily basis (Grant et al, 2011), it is particularly problematic to locate the disease within the person’s psychology. As with most disorders listed in the DSM and ICD, disturbances are determined based on “clinically significant distress or impairment in social, occupational, or other important areas of functioning” (APA, 2000). Transgender people may be unable to maintain employment not because they are distressed about their gender, but because of the pervasive stigma restricting their ability to function in a transphobic society (Grant et al, 2011). In addition to employment discrimination, gender variant people face inadequate access to medical care due to discrimination, harassment and violence from providers hospitals and nursing care facilities (Grant et al, 2011). Although proponents of the diagnosis suggest that it legitimizes transgender people and their treatment, many health providers are left untrained and ignorant about the complexities of transgender health care needs. As a result, many are denied access to care if insurers refuse coverage if they arbitrarily deem these types of basic services as related to gender transition (Rounds, McGrath & Walsh, 2013). Advocate Kelly Winters and other advocates and clinicians listed on their GIDreform.org site suggest reforming GID, just as homosexuality was reformed in the DSM because it caused harm to many people. Homosexuality was also removed, in part,
45 because it was seen as a more common phenomon (Lev, 2004). Therefore, as the prevalence of gender variance becomes more widely known, gender diagnoses may also be removed. The sexism inherent in descriptions of the criteria also pathologize gender-variant masculine and feminine behaviors in children (Lev, 2005). Diagnostic criteria for GID features detailed descriptions of masculine and feminine stereotypes of behavior and feelings, including for children: A strong preference for playmates of the other sex… in boys, assertions that his penis or testes are disgusting or will disappear or … aversion toward rough-and- tumble play and rejection of male stereotypical toys, games, and activities; in girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing.” (APA, 1994, pp. 532-538) These over-inclusive diagnostic criteria contribute to the stigma of gender nonconforming youth (Winters, 2007). Involved with the DSM-IV (1994) gender diagnosis committees, Canadian psychologist Kenneth Zucker participated in the creation of the GID diagnosis used for children in an attempt to prevent adult onset of transsexuality (Zucker and Bradley, 1995). Zucker held similar views to his mentor John Money, who sought to cure people of gender variance through psychological intervention. Zucker treated over 500 preadolescent gender-variant children with reparative therapy in order to conform to his expectations for male and female behavior in children (Brown, 2006). Zucker promoted the National Association for Research & Therapy of Homosexuals. According to his colleague Michael J. Baily (2003) Zucker considers transsexual women a "bad outcome" for gay men. Despite Zucker’s distain for sexual and gender variance, he was one of 23
46 authors of the current 7th version of the WPATH Standards of Care, which states that treatment designed to realign gender variant people with their assigned gender at birth is unethical (Coleman et al, 2011). Advocates for the removal of gender diagnoses in the DSM and ICD highlight the multicultural perspectives of gender that are omitted from the medical nosology. The psycho-medical history of gender variance in the U.S. and Canada was written by white, heterosexual, non-transgender males (Meyerowitz, 2002; Stryker, 2008). International and historical archives, as well as recent evidence reveal positive perspectives on gender variance as a naturally occurring variation (Feinberg, 1996; Ophelian, 2009). In the 1990s, the term “transgender” became a more inclusive, politically unifying term for gender variance (Lev, 2007). Psychologists who sought to avoid the stigmatization of the diagnoses reformed their psychotherapeutic approach in order to provide more culturally competent care (Fraser, 2009, 2009a; Lev, 2005, 2009; Tilsen et al, 2007). Essentialist and social constructionist perspectives on trans identity and language. For the last hundred years, medical professionals in the United States and Europe diagnosed sexuality and gender variance (APA 1952, 1968, 1975; Benjamin, 1966; Caudwell, 1949; Ellis, 1928; Freud, 1905; Green & Money, 1969; Krafft-Ebbing, 1886; Meerloo, 1967), while transgender people sought ways to recognize and name their sexuality and gender identity (Hirschfeld, 1910; Jorgensen, 1967, 1970; Lind, 1918, 1922). Each explored essentialist or social constructionist perspectives. Essentialists regard sex or gender as essential features a person is born with or inherently fixed, while social constructionists perceive sex and gender as co-constructed within one’s self and social and cultural contexts.
47 The controversy over transgender language and identity began in the mid- 18th century, when transgender advocates attempted to describe themselves in the first wave of transgender activism (Meyerowitz, 2002). Working with their doctors, early transsexual-identified people introduced essentialist perspectives of having been “born in the wrong body,” asserting themselves “true transsexuals” who successfully “passed” as heterosexual women or men (Benjamin, 1966; Jorgensen, 1967, 1970). Many transsexual people identify strongly with the binary view, stating that they do not simply identify with their gender, but feel that they are male or female as a core part of themselves. Transsexuals feel that hormones and surgery affirm their true sex, and rather than “reassignment,” they receive sexual “realignment” procedures. Subsequently, medical professionals and scientists categorize sex and gender using essentialist, or inherent or fixed traits in order to universalize transgender experiences into male or female sex characteristics and expressions (Benjamin, 1966; Broido, 2000). Many doctors, including Magnus Hirschfeld (1910), Alfred Kinsey (1948, 1953), and Harry Benjamin (1966) included intersex as a means to promote essential biological diversity. Doctors Richard Green and John Money (1969) used conservative views of a two-sex system to promote segregated ideas of masculine and female gender identity. The American Psychiatric Association utilized essentialist perceptions of male and female sex to pathologize gender variance in the Diagnostic and Statistical Manual for Mental Disorders (APA, 1952, 1968, 1975, 1980, 1987, 1994, 2000). In the 1960s and 70s, the second wave of transgender activism focused on civil rights and gender fluidity (Meyerowitz, 2002). During this time, transgender activists objected to the straight, gender binary, rigid model of beauty, particularly as doctors
48 rejected them regardless of how well they passed as male or female (Denny, 1992; Stryker, 2008). Young, homeless and transgender people of color who were denied treatment or could not afford hormones or surgery were constantly harassed by police and incarcerated (Feinberg, 1996). Activists argued against essentialist scientific notions of “the perfect gender” (Bornstein, 1998), utilizing social constructionist or post-modern perspectives to promote a paradigm shift in society’s construction of gender (Butler, 1998; Wilchins, 2004). Social Constructionism or deconstructionism argues that the language and experience of gender is a culture-bound, socially constructed phenomena whereby those in power privilege their definitions over others (Derrida, 1974; Foucault, 1969, 1978). Social Constructionism argues that essentialism falsely universalizes experiences, resulting in racist, transphobic, homophobic and sexist perspectives (Arseneau, 2008). In the 1990s to early 2000s, there was a resurgence in social constructionist perspectives related to reclaiming the terms queer and transgender in order to promote sexual and gender variance (Blumenstein, 2003; Bornstein, 1995, 1998, 2011; Butler, 1990; Feinberg, 1993, 1996; Green, 2004; Roughgarden, 2004, 2009; Wilchins, 2004). In fact, both essentialist and social constructionist perspectives have been used to justify mistreatment of trans people. On the one hand, doctors such as psychologist John Money (1971), believing that gender was entirely socially constructed, promoted psychosocial “cures,” conducting research experiments using “reparative” or “rehabilitative” therapy techniques, based on the assumption that they could return people to identifying with the gender assigned to them at birth (Colapinto, 2000; Money, 1971; Meyerowitz, 2002). On the other hand, essentialist perspectives have been used to
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Amanda B Elder Dissertation Final 2013 (2)
Amanda B Elder Dissertation Final 2013 (2)
Amanda B Elder Dissertation Final 2013 (2)
Amanda B Elder Dissertation Final 2013 (2)
Amanda B Elder Dissertation Final 2013 (2)
Amanda B Elder Dissertation Final 2013 (2)
Amanda B Elder Dissertation Final 2013 (2)
Amanda B Elder Dissertation Final 2013 (2)
Amanda B Elder Dissertation Final 2013 (2)
Amanda B Elder Dissertation Final 2013 (2)
Amanda B Elder Dissertation Final 2013 (2)
Amanda B Elder Dissertation Final 2013 (2)
Amanda B Elder Dissertation Final 2013 (2)
Amanda B Elder Dissertation Final 2013 (2)
Amanda B Elder Dissertation Final 2013 (2)
Amanda B Elder Dissertation Final 2013 (2)
Amanda B Elder Dissertation Final 2013 (2)
Amanda B Elder Dissertation Final 2013 (2)
Amanda B Elder Dissertation Final 2013 (2)
Amanda B Elder Dissertation Final 2013 (2)
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Amanda B Elder Dissertation Final 2013 (2)

  • 1. OLDER TRANSGENDER EXPERIENCES IN PSYCHOTHERAPY A dissertation submitted to The Wright Institute Graduate School of Psychology in partial fulfillment of the requirements for the degree of Doctor of Psychology By AMANDA BETH ELDER, M.A. MAY 2013 © 2013 AMANDA BETH ELDER ALL RIGHTS RESERVED
  • 2. ii May 2013 OLDER TRANSGENDER EXPERIENCES IN PSYCHOTHERAPY By AMANDA BETH ELDER, M.A. This study sought to enrich the understanding of transgender individuals’ subjective experiences in psychotherapy throughout their lifespan, both to offer perspectives that are often overlooked due to transgender marginalization, and to improve the quality of psychotherapeutic care for gender variant people. Although many gender variant people have received psychotherapy, only three studies have researched transgender experiences in psychotherapy. This gap in the literature is significant given the amount of harassment, discrimination and violence that transgender people continually deal with when receiving medical and psychotherapeutic services; that psychotherapy has been required and continues to be strongly encouraged in the Standards of Care for transgender people during the process of obtaining gender realignment procedures; and because in order to be multiculturally competent, psychologists must be aware of the needs and experiences of transgender communities. Despite the growing population of older transgender people, and more transgender people transitioning later in life, the few studies on the experiences of psychotherapy have not included the experiences of older transgender people. Therefore, more research is also needed on older transgender people regarding the psychotherapy they received throughout their lifespan.
  • 3. iii The researcher conducted one-hour interviews with nine transgender-identified participants whose ages ranged between 60-83 years of age. Older transgender-identified people offer historical perspectives that may elaborate on progression of psychotherapeutic services for transgender people in the last several decades. A qualitative research method using thematic analysis was used to identify and analyze themes embedded in the data. The results were organized into ten themes within three categories: 1) Experiences in therapy, including healing and painful moments in therapy, and positive ways that therapy has changed; 2) Life experiences, including transitioning and trans issues, older trans issues, family of origin, discrimination and abuse, resiliency and activism; and 3) Recommendations to other people of transgender experiences and to mental health providers. Overall, participants indicated that they found that therapists are currently more knowledgeable about transgender experiences, are better acquainted with gender fluid language, are less biased and more flexible and resourceful in their approaches. Negative experiences included therapists failing to recognize and affirm their gender as well as overt and covert judgments about gender variance. As in earlier studies on psychotherapy, participants went beyond questions asked, leaving their legacies by relating the challenges and joyful moments of their lives.
  • 4. iv Dedication I dedicate this dissertation to the brilliant participants. I am so thankful that you bravely stepped forward to get your voices heard. I hope I have done justice to your in- credible life stories and experiences in therapy. Thank you so much for your recommen- dations and contributing to the trans-affirmative psychotherapy literature. This research also belongs to all the fabulous trans, transgender, and gender queer researchers, providers, and activists whom I cited throughout the text. I have had the good fortune to get to know many of you through UCSF’s Transgender Center of Excel- lence, Center for AIDS Prevention Studies, the World Professional Association for Transgender Health, as well as through the Asian & Pacific Islander Wellness Center. I am honored to have presented the preliminary findings of this study at the National Transgender Health Summit this month. I am so grateful for our collaborations and your friendship. In particular, I dedicate this research to Tatiana Kaneholani, my sistah and kumu. Thank you for teaching me how to be graceful and fierce. I also dedicate this to Janetta and Nick.
