Specialists in the Medical & Psychological Aspects of Transgender Health Care
|guidance & transition||
Carl W. Bushong, Ph.D., LMFT
During my years of work and study with gender folk, I have consistently been surprised and amazed at both the depth and breath of change that has occurred during transition. And when I say transition, I am not just speaking of individuals described (either by oneself or by others) as “transsexuals,” but also “crossdressers,” “transvestites,” “transgendered people,” etc.
As I discussed in my article, What is Gender and Who is Transgendered, one’s Gender Identity is only one of our five semi-independent aspects of gender (Genetic, Physical, Brain Gender, Brain Sex and Gender Identity). One’s Gender Identity is established early in childhood and is our Self Map. Gender identity is one's subjective sense of one's own sex. Like pain, it is unambiguously felt but one is unable to prove or display it to others. One's subjective gender is just as real and more immalleable than one's physical gender but unfortunately not recognized in our culture. This internal map forms how we see ourselves as a sexual