  • 5. v Acknowledgements I am eternally grateful to Dr. Ellen Balis, my chair, and to my readers, Dr. Amy Walthall and Dr. Jamison Green. Thank you for believing in me and this work. Thank you for all your hard work and perseverance through four years of a labor of love, sweat, and tears. I am honored to share this with you. A HUGE congrats and thanks goes to my study-buddy in crime who just gradu- ated himself, Dr. John Michael Brown. All the hugs I could give won’t pay back the love you have given me with Huck and Will. I can always count on you to get me to laugh, usually at ourselves and the ridiculousness of the stress we have been under with our hard work. I also attribute my survival and sense of humor from Dr. Susan Guerrero, who’s many words of wisdom she invented, like The D MONSTER. I am ever grateful for our study time together, commiseration, and most of all your friendship. Thank you to Dr. Kaili Moyer, another study buddy and good friend who also did a fabulous gay dissertation that I cited. I want to thank more of my chosen family for all your love and support. Words cannot express, so let’s just keep being family so that I can love you up, ok? I want to thank Ayesha Star Cammaerts, Heather Frank, Shin Yi Tsai, Ronald Pineda, Kaylene Holvenstot, Justine Saunders, Shirin Shoai, and Valeria Velazquez. I want to thank a few more friends and colleagues here who contributed to this work: Maci & the hilarious article she gifted me by Dr. Sehy (Sehy, 1990), Dr. Leon
  • 6. vi Wann, Cole Moyer, Dr. Greg Gayle, Dr. Annalise Ophelian, Willy Wilkinson, Kelsey Evan Rounds, Carolyn Hunt, Jean Brennan, G. Richard Bellamy, Michelle Cilia, Joseph Nolan, Beanie, Michele Senitzer, and Megan Montgomery. There are many more who I want to include here, so I raise a toast to you in gratitude. I want to thank you, Deborah Dallinger, my editor-in-chief, particularly when you got me through the first pages at my apartment while I was laid up with a healing broken ankle. I want to thank my clients. I am so grateful for our work together. Thank you for helping me become a better person and therapist. I want to thank the staff at the Wright Institute for being so friendly and patient with my constant surprise visits, and fielding all my ridiculous questions. In particular, I want to acknowledge Virginia Morgan, Curtis Lew, Dolores Sullivan, Ais Harvey, Mark Abramowsky, and Jason Strauss. Finally, I have the most to thank to my family of origin. I love you all so much. To my sisters Veronica and Shelly, my brother David, and to Grandma Jean, Nancy, Dan, Jim, Ann, Gale, Steve, and Elizabeth. Especially I want to thank my parents—to you Dad, and to both of you Moms for sending me so much love and strength.
  • 7. vii Table of Contents Abstract ii Dedication iv Acknowledgements v Table of Contents vii Chapter 1: Introduction 1 Statement of Purpose 1 Background and Significance of Study 1 Historic and Global Gender Variance 1 Prevalence 2 Transgender Discrimination and Resilience 3 Transgender Psychotherapy 4 Need for Study 4 Definition of Terms 5 Research Questions 9 Chapter 2: Review of the Literature 10 History of Psycho-medical Research and Treatment of Gender Variance 10 Sexologists and Early Transgender Conceptualizations 10 Early Medical Advances 14 Mid-20th Century Psychological Perspectives on Gender Variance 17 University-affiliated Gender Identity Clinics 22 Mid-20th Century Transgender Advocates 27
  • 8. viii Street Queens and Grassroots Activism 29 Development of Standards of Care 32 Gender Diagnoses in the Diagnostic and Statistical Manual for Mental Disorders 36 Gender Diagnoses in the International Classification of Diseases 40 Gender Diagnostic Reform 42 Essentialist and Social Constructionist Trans Identity and Language 46 Trans-affirmative Models of Care 49 Transgender Experiences in Psychotherapy 52 Participants’ Demographics and Study Design 52 Reasons for Seeking Therapy 53 Positive Experiences in Psychotherapy 54 Negative Experiences in Psychotherapy 55 Recommendations for Providers 56 Recommendations for Further Research 58 Issues Facing Older and Aging Transgender People 58 Invisible Minority 59 Diversity within Age Cohort 60 Transitioning Later in Life 60 Discrimination, Violence and Legal Issues 61 Social Support 65 Health Care and Access 66 End of Life Issues 68
  • 9. ix Areas for Further Research 70 Summary of Current Literature 71 Chapter 3: Methodology 73 Qualitative Research and Thematic Analysis 73 Participant Criteria, Recruitment, and Selection 74 Instruments 75 Procedure and Data Collection 76 Data Analysis 77 Ethical Considerations 78 Bracketing of Potential Bias 79 Chapter 4: Results 81 Research Participants and Therapy Experience 81 Table 1: Self-Reported Demographic Data 81 Table 2: Therapy Experiences 84 Table 3: Transgender Therapists’ Professional Background 85 Themes of Participant Data 86 Table 4: Results of Data Analysis 89 Category I: Experiences in Therapy 90 Theme 1: Trans-Affirmative & Healing Experiences in Therapy 90 Theme 1A: Therapist Affirming Gender and Sexuality 91 Theme 1B: Professional and Respectful Therapists 95 Theme 1C: Range in Theoretical Approach 96 Theme 1D: Range of Issues Addressed in Therapy 97
  • 10. x Theme 1E: Peer Support Groups 99 Theme 2: Negative or Transphobic Experiences in Therapy 102 Theme 2A: Uninformed Providers 102 Theme 2B: Unhelpful Behaviors by Therapists 103 Theme 2C: Homophobic and Transphobic Experiences 106 Theme 2D: Biased & Derogatory Psychology Literature 107 Theme 3: Positive Changes in the Way Therapy is Conducted 109 Category II: Life Experiences 110 Theme 4: Transition and Trans Issues 111 Theme 4A: Gender Identity Formation 111 Theme 4B: Gender Language 113 Theme 4C: Sex and Sexuality 115 Theme 4D: Waiting to Transition 116 Theme 4E: Passing, Stealth and Living Two Lives 118 Theme 4F: Hormone and Surgery Treatments 121 Theme 4G: Coming Out and Social Relationships 121 Theme 4H: Gender Social Roles 124 Theme 4I: Authenticity 126 Theme 5: Older Trans Issues 126 Theme 5A: Differences in Age Cohorts 127 Theme 5B: Transitioning Later in Life 127 Theme 5C: Health Issues and Disability 128 Theme 5D: Benefits of Older Age 128
  • 11. xi Theme 6: Family of Origin 129 Theme 6A: Family Acceptance or Non-acceptance 129 Theme 6B: Mental Health Issues in Family 131 Theme 7: Discrimination, Harassment and Abuse 132 Theme 7A: Violence and Abuse 132 Theme 7B: Employment Discrimination 135 Theme 7C: Discrimination by Spiritual Community 135 Theme 8: Resiliency, Community Activism, and Education 136 Theme 8A: Educating and Advocating for Oneself 136 Theme 8B: Teaching Others 137 Theme 8C: Volunteering and Activism 138 Theme 8D: Connecting with Spiritual Community 139 Category III: Recommendations 139 Theme 9: Recommendations to Other Trans People 139 Theme 9A: Advocate for Yourself and Do the Research 140 Theme 9B: Find a Supportive and Informed Therapist 140 Theme 10: Recommendations to Providers 141 Theme 10A: Provide trans-affirmative therapy 142 Theme 10B: Utilize consultation or co-therapy 144 Theme 10C: Research Trans Issues & Language 144 Theme 10D: Attend Community Events 145 Theme 10E: Address Co-occurring Issues in Therapy 146 Theme 10F: Recommendations for Further Research 146
  • 12. xii Chapter 5: Discussion 147 Discussion of Themes 148 Experiences in Therapy 149 Positive Therapy Experiences 149 Negative Experiences in Therapy 153 Positive Changes in the Way Therapy is Conducted 156 Life experiences 157 Transition and Trans Issues 158 Older Trans Issues 160 Family of Origin 161 Discrimination, Harassment, and Abuse 161 Resiliency, Community Activism, Education, and Celebration 162 Recommendations 163 Clinical Implications 165 Limitations 167 Directions for Future Research 169 Conclusion 170 References 172 Appendices 189 Appendix A: Letter of Introduction 189 Appendix B: Informed Consent 191 Appendix C: General Demographic Information and Therapy Survey 195 Appendix D: Interview Guide 197
  • 13. xiii Appendix E: Consultation Resources 199 Appendix F: GID Diagnoses with Full Criteria 200 Appendix G: International Bill of Gender Rights 205 Appendix H: Research Committee 208
  • 14. 1 Chapter 1: Introduction Statement of Purpose The purpose of this study is to enrich the understanding of transgender individuals’ subjective experiences in psychotherapy throughout their lifespan, both to offer perspectives that are often overlooked due to transgender marginalization, and to improve the quality of psychotherapeutic care for gender variant people. The researcher conducted one-hour interviews with a diverse sample of 9 transgender-identified people who discussed at least one significant psychotherapeutic experience, regardless of their gender identity at the time of treatment. Participants were between 60-83 years of age. Older transgender participants offered the historical perspectives on how psychotherapeutic services for trans people have progressed over the last several decades. This study may help clinicians question simplistic notions of gender, as well as address clinical competency in service provision, particularly as discrimination towards trans people has become much more widely understood as a civil rights issue (Bendery, 2012; Grant et al, 2011). A qualitative research method using thematic analysis was used to identify and analyze themes embedded in the data (Braun & Clark, 2006). Background and Significance of Study Historic and global gender variance. Gender variance has been found throughout history worldwide. What is sometimes referred to as third gender is revered in many cultures as respected shamans, representatives of goddesses, gods and intersexual deities, or accepted as a diverse population within society which may encompass gender role play to living full-time as another gender. Cross-culturally gender variance has many names, for example: Okule and Agule among the Lugbara people and
  • 15. 2 Isangoma among the Zulu people in Africa; Hijra and Jogappas in India; Baylans or Catalonans in the Philippines; Bissu and Basaja in South Sulawesi, Indonesia; Mudang in Korea; Shih-niang and Wingagu Nati in China; Xanith in Oman; Mahu in Hawaii and other Polynesia societies; Two-Spirit among many Native American tribes; Vestida in Mexico; Guevedoche in the Dominican Republic; and Gallae in Turkey (Feinberg, 1996; Roughgarden, 2004; Wiesner-Hanks, 2011). Prevalence. Minority groups will remain invisible in policy reports on health care disparity and aging until additional research efforts focus on their behalf (Witten & Eyler, 2012, p. 15). Because gender variance is still not recognized in the United States, as an invisible minority, transgender-identified people are not reported in the census data, and their prevalence is difficult to assess. Locating accurate data on the diversity of transgender identity is also more difficult to find, largely due to discrimination and stigma. Thus, it is difficult to determine the prevalence of older and aging transgender people based on the literature. However, the broader lesbian, gay, bisexual, transgender, intersex and queer-identified population in the U.S. aged 65 and older may number three million, perhaps expanding to as many as four million by 2030 (DeVries et al, 2006). According to the World Professional Association for Transgender Health, researchers who have studied prevalence of transgender people have focused predominantly on transsexual individuals who have sought gender transition-related care (Coleman, 2011). Combining most of the research findings in the last 39 years internationally, prevalence ranges from 1 in 11,900 to 1 in 45,000 for male-to-female transwomen (MtF) and 1 in 30,400 to 1 in 200,000 for female-to-male (FtM) transmen (Coleman, 2011).
  • 16. 3 Transgender discrimination and resilience. Transgender and gender non- conforming people face severe harassment, discrimination and violence from numerous aspects of society and are often denied housing, education, employment, health care, legal assistance, and citizenship. In addition to being denied basic human rights due to institutional transphobia, transgender people face discrimination and violence from their partners, family members, friends and communities. As a result, transgender people must often cope with isolation, extreme poverty, and severe health disparities; according to a research study, nearly half of them attempt suicide at some point in their lives (Grant et al, 2011). Despite these formidable challenges, transgender people are resilient, finding their way toward resources and community support, and managing to live full, complete lives. Grant et al (2011) found that 76% of the 6,450 respondents in their study involving the largest amount of trans people ever participated in a study entitled Injustice at every turn: A report of the national transgender discrimination survey by the National Center for Transgender Equality and National Gay and Lesbian Task Force have been able to receive hormone therapy, indicating a determination to endure the abuse or search for sensitive medical providers. In addition to the universal areas of concern associated with aging, such as health care and income disparities, ageism, and end-of-life issues, older and aging transgender- identified people face additional risks. Already marginalized in gay and lesbian communities, transgender-identified people are further discriminated as older adults (Persson, 2009; Witten & Eyler, 2012). Ageism is common in LGBT communities, and in the psychological literature on LGBT aging, older transgender and gender non- conforming experiences continue to be under reported (Witten & Eyler, 2012).
  • 17. 4 Transgender psychotherapy. Given the challenges of discrimination and the inevitable stress that institutional and personal discrimination cause, transgender people have sought psychotherapy to support their coping strategies, strengths, and resilience as well as to address issues that result from stress. The psychotherapeutic literature reveals that transgender-identified peoples' psychotherapy includes self-exploration, relationship and family dynamics, career challenges, and phase of life issues (Bess, 2006; Joy, 2008; Lev, 2004; Witten, 2009, Rachlin, 2002). Need for Study Although many gender variant people have received psychotherapy, only three studies have researched transgender experiences in psychotherapy: Bess, 2006; Joy, 2008; Rachlin, 2002. The dearth in the literature is disturbing given the amount of harassment, discrimination and violence that transgender people continually deal with when receiving medical and psychotherapeutic services, and that psychotherapy has been required and continues to be strongly encouraged during the process of obtaining gender realignment procedures by the Standards of Care for trans people (Coleman et al, 2011). Of the three studies, each examined various aspects of psychotherapy, including the individual reasons for seeking therapy, positive and negative experiences in therapy, and recommendations for mental health providers. In all three studies, researchers pointed out the need for increased training in transgender and gender variance issues. These studies also indicated the need for more psychological research on transgender care from the perspective of transgender people. Many participants in the current studies were middle-aged, but only one was 60 years of age. Although there are is a growing population of older transgender people, and more transgender people transitioning later in life (Witten & Eyler, 2012), the
  • 18. 5 few studies on the experiences of psychotherapy have not included the experiences of older transgender people. Therefore, more research is also needed on older transgender people regarding the psychotherapy they received throughout their lifespan. Definition of Terms The following is a list of terms and definitions used in this study. Many of the definitions are cited by transgender researchers and activists who described themselves and their trans communities. The power to name one’s identity is a critical issue for trans people who face discrimination and violence. Therefore, the terminology will be further discussed within socio-historical context in the following literature review. Throughout the text, trans, transgender, and transgenderism are also used interchangeably with gender variance, to represent the spectrum of gender. Transgender and trans are used as inclusive terms to describe people whose gender identity (subjective experience of themselves as male, female, or other gender designation) or gender expression differs from socially constructed norms associated with the biological sex or gender identity assigned to them at birth (Coleman et al, 2011). Transgender and trans also refers to androgynous, bi-gendered and gender-queer people, who may view traditional concepts of gender as restrictive (Coleman et al, 2011; Green et al, 2011). The terms transgenderist and later transgender were coined by Virginia Prince in the 1970s and 80s to define people who identify and live full-time in the gender opposite to the one assigned at birth, and who may not elect for hormonal or surgical sex realignment procedures (Keatley, 2011; Feinberg, 1996, Lev, 2007). In the 1990s, transgender became used also as an inclusive, politically unifying term for gender variance (Lev, 2007).
  • 19. 6 Transsexual or transsexualism describes a person who obtains sexual reassignment or realignment surgery (SRS) and hormone treatments. The term was popularized in the American media in 1952 by Christine Jorgensen and her doctor Harry Benjamin who monitored her hormone treatments. Some older trans people who grew up during that time and obtained SRS, identify strongly with transsexual identity and feel than that the term transgender does not adequately represent their experience. Pre-op and post-op refer to before and after sexual reassignment or realignment hormones and surgeries. Transvestite was a medical term initially coined in 1910 by Magnus Hirschfeld, a German sexologist, in his text Transvestites: The Erotic Drive to Cross-Dress (Hirschfeld, 1910). Similar to current usage of trans, Hirschfeld defined transvestite beyond the “erotic urge for disguise” and included those whom he referred to as sexual intermediaries including people who were gay and those with intersex bodies (Hirshfeld, 1910; Stryker, 2008). Since the mid-20th century when psychiatrists defined transvestism as a perversion (APA, 1952, 1968, 1975, 1980, 1987, 1994, 2000), transvestite remains a stigmatizing term. Therefore, many people prefer to use the term crossdresser to describe the practice of presenting as genders different from the one assigned to them at birth (Peters, 2012). Crossdressers associated with performance may identify as drag queens or kings, transgender or trans, or perhaps reclaim transvestite in an empowered, self- actualized political identity. Sex and gender are used interchangeably in the psychological literature and colloquially, but they are not the same (APA, 1994; Stryker, 2008). Sex relates to biological aspects as chromosomes, hormones, and reproductive capacity. Sperm-
  • 20. 7 producing bodies tend to be designated as male, while egg-producing bodies tend to be designated as female (Stryker, 2008). However, those who identify as intersex may have characteristics of male and female biology or morphology or shape of the body. Although there may some biological aspects to gender, gender is largely influenced by culture and socialization, whereby one grows into their subjective sense of their gender identity (Butler, 1990, 2004; Lev, 2004; Stryker, 2008). Gender binary refers to gender identities being categorized as either male/man or female/woman. Although there are people who identify as intersex who may be born with characteristics of male and female biology, morphology or shape of the body, these variances, along with the spectrum of varied cultural and psychological perceptions of gender, are often ignored in favor of the gender binary perspective. The gender binary view conflates biological sex and gender identity, suggesting that individual gender identity, presentation, and performance must be congruent with physical sex characteristics or anatomy (Tilsen et al, 2007). Gender non-conforming or gender-queer describe people whose gender expressions, roles, and identities varies from societal expectations and stereotypes of gender presentation (Grant et al, 2011), or people who defy or do not accept stereotypical gender roles and may choose to live outside expected gender norms (Green et al, 2012). Gender non-conforming and gender-queer people may or may not avail themselves of hormonal or surgical treatments (Green et al, 2011). Similarly, those who identify as androgynous may include those whose appearance and identity do not conform to conventional views of masculinity or femininity, and who may combine both aspects or present in a way that is outside expected gender norms (Grant et al, 2011).
  • 21. 8 Queer refers to a gender inclusive identity that may refer to gender and to sexuality. This term is controversial due to its historical and current use as a derogatory term for gay-identified people. In 1990 the use of queer was reclaimed by activists in New York who called themselves Queer Nation, and would produce actions such as sitting in bars and clubs where primarily heterosexual people were consumers. Queen was a term coined by older grassroots activists who may also identify as drag queen, trans, transsexual or transgender. Self-identified queens may include youth, the homeless, sex workers, prostitutes, husslers, activists or advocates for trans rights who may or may not live on the streets. Lesbian, Gay, Bisexual, Transgender, Intersex, Queer and Questioning (LGBTIQQ), also known as alphabet soup, refers to the spectrum of gender and sexuality (Stryker, 2008). Straight refers to heterosexual- identified people who are cisgendered or who identify with the gender assigned to them at birth. The homosexual identification may be used as a derogatory term due it first being used as a medical diagnosis describing people who are sexually attracted to the same gender as pathological (APA 1952, 1968). Homophobia describes the phenomenon by which people are afraid of LGBTIQ- identified people. Transphobia describes the phenomenon by which people are afraid of gender variance. The above terminology and descriptions are not an exhaustive list. Gender terminology continues to shift and evolve. Rarely do the definitions of these terms remain fixed, and individuals' gender identities may not remain the same throughout their lifespan. Trans-affirmative researchers and providers are continually learning new ways to be more universally-minded in their approach towards inclusivity for all (Lev, 2004).
  • 22. 9 Research Questions By listening to trans peoples’ subjective experiences in psychotherapy, this study hopes to capture a glimpse of the historical gender paradigm shift from a binary one to a more inclusive one, as well as contribute to developing theories of trans-affirmative therapy and improve service provision. Questions were asked to gain experiential information about participant dealings with the topic. The study’s intent was to learn about healing and negative therapy experiences, trends on how therapy is changing, and recognize ways in which therapy can improve and be more trans-affirmative in practice.
  • 23. 10 Chapter 2: Review of the Literature History of Psycho-Medical Research and Treatment of Gender Variance The literature on the psycho-medical concept and clinical approaches to transgenderism is mainly published in Europe and the United States beginning in the 1800s (Meyerowitz, 2002; Stryker, 2008; and Lev, 2004, 2005 & 2007). Most research and theories of gender variance emanated from a pathologizing, reparative perspective (Lev, 2005), although some scientists advocated for human rights and promoted acceptance through their research (Meyerowitz, 2002). The following sections trace the history of the psycho-medical research and treatment of gender variance including: early sexologists and their conceptualizations of transgenderism, the advent of hormonal and sexual realignment or reassignment surgical (SRS) medical treatments in the 1930s, mid- 20th century psychological perspectives on gender variance, and the rise of university affiliated gender clinics, mid-20th century transgender advocates and activism, the development of standards of care for medical and psychological practitioners treating gender variant individuals, the evolution of gender diagnoses and gender diagnostic reform, trans-affirmative models of care, and transgender experiences in psychotherapy. Sexologists and early transgender conceptualizations. In the 19th and early 20th centuries, Western society condemned gender variance. In parts of Europe and the U.S., it was illegal for people to appear in public if they were wearing clothes deemed inappropriate to their gender assigned at birth (Stryker, 2008, p. 33). However, an increasing number of European and American scientists studying human sexuality began to challenge the notion of separate and opposite sexes (Meyerowitz, 2002, p.22). During the 19th century, sexual and gender variance became the focal point of sexologists who
  • 24. 11 were seeking to define sexual behavior within a larger cultural discourse of categorizing madness and deviance (Foucault, 1965; Lev, 2007). While the work of some of the clinicians and researchers described in the following sections supported societal fears with condemnation or cures, others encouraged acceptance of difference. Along the way, scientists developed medical terminology, labels, and criteria; however, the language they used was often ambiguous (Lev, 2007). Biological determinists attempted to describe gender variant people as somewhere between a man or a woman. In 1868, naturalist Charles Darwin described “latent hermaphroditism,” whereby males and females retained latent aspects of each other, ready to express themselves in certain circumstances (Darwin, 1868; Meyerowitz, 2002, p. 23). In the 1860s, Karl Heinrich Ulrichs, a gay German lawyer fought for homosexual rights based on his belief in the “sex of the soul” or psyche (Meyerowitz, 2002). Echoing Ulrichs, U.S. physician William Lee Howard described a type of “sexual inversion” as “psychical hermaphroditism” in his 1897 case study of “a female soul in a male body” (Bullough, 1987). In 1886, Richard von Krafft-Ebing, a prominent Austro-German psychiatrist who wrote the definitive medical compendium, Psychopathia Sexualis, defined “metamorphosis sexualis paranoica” as “the psychotic belief that one’s body is transforming into the other sex” (Stryker, p.38; Krafft-Ebbing, 1886). Conflicting accounts suggest that Krafft-Ebbing was influential in criminalizing homosexuality, arguing that sex drive was meant for procreation, and any other sexual activities were perverse and pathological, and therefore needed to be caught, isolated and cured
  • 25. 12 (Meyerowitz, 2002); while other accounts suggested Krafft-Ebing “reframed sexual deviations as a ‘disease’ and not a sin, a crime, or decadence” (Lev, 2004, p. 70). The Cercle Hermaphroditos was a collective developed in 1895 that proclaimed “to unite for defense against the world’s bitter persecution” against gender variance, promoting self-identity and self-actualization (Stryker, 2008). A member of the collective, Earl Lind, also known as Jennie June, a self-described “androgyne,” “hermaphrodite,” and “fairy,” wrote two autobiographies, Autobiography of an Androgyne (1918) and The Female Impersonators (1922). In 1897, German physician Magnus Hirschfeld cofounded the Scientific Humanitarian Committee, an international organization devoted to social reform on behalf of sexual minorities (Stryker, p. 39). Hirschfeld, a gay, Jewish cross-dresser (Feinberg, 1996), promoted the social acceptance of human sexuality and gender variance, and fought against the criminalization of sexual and gender variance (Stryker, 2008). In 1899 he coined the term “sexual intermediaries” in the first scientific journal on sexual variants, the Yearbook for Sexual Intermediaries, published from 1899 -1923 which described how every human being represents a unique combination of sex characteristics, secondary sex-linked traits, erotic preferences, psychological inclinations, and culturally acquired habits and practices (Stryker, 2008, p. 39). Using this definition, he combined all aspects of a person’s gender presentation and identity. Between 1897 and 1928, British physician Henry Havelock Ellis wrote extensively about sexuality and gender in his highly influential body of work, The Psychology of Sex, Volumes I-VII. In 1913, he coined the term “sexo-aesthetic inversion,” describing the desire to look like the other sex, and in the 1920s, Ellis used
  • 26. 13 the term “eonism” to describe Chevalier D’eon, a member of the court of Louis XVI who, at various stages of life, lived alternately as a man or a woman (Ellis, 1928/1933; Stryker, 2008). In 1905, German psychiatrist Sigmund Freud described inversion or “psychosexual hermaphroditism” as naturally occurring human sexual and gender variance located in the psyche, rather than a biological predisposition. He acknowledged anatomical bisexuality, but believed this did not explain cross gender behavior or same- sex object choice (Freud, 1905; Meyerowitz, 2002). Freud described the transgender experience as a “gender inversion” related to homosexuality (Freud, 1905). Gender inversion was used to characterize men who were attracted to other men as acting like women, and women who desired women as acting like men (Stryker, 2008, p. 34). As founding members of Freud’s Vienna Psychoanalytic Society in 1908-1911, Hirschfeld and Freud influenced each other’s work on gender variance. In 1910, Hirschfeld wrote the first book-length treatise on transgender experience, entitled The Transvestites: The Erotic Drive to Cross-Dress. Other researchers used different terms, but Hirschfeld’s term “transvestite” to describe people who had the urge to wear clothing of the opposite sex survived contemporary usage (Stryker, 2008, p.38). The term “seelischen transsexualismus”or spiritual transsexualism, was articulated by Hirschfeld in his 1923 paper entitled Die Intersexuelle Konstitution as a form of “inversion” (Meyerowitz, 2002, p. 19). In 1949, David O. Cauldwell, an American physician, surgeon, and neuropsychiatrist used Transsexualism to describe those who identified with the opposite sex (Bullough, 1987; Ekins & King, 2001). In his article Psychopathia Transexualis
  • 27. 14 (1949), Cauldwell wrote that the term “transsexual” referred to "individuals who wish to be members of the sex to which they do not properly belong" (Cauldwell, 1949, p. 275). Cauldwell used the spellings "trans-sexual" and "transsexual" interchangeably, and sometimes he used different terms, such as sex transmutationist, gynecomastia, hermaphrodite, intersexual, and transvestite (Ekins & King, 2001). Prominent American biologist and sexologist Alfred C. Kinsey was avidly interested in researching transvestites and transsexuals (Meyerowitz, 2002). Kinsey (1948, 1953) found enormous human diversity in sexual expression and behavior, raising questions of heterosexual “normalcy” (Lev, 2005). Early medical advances. Advances in medical technology in the 1930s and 40s were accompanied by many successful sex reassignment operations and hormone treatments (Meyerowitz, 2002). Operations would include breast removal or enhancement and genital removal, but genital reconstructions, particularly phalloplasty were not available in the early 1900s. Most advances taking place involved hormone treatment by endocrinologists. In 1919, Hirschfeld and his collaborators opened the Institut für Sexualwissenschaft (Institute for Sexology) in Berlin (Meyerowitz, 2002; Stryker, 2008; Wolf, 1986). A research library and archive, the Institute also included medical, psychological, and ethnological divisions, as well as a marriage and sex counseling office (Wolf, 1986). In 1931, Hirschfeld supervised the operation of Dora Richter, who was one of the first documented male-to-female to receive genital transformation surgery. She remained in the Institute as a domestic worker and demonstration patient (Meyerowitz, 2002;
  • 28. 15 Stryker, 2008). Danish artist Einar Wegener, who later became Lili Elbe, was another of the first individuals reported to undergo a sex change operation (Bullough, 1975; Meyerowitz, 2002). Elbe may have been intersex, and may have had Klinefelter's Syndrome, a condition in which human males have an extra X chromosome (Green, 2004). On May 6, 1933, the Nazis raided and burned the Institute’s archive of more than 10,000 books, articles, and magazines (Meyerowitz, 2002; Stryker, 2008). Hirschfeld died in 1935, but many of his colleagues continued related work in the United States. In 1945, Michael Dillon was the first female-to-male to receive phalloplasty surgery in Britain (Green, 2004; Kennedy, 2007). Little was published about men of trans experience and their SRS. This may have been due to sexism in the medical and mental health care fields, and transmen not being able to afford such surgeries as compared to people with male bodies who lived as cisgender men since they had the most social and financial opportunities. One of Hirschfeld’s most notable colleagues was German physician Harry Benjamin who was interested in endocrinology, also supported the right of transgender people to live their lives as they chose (Stryker, 2008). Benjamin first lectured on transsexualism in 1953 (Ekins & King, 1996, 2001), and his most notable publication, The Transsexual Phenomenon (1966), describes his work with 307 gender variant people in his offices in San Francisco and New York. Benjamin felt that medical interventions should be the main focus in working with transsexuals, with psychotherapy available for additional support through the transition process. He stated that gender specialists should determine whether surgery was appropriate for “true transsexuals,” who he defined as
  • 29. 16 people with early age onset of gender dysphoria, lack of comorbid mental health issues, intensity of desire for body modification, as well as ability to “pass” with conservative sexual and gender presentation (Benjamin, 1966; Lev, 2007). Christine Jorgensen was one of Benjamin’s first 10 patients (Benjamin, 1996; Meyerowitz, 2002). Benjamin did not perform her sexual reassignment surgery (SRS), but monitored her hormone treatment, provided emotional support, and credited her with teaching him about the challenges facing transsexuals (Meyerowitz, 2002). In 1952, when Jorgensen became the most widely publicized individual to undergo a “sex change,” making the New York Daily News headlines as the “Ex-GI Blonde Beauty,” awareness of the existence of gender variance increased throughout the broader population (Meyerowitz, 2002; Stryker, 2008). After Jorgensen’s public debut in 1952, U.S. medical journals began to publish articles on sexual reassignment, including discourse about biological, sociological, and psychological perspectives on sex, gender and sexuality (Meyerowitz, 2002). As psychological perspectives emerged, SRS and other medical interventions began to lose legitimacy in favor of social rehabilitation treatment via long-term analysis and behavior modification with the aim of curing patients’ of their gender variance by conforming to their gender assigned at birth (Meyerowitz, 2002). Medical interventions were perceived as extreme and inappropriate treatments for an inherently psychological problem (Meyerowtiz, 2002). Psychiatrist Joost A. M. Meerloo likened SRS with assisted suicide or a means of collaborating with sexual delusions (Meerloo, 1967; Meyerowitz, 2002). Meerloo described his patients as “borderline psychotics with a deep-seated depression and a psychotic denial of self” (Meerloo, 1967; Meyerowitz, 2002, p. 266). Karl
  • 30. 17 Bowman, psychiatrist at the University of California San Francisco’s Langley Porter Clinic theorized that, “[SRS] plays into the patient’s illusions and does not really solve the problem” (Meyerowitz, 2002, p. 110). Bowman and research associate Bernice Engle (1957) debated various theories, including castration anxiety and conflicts over sexual impulses (Meyerowitz, 2002). John K. Meyer, a psychiatrist at Johns Hopkins Gender Identity Clinic, and his co-author Donna J. Reter, concluded that SRS provided no objective advances or social rehabilitation, and he preferred long-term psychoanalysis for treatment (Meyer & Reter, 1979; Meyerowitz, 2002). Despite opposition among clinicians regarding medical treatment, there were more requests for hormones and SRS from gender variant people in the 1950s and 60s (Denny, 1992). Psychiatrist Richard Green and Psychologist John Money, editors of the seminal text Transsexualism and Sex Reassignment (1969), described how SRS interventions should be performed, while emphasizing reparative psychoanalysis throughout the process. Mid-20th century psychological perspectives on gender variance. The psychological theories of sexual and gender variance developed in the mid-20th century were later used to justify diagnostic categorization and “reparative” treatments. Rather than perceiving the diversity of human sexuality and gender (Freud, 1905/1914/1937; Kinsey, 1948, 1953), many of Freud’s contemporaries argued that the etiology of gender identity “problems” stemmed from inappropriate rearing in childhood (Bak, 1968; Green & Money, 1969; Greenson, 1964, 1966; Money, 1971; Stoller, 1964, 1968, 1971; Ovesey & Person, 1973). These mid-20th century psychologists and psychiatrists sought to correct gender and sexual variance through the talking cure and behavioral modification
  • 31. 18 (Meyerowitz, 2002). Eventually, many of these theories took root and justified pathologizing gender variance by psychiatrists, a practice which continues in their criteria (APA, 2000). Mid-century physicians, psychiatrists and psychologists who described themselves as gender specialists were generally white men who never identified with gender variance, and diagnosed “sexual deviations,” including hermaphroditism, pseudohermaphroditism, transvestism, homosexuality, fetishism, and exhibitionism under the category “Sociopathic Personality Disturbance” in the American Psychiatric Association’s first Diagnostic and Statistical Manual for Mental Disorders (DSM) (APA, 1952; Meyerowitz, 2002). This diagnostic category did not adequately address the needs of transsexuals, so psychological theories were devised to distinguish transvestism and homosexuality from transsexuality. At the time, gays and many gender non-conforming people who were diagnosed with homosexuality were being “cured” through institutionalization, castration, sterilization and lobotomies (Davis, 2010). California’s Atascadero State Hospital became known as “the Dachau for queers” (Davis, 2010). The California Sex Deviates Research Act of 1950 was created to discover the causes and cures of homosexuality, including administering hormones and castrating male sex offenders in CA prisons to see whether this altered their sexual behavior (Stryker, 2008). These reparative treatments towards gay and transvestite-identified people set the precedent for further psychological theories and treatments for all sexual and gender variant individuals. Transsexualism was described by mid-20th century psychologists as a mental illness, suggesting that the desire to change sex was caused by repressed or denied
  • 32. 19 homosexuality, perversion, masochism, neurosis, psychosis, character or personality disorder, or by brain trauma (Denny, 2004). Physician Robert Bak (1968) argued that most transsexuals “showed a preponderance of obsessional symptoms, impulsive character structures, and borderline personalities.” Bak, and his colleague Robert J. Stoller, connected the concept of perversion with psychotic process, suggesting that a mentally stable person would not identify with a gender other than the one they were assigned to at birth (Bak, 1968; Stoller, 1971). However they also noted that a transsexual is as likely to be psychotic as anyone in the general population (Bak, 1968; Stoller, 1971). In differentiating transvestites from transsexuals, sexologists claimed that transvestites were sexually aroused by cross-dressing using women’s clothing as sexual fetishes, while transsexuals were perceived to be asexual (Green & Money, 1969; Stoller, 1971). Most gender specialists struggled to understand transsexualism with little data from a few patients who identified as transsexual, and most, if not all of whom were male-to-female (MTF) transsexual women or trans women. Transsexual women were thought to be asexual, a perception stemming from the sexist stereotypes that good girls and women were shy and sexually immature, if not virginal (Green & Money, 1969; Stoller, 1971). Psychiatrist Mortimer Ostow described Jorgensen as having “a neurotic aversion” to sexual contact; psychiatrist George H. Wiedeman suggested that she had “features of fetishism, homosexuality, exhibitionism and masochism,” and perhaps an “underlying schizophrenic process” (Meyerowitz, 2002, p. 106). In 1957, psychiatrist Karl M. Bowman and research associate Bernice Engle at the University of California
  • 33. 20 San Francisco’s Langley Porter Clinic defined a transsexual as “the person who hates his own sex organs and craves sexual metamorphosis” (Meyerowitz, 2002, p. 110). The etiology of transsexual developmental stages and psychodynamic relationships with caregivers was explored in 1971 by Robert J. Stoller, psychiatrist and professor at the University of California at Los Angeles. Stoller refers to gender identity as “…one’s self-image as regards to belonging to a specific sex” (Stoller, 1964, p. 220). He theorized that children know their core gender identity by the time they are 2 or 3 years of age, and the remaining gender role development comes from parental reinforcement of their perception of the child’s gender identity (Stoller, 1971). Stoller considered Benjamin’s theories that gender identity was biologically driven (Benjamin, 1966), but he suggested that gender identity was predominantly shaped by child rearing (Stoller, 1964/1968). For most transsexual males, Stoller noted that child rearing typically included a “pathologically intense symbiosis” with a mother who was masculine or bisexual, and a father who was weak or absent (Stoller, 1964/1968). In this context, “bisexual” refers to embodying both the physical masculine and feminine gender traits, as well as playing roles deemed to belong to men and women (Money, 1971; Stoller, 1971). Stoller (1971) emphasized that the inappropriate playing out of these gender roles by the parents produced gender ambiguity in children. The case example provided by Stoller (1968) showed the bisexual mother behaving like a man or the child’s father, which Stoller proposes is what caused the child’s transvestism or transsexuality. Ralph R. Greenson (1964, 1966) suggested the importance of identifying and addressing the
  • 34. 21 issue of transsexualism during childhood if only to prevent homosexuality, which was considered an even more serious problem. Physician Robert Bak (1968) argued that the etiology and defensive positioning of transsexuals stemmed from the childhood identification with the phallic mother who was masculine or bisexual, and represented a perverted denial of the castration complex. He added that the psychological core of a mother’s bisexual identification was the revival of the her primal fantasy of having a penis (Bak, 1968). Bak goes on to explain that her children would become perverted by their “… mother’s ‘uncertain’ sexual identity- ‘penis or no penis’” and thus producing the child’s paraphilia (Bak, 1968, p. 21). American psychoanalysts Lionel Ovesey and Ethel S. Person (1973) attempted to distinguish between core gender identity, whereby a child begins to identify with their gender at approximately three years of age; and their gender role identity, whereby the individual identifies more with their masculinity or femininity into adulthood and throughout life. They stated that dependency is the “nuclear conflict” or central issue in the major gender disorders, again emphasizing unhealthy development and improper rearing (Ovesey & Person, 1973). These developmental theories were the basis of a research-practitioner model used in U.S. and Canadian gender identity clinics. Because the research designs were based upon the theories that incorporated assumptions about the genetic causes and pathological nature of transsexualism, the results were often devastating for gender variant participants, many of whom were turned away without access to hormones or surgery (Denny, 1992).
  • 35. 22 University-affiliated gender identity clinics. More than 40 gender identity research clinics, predominantly university-based, opened in the 1960s in the U.S. and Canada. The first three were located at Johns Hopkins University, the University of Minnesota, and the University of California at Los Angeles, with clinics subsequently opened at Vanderbilt University, the University of Virginia, Stanford University, and Duke University, among others (for a critical examination of the clinics, see Denny, 1992). These clinics assessed patients, and depending on the outcome, offered hormones and SRS. Within a few years of opening, all but one of the clinics closed, due in large part to the mistreatment of participants by untrained clinicians producing flawed research (Denny, 1992). Despite their many flaws, the clinics legitimized the surgical treatment of transsexual people (Denny, 1992). The successful clinic at the University of Minnesota continues to provide ethically sound research, education, and advocacy for transgender and gender non-conforming people (Bockting et al, 2004). The gender identity clinics’ research involved extensive case-by-case analysis by a treatment team that reviewed participants’ results from the admission criteria and procedures. The Case Western Reserve Gender Identity Clinic provided a typical admissions criteria for most clinics, which included at least one full battery of psychological testing, extensive clinical interviews of patients, their partners and family, payment of evaluation fees (based on a sliding scale), and long-term individual and group psychotherapy (Denny, 1992). If all the requirements were met, the treatment team would decide whether the participant was eligible for hormones and surgery; if so, the participant would be required to complete extensive follow-up tests, procedures and psychotherapy (Denny, 1992).
  • 36. 23 Most “experts” in the field were inexperienced and untrained in transsexualism, yet they were instrumental in designing and implementing the research based on arbitrary selection criteria (Denny, 1992). Most applicants were rejected for a variety of reasons, including age, sexual orientation, marital status, occupational choice, and inability to pass well enough in their new gender role (Denny, 1992). For example, Kessler and McKenna (1978) reported that a colleague admitted that his selection process for SRS was based on sexual feelings evoked in him by his transsexual patients who were subsequently described to be “attractive” and “passing well” (Denny, 2004; Kessler & McKenna, 1978). Applicants were expected to become well-adjusted, attractive, heterosexual graduates (Denny, 2004). In alignment with gender conservatism at the time (Broverman et al, 1972), clinicians sought to instill in their clients the notion of a rigid gender male- female binary that adhered only to heterosexual practices (Stryker, 2008); only the most extreme masculine and feminine presentations were acceptable (Bolin, 1988; Denny, 1992). Candidates for SRS were savvy in reading the medical literature which described clinicians’ criteria of expected responses, behavior, and presentation (Denny, 1992 & 2004; Ophelian, 2009). These criteria were initially outlined in Benjamin’s compendium (1966) regarding the “true transsexual” who was deemed appropriate for SRS (Denny, 1992 & 2004). The criteria included the typical story of the origin of their transsexualism from childhood, with feelings of having been “trapped in the wrong body,” and experiencing a psychic pain that could only be treated by body modification (Denny, 1992 & 2004).
  • 37. 24 The case of David Reimer illustrates the harm and suffering these clinics and their presumed experts had on many participants. The case serves as a reminder of the potentially damaging effects of clinicians’ cultural and moral biases on practice and research (Bess, 2006; Colapinto, 2000, 2004; Denny, 1992), and how crucial it is for providers to de-emphasize passing, and support clients’ needs over that of the researchers’ objectives. In 1966, Reimer’s penis was irreparably damaged in a botched circumcision procedure conducted in a hospital when he was 8-months old. In 1967, his parents sought the help of psycho-biologist John Money and his team at the Johns Hopkins Clinic, and were told that nothing could be done to restore their son’s penis (Green, 2004). Reimer’s parents were told he could not possibly live a satisfying life as a man without a penis, but that he could be made into a girl and still be able to have heterosexual sex, though would not be able to bear children. The case study of Bruce and Brian Reimer began in their first year of life and continued through puberty (Colapinto, 2000). Brian continued to be raised as a boy, while Bruce was surgically castrated and raised as Brenda (Colapinto, 2000). Throughout her development, however, Brenda rejected anything feminine and did not adjust to her social role and had terrible problems in school. During her adolescence, Brenda became depressed and refused further surgical procedures, hormones and psychotherapy. The family refused to continue treatment in 1979, after the children were reportedly encouraged by Money to masturbate in front of the doctors to demonstrate their psychosexual development (Colapinto, 2000). Later that same year, the clinic stopped providing SRS treatment services. In 1980, at 15 years of age, after being told the truth about his birth, Brenda changed her name to David and decided to live as male.
  • 38. 25 Green (2004) examined and reflected on how Reimer’s case is often conflated with intersex issues and experience. This may be because Money published research on intersex conditions and the impact of parental and social influence on gender identity development, and was considered an expert on intersex conditions and gender reassignment. Money studied the Reimer twins in order to prove the theory that a person’s gender identity, or sense of their own gender is primarily socialized and not necessarily related to biological aspects. In 1997, Milton Diamond and Keith Sigmundson published the John/Joan case based on the case of Bruce/Brenda to promote socialization without SRS for intersex children. David was not intersexed, nor did he identify as transgender, but there are parallels between his story and the issues people with trans and intersex identities face, including the ethical right to informed consent, medical status and history, the right to be free of surgeries imposed by others, and that their anatomy not be discussed as abnormal or “inadequate” as compared to bodies that have reproductive capabilities (Green, 2004). However, some providers regard intersex- related surgeries as “corrective,” and transgender-related gender affirming surgeries as “mutilation” (Green, 2004). Once David Reimer was allowed to express his gender, similarities arose between his treatment and that of men of trans experiences, including being treated with testosterone, offered phalloplasty for penis construction, and living his life continually aware that his body was different than those of other men. (Green, 2004). Similar to the mistreatment trans people have had to face by psychological and medical providers, David “had to deal with the collective family stress of the slowly unraveling social experiment of which they were all victims” (Green, 2004, p.204). In 2000, David Reimer
  • 39. 26 collaborated with John Colapinto in their widely publicized book about David’s life, As Nature Made Him: The Boy Who was Raised as a Girl. In 2004, David committed suicide following his divorce from his wife and his brother’s death two years earlier (Colapinto, 2004). The hardship that may have led to David’s eventual suicide was due to having to endure unethical treatment by physicians and psychologists who sexually harassed him, lied to him, and treated him as an experiment rather than respectfully regard his right to self-determine his gender identity and body presentation. In a more recent study of over 6,000 transgender and gender non-conforming participants, 41% reported that they had attempted suicide (Grant et al, 2011). Many researchers and advocates recognize that transgender patients are among the most socially stigmatized of sexual minorities who face discrimination in health care coverage and insensitivity from ill-informed health providers (Bockting et al, 2004). In an effort to remedy the sordid past of many of the gender clinics, and the transphobia in treatment centers and hospitals, the University of Minnesota has incorporated quality controls, including direct accounts of patient satisfaction with services (Bockting et al, 2004). Psychologist Walter Bockting and his research team in the Program in Human Sexuality, Department of Family Practice and Community Health, University of Minnesota reported on patient satisfaction surveys conducted from 1993- 2003 of 180 transgender and 837 other sexual health patients (Bockting et al, 2004). Bockting recognized the difficulty in achieving patient satisfaction when mental health professionals are the primary gatekeepers regarding access to sex reassignment procedures. They found that in the face of this barrier, satisfaction was achieved when
  • 40. 27 providers were non-judgmental and open to honest responses. Transgender and gender non-conforming participants appreciated providers who de-emphasized passing, and supported clients’ needs over that of the researchers’ objectives. While completing the survey and during service delivery in general, Bockting (2004) found that many of the clinic’s transgender patients strongly advocated for self-determination and challenged the traditionally passive patient role. Bockting (2004) reported that a shift in patient care occurred in the 1980s with attention to the treatment of co-existing psychological problems often compounded by living with a stigmatized identity. “In the 1990s,” Bockting noted, “…the paradigm shifted between helping individuals to adjust within the two binary options of male versus female toward fostering coming out as a transgender person as patients more openly affirmed their unique gender identities in the context of a gender-diverse, increasingly visible transgender community.” Mid-20th century transgender advocates. In the mid- 20th century, a few prominent transsexual and transgender advocates created social networks with doctors and other professionals in order to advocate for issues of profound importance to transgender people (Stryker, 2008). These networks provided doctor and patient referrals, as well as participant recruitment and funding for research programs. In the 1940s, Louise Lawrence, a transgender community organizer in San Francisco, formed a worldwide network of transgender people, and frequently lectured on transgender topics at the University of California at San Francisco (UCSF) (Stryker, 2008). She corresponded with biologist and sexologist Alfred C. Kinsey regarding her extensive knowledge of transsexual medical history, and Kinsey introduced her to
  • 41. 28 Benjamin (Meyerowitz, 2002). Through Lawrence, Kinsey and psychiatrist Karl Bowman met in 1949 to discuss Benjamin’s work (Stryker, 2008). Lawrence met with Jorgensen, and hosted many transgender friends and acquaintances who sought her counsel and referrals for treating doctors (Meyerowitz, 2002). In 1942, she met and mentored Virginia Prince, another transgender advocate who was studying pharmacology at UCSF. In the 1940s and 50s, Virginia Prince, a transgender woman with a Ph.D. in biochemistry based in Los Angeles, began to advocate on behalf of herself and other transgender people who were not interested in pursuing SRS (Meyerowitz, 2002; Stryker, 2008). In the 1960s, Prince opened the Hose and Heels Club and was founder and editor of Transvestia magazine (Lev, 2007). In the late 1960s, she began living full time as a woman (Stryker, 2008). Prince was influential in Benjamin’s treatise, The Transsexual Phenomenon, particularly regarding the affirmation of transvestitism as a legitimate gender presentation and downplaying the overt sexualization of transvestites (Benjamin, 1966; Lev, 2007). Prince is most noted, however, for coining the term “transgenderist” which distinguished transvestites from transsexuals; she later modified the word to “transgender” (JoAnne Keatley, UCSF Transgender Health Conference, April 2011; Feinberg, 1996, Lev, 2007). Decades following her 1952 public debut, Christine Jorgensen continued to promote herself and advocate for transsexual people through her autobiography, Christine Jorgensen: A Personal Autobiography (1967), book signings, live stage shows, and the film The Christine Jorgenson Story (1970) (Jorgensen, 1967; Meyerowitz, 2002; Stryker, 2008). Although she never considered herself a political activist, Jorgenson’s life and
  • 42. 29 work educated the general public and provided hope for many struggling transsexuals (Meyerowitz, 2002; Stryker, 2008). Reed Erickson, a wealthy FTM transsexual, founded the Erickson Educational Foundation in 1964, an organization promoting research and education on transsexuality (Meyerowitz, 2002). Erickson funded three years of Benjamin’s research (Benjamin, 1966; Meyerowitz, 2002), which was critical because Benjamin struggled to secure grants to fund SRS research, considered a taboo medical intervention (Meyerowitz, 2002). The Erickson Education Foundation also funded research at the Johns Hopkins Gender Identity Clinic (Lev, 2007). These transgender advocates and their networks laid the groundwork for many transgender organizations including Conversion Our Goal, the National Gender-Sexual Identification Council, Street Transvestite Action Revolutionaries or STAR House, the Queen’s Liberation Front, Transsexual Activist Organization, and the Transexual Counseling Service which used one “s” to distinguish from the medical term transsexual (Lev, 2007; Stryker, 2008). Their connections with gender specialists provided support for research and medical care, as well as efforts to de-pathologize gender variance (Lev, 2007; Meyerowitz, 2002; Stryker, 2008). Street queens and grassroots activism. While middle class transgender advocates wielded their influence to effect change in the medical establishment, uprisings in the streets by transgender youth protested police brutality, and legally sanctioned racism and transphobia in all areas of service provision, including access to health care and other basic human rights (for historical accounts, see Feinberg, 1996; Meyerowitz, 2002; Stryker, 2008). Often targeted and brutalized by the police, street queens have
  • 43. 30 been on the front lines and the first to rise up against the paradigm of the gender binary and fight for basic human rights of housing, employment, medical treatment and the right to live free of discrimination, harassment, violence and stigmatizing diagnoses. Access to proper health care, job equality, and diagnostic reform would not exist had street queens not demanded recognition and fair treatment. Their direct actions inspired collaborations among transgender activists, their health care providers, and police. The first transgender organizations united to provide social support and share resources, as well as to demand civil rights for transsexuals, transvestites, and gender non-conforming people nationally and internationally. The following section describes the uprisings and the transgender activists who formed the first transgender organizations. Spontaneous protests erupted following brutal treatment of transgender people by police who routinely raided bars and diners to humiliate, harass, and incarcerate trans patrons on suspicion of prostitution, vagrancy, or loitering (Stryker, 2008). The first collective resistance occurred in May 1959 at Cooper’s Donuts in Los Angeles when police entered the coffee shop to arbitrarily arrest drag queen patrons, and the other customers decided to resist en masse (Stryker, 2008). Fighting extended into the streets, and many people who were arrested escaped being loaded into the police paddy wagons (Stryker, 2008). The first organized civil disobedience took place in Philadelphia on April 25, 1965 at Dewey’s lunch counter where more than 150 patrons staged a sit-in, but were turned away by the management and three teenagers refused to leave (Stryker, 2008). Activists picketed and arranged a sit-in on May 2 and police were called in, but no arrests were made, and indiscriminate denials of service ceased (Stryker, 2008).
  • 44. 31 Historian Susan Stryker directed and produced the documentary Screaming Queens (2005), based on the protest in 1966 when patrons of Compton’s Cafeteria in San Francisco rioted against police and destroyed a squad car (Stryker, 2005 & 2008). Tamara Ching, a transgender activist involved in the riot, reported that after the protest, police stopped harassing transgender people on the streets of the Tenderloin District where Compton’s was located (Stryker, 2005). After transgender activist Louis Ergestrasse introduced police sergeant Elliot Blackstone to Harry Benjamin’s Transsexual Phenomenon, Blackstone took a leading role in changing police treatment of transgender people (Stryker, 2008, p. 75). He asked Dr. Joel Fort at the Center for Special Problems, a radical enclave of the San Francisco Department of Public Health, to provide services for transsexuals (Meyerowitz, 2002). Dr. Joel Fort worked with Benjamin and his patient transgender activist Wendy Kohler, who formed the first transgender support group, “Conversion Our Goal,” and the National Gender-Sexual Identification Council (Meyerowtiz, 2002; Stryker, 2008). Blackstone supported Kohler and her group which met in Glide Memorial Church, an organization dedicated to providing social services and health care for transient and diverse populations. Kate Davis and David Heilbroner directed the documentary film Stonewall Uprising (2010) which describes the three days of rioting against police at the Stonewall Inn bar in New York City’s Greenwich Village in June 1969. This action resulted in increased community organizing. A shift occurred in gay activism in which it veered away from attempts to mainstream with straight, gender binary dominant culture. Drag queens, hustlers, gender non-conformists, gay men, lesbians and counterculture youth started to collaborate with the provision of food, clothing and shelter, as well as to
  • 45. 32 advocate for civil rights for transgender people. In 1970, veterans of the Stonewall Uprising, Sylvia Rivera and Marsha P. Johnson, established Street Transvestite Action Revolutionaries or STAR House, providing care for African American and Latino transgender youth. Lee Brewster and Bunny Eisenhower founded the Queen’s Liberation Front which instituted the commemoration of the Stonewall Uprising each June, now known as Pride celebrations for LGBTIQQ people. In 1970 Angela K. Douglas formed the first international transgender organization, Transsexual Activist Organization, with chapters in seven cities across the U.S. as well as in Canada, England, and Northern Ireland. Douglas deplored the pathologization of gender variance and fought for institutional reform. In 1973, the Transexual Counseling Service was formed and used one “s” to distinguish from the medical term transsexual. The uprisings at Cooper’s Donuts, Dewey’s, Compton’s Cafeteria, and the Stonewall Inn paved the way for street queens and other transgender activists to organize and effect a reduction in police harassment and brutality, eventual policy change, as well as improved quality of health care. Although more medical doctors began advocating for their clients, others were still inclined to hold firmly to the medicalization and pathologization of transgender people. Development of standards of care. In 1979 the Harry Benjamin International Gender Dysphoria Association (HBIGDA), a group of therapists and physicians, designed guidelines for hormonal and surgical sex assignment procedures and psychotherapeutic interventions described in their Standards of Care (SOC). These guidelines were developed in order to improve health services for transsexual and transgender people (Fraser, 2009). Throughout the next three decades, six additional versions of the
  • 46. 33 guidelines were published with the seventh most recent version released in 2011. The name of the HBIGDA changed to the World Professional Association for Transgender Health (WPATH) in 2006, and was ratified by the members in 2009. The original HBIGDA SOC for Gender Identity Disorders were approved at the 6th International Gender Dysphoria Symposium in San Diego, California (1979). Although the guidelines referred to hormonal and sex reassignment, psychotherapeutic interventions were also included in SRS service provision. The first four versions of the SOC (1979, 1980, 1981, and 1990) focused treatment on behavioral intervention, with the possibility of referrals for hormones and surgery. Psychotherapy was required for approval of hormones and surgery, and thus interventions focused primarily on evaluation and referral. Psychotherapy was required throughout the process and following SRS. Although the SOC were intended to respond to the needs of transsexual clients, controversy about the Standards focused on the role of psychotherapists as gatekeepers providing access to SRS via letters of recommendation with a diagnosis (Bockting et al, 2004; Denny, 2004; Fraser, 2009; Lev, 2005). After the American Psychiatric Association developed an official diagnostic nomenclature for gender variance distinct from transvestitism in the third edition of the DSM published in 1980 (APA, 1980; Meyer et al, 2001), subsequent versions of the SOC included diagnoses in recommendation letters written by mental health providers for SRS. Although the diagnosis and letter were (and still are) advised in the SOC, the HBIGDA recognized that assigning a specified amount of psychotherapy negatively impacted the therapeutic alliance. Thus, the HBIGDA removed psychotherapy as a requirement, but highly recommended it in the 5th and 6th versions (1998 and 2001,
  • 47. 34 respectively) (Fraser, 2009; Levine et al, 1998; Meyer et al, 2001). Psychotherapy guidelines included in the 5th and 6th SOC emphasize the importance of a strong therapeutic alliance, recognition of patients’ autonomy, and support of multiple options for gender adaptation (Fraser, 2009; Levine et al, 1998; Meyer et al, 2001). The SOC began to acknowledge that a person can never completely eradicate aspects of their original sex assignment (Fraser, 2009). Rather than emphasize passing as male or female, transgender people were, in this way, understood with “…the whole of the person’s complexity… the goals of therapy are to help the person live more comfortably within a gender identity and to deal effectively with non-gender issues” (Meyer et al., 2001, p.12). The HBIGDA changed its name to the World Professional Association for Transgender Health (WPATH) in 2006 at a board retreat (Fraser, 2009). According to the 2006 board minutes, the new name incorporated the new vision and mission statements: “As an international multidisciplinary professional association, the mission of HBIGDA, (now WPATH), is to promote evidence-based care, education, research, advocacy, public policy and respect in transgender health” (Meyer et al, 2001). With this name change, WPATH began to acknowledge shifting cultural gender paradigms in international medical and psychotherapeutic practice (Fraser, 2009). Eli Coleman, former HBIGDA president, addressed this issue with the HBIGDA in 2003: “…there has been a significant paradigm shift in how we have treated transgendered persons…” (Fraser, 2009). He presented his Ten Steps to Promote Transgender Health: 1) Promote sexual health including elimination of the barriers to sexual health, 2) Learn from other cultures, 3) Let old paradigms die and new ones emerge, 4) Provide access to
  • 48. 35 optimal care, 5) Provide training to allied health professionals, 6) Provide sound and ethical research, 7) End discrimination and stigma, 8) Change laws and public policies, 9) Change religious views, and 10) Promote social tolerance for diversity. WPATH included transgender in the title for “a better representation of our membership and to confirm that full membership is for professionally trained people who work with trans-patients or clients” (Fraser, 2009). WPATH’s new vision incorporated Coleman’s Ten Steps, and sought to ally with the World Health Organization definition of health as stated in the preamble to their constitution (1949): “…a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (Fraser, 2009).” Intending to steer away from pathologizing gender variance, WPATH presented the new vision of a multidisciplinary approach to care that promoted “…education, advocacy, training, research, quality health care and best practice standards for service providers and policy makers regarding gender variant individuals” (WPATH, board minutes, 2006 as cited by Fraser, 2009). The 7th version of the SOC in press ten years later in September 2011 was a departure from subsequent versions, particularly with regard to respecting gender fluidity. The new SOC states that gender variance is “…a common and cultural-diverse phenomenon that should not be judged as inherently pathological or negative” (Coleman, et al, 2011, p. 4), and that discrimination and stigmatization are directly associated with pathologization. Mental health care providers are urged “… to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment” (Coleman et al, 2011, p. 1).
  • 49. 36 The SOC emphasizes that providers should not impose a binary view of gender, and that the practice of trying to change a person’s gender to become more congruent with the sex assigned at birth is no longer ethical. Despite the proclamations against pathologization, the SOC continue to promote diagnostic nomenclature in the DSM-5. WPATH proposed the term “Gender Dysphoria” to replace “Gender Identity Disorder” in the 5th version (Coleman et al, 2011). Rather than using the terms intersex or intersexuality, WPATH suggests using the term “Disorder of Sex Development (DSD),” which is controversial to intersex individuals who strongly object to the naming of their identity as a disorder (Coleman et al, 2011). There are still some contributors to the SOC and the DSM who continue to resist the de-pathologization of gender variance. However, WPATH and updated versions of the SOC for transsexual, transgender and gender-nonconforming people continue to shift in positive ways, particularly as more transgender people and their allies direct the course of health care. Gender diagnoses in the Diagnostic and Statistical Manual of Mental Disorders. There are four versions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), with three revisions (APA, 1952, 1968, 1975, 1980, 1987, 1994, 2000). Between versions and revisions, gender diagnoses were listed under different categories with varied numeric coding. In the first edition of the DSM (1952), under the diagnostic category of Sociopathic Personality Disturbance (000-x60) a diagnosis of Sexual Deviations (000- x63) included:
  • 50. 37 … Most of the cases formerly classed as ‘psychopathic personality with pathologic sexuality.’ This diagnosis will specify the type of pathologic behavior, such as homosexuality, transvestism, pedophilia, fetishism, and sexual sadism (including rape, sexual assault, mutilation). (APA, 1952, p. 39) In the second edition of the DSM (1968), the category Personality Disorders and Certain Other Non-Psychotic Mental Disorders maintained the same subcategory of Sexual Deviations, which includes 302.3 Transvestitism, with a change of spelling, 302.8 Other sexual deviation, and 302.9 Unspecified sexual deviation. This subcategory was described as: For individuals whose sexual interests [were] directed primarily towards objects other than people of the opposite sex, toward sexual acts not usually associated with coitus, or toward coitus performed under bizarre circumstances as in necrophilia, pedophilia, sexual sadism, and fetishism. Even though many [found] their practices distasteful, they remain unable to substitute normal sexual behavior for them. (APA, 1952, p.44) Transsexuals and intersex individuals were presumably subsumed in the Other or Unspecifed sexual deviation diagnoses, however, no clarifications were made regarding diagnoses for gender variance. Homosexuality was listed as a disorder, but removed in the DSM nosology in 1973 by the APA, and replaced with Sexual Orientation Disturbance. In the third edition of the DSM (1980), the category Psychosexual Disorders included three new diagnoses: 302.5x Transsexualism, 302.60 Gender Identity Disorder of Childhood, and 302.85 Atypical Gender Identity Disorder. Transsexualism was defined as “a persistent sense of discomfort and inappropriateness about one’s anatomic sex and a persistent wish to be rid of one’s genitals and to live as a member of the other sex” (APA, 1980, p. 261-2). Transsexualism also included sexual orientation subtypes: 0= unspecified, 1= asexual, 2= homosexual, and 3= heterosexual. Doctors would refer
  • 51. 38 these designations based on patients’ sex assigned at birth, not on the gender with which they identified. In the revised third edition of the DSM (1987), three new diagnoses were added, as well as a new diagnostic category. Two of the new diagnoses—302.85 Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type (GIDAANT), and 302.85 Gender Identity Disorder Not Otherwise Specified (GID NOS) – shared the same coding, and were included in Disorders Usually First Evident in Infancy, Childhood, or Adolescence. The third new diagnosis, 302.30 Transvestic Fetishism, was the only remaining gender-related diagnosis in the Psychosexual Disorders category, and listed in the Paraphilia subcategory. Diagnostic criteria for GID NOS included people with intersex conditions. The essential feature of Transvestic Fetishism was described as “recurrent, intense, sexual urges and sexually arousing fantasies, of at least six months’ duration, involving cross-dressing” (APA, 1987, p. 288). This disorder was used primarily to describe heterosexual males who may have engaged in homosexual activities. In the fourth edition of the DSM (1994), a new category of Sexual and Gender Identity Disorders included two subcategories: Gender Identity Disorders and Paraphilias. GID NOS is listed under Gender Identity Disorders, in addition to the two revised diagnoses of 302.xx GID in 302.85 Adults and Adolescents, and 302.6 GID in Children. Transvestic Fetishism continued to be listed under the Paraphilia subcategory, and specify if With Gender Dysphoria. DSM-IV also described the possibility for a concurrent diagnosis of GID and Transvestic Fetishism.
  • 52. 39 There were no changes in categorizations or diagnoses in the revised edition of the DSM-IV (2000) [see Appendix F for full diagnostic criteria]. Autogynephilia was included as an associated feature of Transvestic Fetishism, with subtypes based on sexual orientation and arousal. Autogynephilia is described as a phenomenon in males “who experience sexual arousal produced by the accompanying thought or image of themselves as females” (APA, 2000, p.574). DSM-V proposes that the GID diagnosis change to Gender Dysphoria, defined as “a marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration” (APA, www.DSM5.org). This includes the subtypes with or without the “Disorder of Sex Development,” which may indicate the person’s intersexuality. Also specified is “Post-transition,” indicating whether the person “… has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is undergoing) at least one cross-sex medical procedure or treatment regimen, namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in a natal male, mastectomy, phalloplasty in a natal female)” (APA, 2012). In the Paraphilia subcategory, Transvestic Fetishism may be revised in DSM-V to Transvestic Disorder, defined as a “…recurrent and intense sexual arousal from cross- dressing, as manifested by fantasies, urges, or behaviors.” Clinicians can subsequently, specify “With Fetishism (Sexually Aroused by Fabrics, Materials, or Garments),” or “With Autogynephilia (Sexually Aroused by Thought or Image of Self as Female),” or “With Autoandrophilia (Sexually Aroused by Thought or Image of Self as Male). Final specifiers include “In Remission (No Distress, Impairment, or Recurring Behavior and in
  • 53. 40 an Uncontrolled Environment)” with time of duration, and “In a Controlled Environment.” The diagnostic rationale in the DSM neglects to explain the final specifiers. The American Psychiatric Association’s DSM criteria including gender diagnoses are used by most mental health providers in the United States. Often diagnoses are necessary in order for patients to receive medical benefits including gender realignment surgeries (Green & Wilson, 2012), but providers are urging other providers to use caution when using diagnoses, and avoid pathologizing gender and sexual variance (Coleman et al, 2011). Internationally, gender and sexual variance has been classified in the International Classification of Diseases discussed in the next section. Gender diagnoses in the International Classification of Diseases. WHO assumed leadership of the ICD in 1948 (Jette et al, 2010). The DSM was influenced by the World Health Organization’s diagnostic nomenclature in the International Classification of Diseases (ICD) (APA, 1968). In conjunction with the DSM, the U.S. National Center for Health Statistics (NCHS) developed its own clinical modification (CM) to the ICD (NCHS, 1999; WHO, 1992). The Sexual Deviation classification was introduced to the ICD-6 (1948), and was later included in the DSM-I in 1952 (APA, 1952; Reiersøl & Skeid , 2006). In the fifth chapter of the ICD-10 “Mental and Behavioral Disorders” the classification of Gender Identity Disorders, (coded as F64) is listed under the Disorders of Adult Personality and Behavior, (F60-69). This subcategory includes Transsexualism (F64) described as:
  • 54. 41 A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one's anatomic sex, and a wish to have surgery and hormonal treatment to make one's body as congruent as possible with one's preferred sex. (WHO, 1992, p.215) The diagnosis Dual-role Transvestism (F64.1) is described as: The wearing of clothes of the opposite sex for part of the individual's existence in order to enjoy the temporary experience of membership of the opposite sex, but without any desire for a more permanent sex change or associated surgical reassignment, and without sexual excitement accompanying the cross-dressing. (WHO, 1992, p.215) The diagnosis Gender Identity Disorder of Childhood (F64.2) is described as: A disorder, usually first manifest during early childhood (and always well before puberty), characterized by a persistent and intense distress about assigned sex, together with a desire to be (or insistence that one is) of the other sex. There is a persistent preoccupation with the dress and activities of the opposite sex and repudiation of the individual's own sex. The diagnosis requires a profound disturbance of the normal gender identity; mere tomboyishness in girls or girlish behaviour in boys is not sufficient. Gender identity disorders in individuals who have reached or are entering puberty should not be classified here but in F66. (WHO, 1992, p. 215-216) The diagnosis Sexual Maturation Disorder (F66) is described as: The patient suffers from uncertainty about his or her gender identity or sexual orientation, which causes anxiety or depression. Most commonly this occurs in adolescents who are not certain whether they are homosexual, heterosexual or bisexual in orientation, or in individuals who, after a period of apparently stable sexual orientation (often within a longstanding relationship), find that their sexual orientation is changing. (WHO, 1992, p. 221) The Gender Identity Disorders subcatory includes (without description) Other gender Identity Disorders (F64.8), and Gender Identity Disorder Unspecified (F64.9). Listed under the subcategory Disorders of Sexual Preference (F65) is the diagnosis Fetishistic Transvestism (F65.1) described as:
  • 55. 42 The wearing of clothes of the opposite sex principally to obtain sexual excitement. Fetishistic transvestism is distinguished from transsexual transvestism by its clear association with sexual arousal and the strong desire to remove the clothing once orgasm occurs and sexual arousal declines. A history of fetishistic transvestism is commonly reported as an earlier phase by transsexuals and probably represents a stage in the development of transsexualism in such cases. (WHO, 1992, p.218) The classification of diseases and disorders in the World Health Organization’s ICD mirrors much of the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders. Although there have been suggestions to universalize a diagnostic manual internationally, other countries have come up with their own classifications which incorporate the nuances of their cultural experiences of psychopathology (Paoin et al, 2009). Gender diagnostic reform. For more than three decades, medical and psychological practitioners have worked with the gender diagnoses in the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM). The controversy related to Gender Identity Disorder (GID) reform in both texts involves multifaceted viewpoints from within the transgender human rights movement, and psycho-medical communities. Arguments focus on whether to include or remove the gender diagnoses. Physicians, psychiatrists, psychologists, and legal reform advocates of the World Professional Association for Transgender Health (WPATH) who are in favor of including GID in the ICD and DSM, maintain that the diagnosis serves those who suffer from gender dyphoria, and legitimizes hormones and SRS for legal and policy reform including insurance coverage (Coleman et al, 2011). Insurance companies rarely cover SRS or hormone treatments (Stryker, 2008); however some state and national health
  • 56. 43 programs provide coverage for individuals diagnosed with GID (Green & Wilson, 2012). Ironically, health providers will continue to be untrained in schools until insurance will reimburse for it (Green, 2012, personal communication). Discussions regarding the DSM-V suggested revisions, include changing the terminology to be less stigmatizing of gender variance, or changing the diagnosis to a medical condition. Suggested terminology include: gender dysphoria (Coleman et al, 2011); gender dissonance (Winters, 2005); gender incongruity (Rochman, 2007); and Gender Expression Deprivation Anxiety Disorder, or GEDAD (Vitale, 2005). Vitale (2005) suggests removing GID listing GEDAD under Anxiety Disorders. Lev (2005) suggests removing GID from the DSM and using the ICD-10 codes for Transsexuality under Axis III medical conditions. Lev’s proposal would enable insurance companies to reimburse the medical condition “similar to pregnancy” thereby avoiding the stigmatization of an Axis I mental health diagnosis (Lev, 2005). However, Bockting points out that “there is no physical marker that a person has gender dysphoria” unless a person has begun hormone treatment, “it would be possible to physically assess if a person’s chromosomes don’t match their genitalia. Perhaps an ICD classification could be used for people who have transitioned and continue to need hormone therapy” (Rochman, 2007). Accessing hormones on the street or online can be a health risk without a doctor’s prescription and well-trained, careful observation particularly for individuals with hormonal conditions, as well as the potential for Hepatitis C and HIV infection for those who share injection equipment (Bockting, 2008; Coleman et al, 2011; Grant et al, 2011).
  • 57. 44 Some advocates urge for the complete removal of the diagnoses, due to the medical and societal discrimination transgender people face as a result of institutionalized transphobia inherent in the diagnosis (Bolin, 1988). Gender identity pathology assumes that the problem resides within the person, and fails to account for societal stigma from which the person suffers. Because of discrimination, harassment and violence faced by transgender people on a daily basis (Grant et al, 2011), it is particularly problematic to locate the disease within the person’s psychology. As with most disorders listed in the DSM and ICD, disturbances are determined based on “clinically significant distress or impairment in social, occupational, or other important areas of functioning” (APA, 2000). Transgender people may be unable to maintain employment not because they are distressed about their gender, but because of the pervasive stigma restricting their ability to function in a transphobic society (Grant et al, 2011). In addition to employment discrimination, gender variant people face inadequate access to medical care due to discrimination, harassment and violence from providers hospitals and nursing care facilities (Grant et al, 2011). Although proponents of the diagnosis suggest that it legitimizes transgender people and their treatment, many health providers are left untrained and ignorant about the complexities of transgender health care needs. As a result, many are denied access to care if insurers refuse coverage if they arbitrarily deem these types of basic services as related to gender transition (Rounds, McGrath & Walsh, 2013). Advocate Kelly Winters and other advocates and clinicians listed on their GIDreform.org site suggest reforming GID, just as homosexuality was reformed in the DSM because it caused harm to many people. Homosexuality was also removed, in part,
  • 58. 45 because it was seen as a more common phenomon (Lev, 2004). Therefore, as the prevalence of gender variance becomes more widely known, gender diagnoses may also be removed. The sexism inherent in descriptions of the criteria also pathologize gender-variant masculine and feminine behaviors in children (Lev, 2005). Diagnostic criteria for GID features detailed descriptions of masculine and feminine stereotypes of behavior and feelings, including for children: A strong preference for playmates of the other sex… in boys, assertions that his penis or testes are disgusting or will disappear or … aversion toward rough-and- tumble play and rejection of male stereotypical toys, games, and activities; in girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing.” (APA, 1994, pp. 532-538) These over-inclusive diagnostic criteria contribute to the stigma of gender nonconforming youth (Winters, 2007). Involved with the DSM-IV (1994) gender diagnosis committees, Canadian psychologist Kenneth Zucker participated in the creation of the GID diagnosis used for children in an attempt to prevent adult onset of transsexuality (Zucker and Bradley, 1995). Zucker held similar views to his mentor John Money, who sought to cure people of gender variance through psychological intervention. Zucker treated over 500 preadolescent gender-variant children with reparative therapy in order to conform to his expectations for male and female behavior in children (Brown, 2006). Zucker promoted the National Association for Research & Therapy of Homosexuals. According to his colleague Michael J. Baily (2003) Zucker considers transsexual women a "bad outcome" for gay men. Despite Zucker’s distain for sexual and gender variance, he was one of 23
  • 59. 46 authors of the current 7th version of the WPATH Standards of Care, which states that treatment designed to realign gender variant people with their assigned gender at birth is unethical (Coleman et al, 2011). Advocates for the removal of gender diagnoses in the DSM and ICD highlight the multicultural perspectives of gender that are omitted from the medical nosology. The psycho-medical history of gender variance in the U.S. and Canada was written by white, heterosexual, non-transgender males (Meyerowitz, 2002; Stryker, 2008). International and historical archives, as well as recent evidence reveal positive perspectives on gender variance as a naturally occurring variation (Feinberg, 1996; Ophelian, 2009). In the 1990s, the term “transgender” became a more inclusive, politically unifying term for gender variance (Lev, 2007). Psychologists who sought to avoid the stigmatization of the diagnoses reformed their psychotherapeutic approach in order to provide more culturally competent care (Fraser, 2009, 2009a; Lev, 2005, 2009; Tilsen et al, 2007). Essentialist and social constructionist perspectives on trans identity and language. For the last hundred years, medical professionals in the United States and Europe diagnosed sexuality and gender variance (APA 1952, 1968, 1975; Benjamin, 1966; Caudwell, 1949; Ellis, 1928; Freud, 1905; Green & Money, 1969; Krafft-Ebbing, 1886; Meerloo, 1967), while transgender people sought ways to recognize and name their sexuality and gender identity (Hirschfeld, 1910; Jorgensen, 1967, 1970; Lind, 1918, 1922). Each explored essentialist or social constructionist perspectives. Essentialists regard sex or gender as essential features a person is born with or inherently fixed, while social constructionists perceive sex and gender as co-constructed within one’s self and social and cultural contexts.
  • 60. 47 The controversy over transgender language and identity began in the mid- 18th century, when transgender advocates attempted to describe themselves in the first wave of transgender activism (Meyerowitz, 2002). Working with their doctors, early transsexual-identified people introduced essentialist perspectives of having been “born in the wrong body,” asserting themselves “true transsexuals” who successfully “passed” as heterosexual women or men (Benjamin, 1966; Jorgensen, 1967, 1970). Many transsexual people identify strongly with the binary view, stating that they do not simply identify with their gender, but feel that they are male or female as a core part of themselves. Transsexuals feel that hormones and surgery affirm their true sex, and rather than “reassignment,” they receive sexual “realignment” procedures. Subsequently, medical professionals and scientists categorize sex and gender using essentialist, or inherent or fixed traits in order to universalize transgender experiences into male or female sex characteristics and expressions (Benjamin, 1966; Broido, 2000). Many doctors, including Magnus Hirschfeld (1910), Alfred Kinsey (1948, 1953), and Harry Benjamin (1966) included intersex as a means to promote essential biological diversity. Doctors Richard Green and John Money (1969) used conservative views of a two-sex system to promote segregated ideas of masculine and female gender identity. The American Psychiatric Association utilized essentialist perceptions of male and female sex to pathologize gender variance in the Diagnostic and Statistical Manual for Mental Disorders (APA, 1952, 1968, 1975, 1980, 1987, 1994, 2000). In the 1960s and 70s, the second wave of transgender activism focused on civil rights and gender fluidity (Meyerowitz, 2002). During this time, transgender activists objected to the straight, gender binary, rigid model of beauty, particularly as doctors
  • 61. 48 rejected them regardless of how well they passed as male or female (Denny, 1992; Stryker, 2008). Young, homeless and transgender people of color who were denied treatment or could not afford hormones or surgery were constantly harassed by police and incarcerated (Feinberg, 1996). Activists argued against essentialist scientific notions of “the perfect gender” (Bornstein, 1998), utilizing social constructionist or post-modern perspectives to promote a paradigm shift in society’s construction of gender (Butler, 1998; Wilchins, 2004). Social Constructionism or deconstructionism argues that the language and experience of gender is a culture-bound, socially constructed phenomena whereby those in power privilege their definitions over others (Derrida, 1974; Foucault, 1969, 1978). Social Constructionism argues that essentialism falsely universalizes experiences, resulting in racist, transphobic, homophobic and sexist perspectives (Arseneau, 2008). In the 1990s to early 2000s, there was a resurgence in social constructionist perspectives related to reclaiming the terms queer and transgender in order to promote sexual and gender variance (Blumenstein, 2003; Bornstein, 1995, 1998, 2011; Butler, 1990; Feinberg, 1993, 1996; Green, 2004; Roughgarden, 2004, 2009; Wilchins, 2004). In fact, both essentialist and social constructionist perspectives have been used to justify mistreatment of trans people. On the one hand, doctors such as psychologist John Money (1971), believing that gender was entirely socially constructed, promoted psychosocial “cures,” conducting research experiments using “reparative” or “rehabilitative” therapy techniques, based on the assumption that they could return people to identifying with the gender assigned to them at birth (Colapinto, 2000; Money, 1971; Meyerowitz, 2002). On the other hand, essentialist perspectives have been used to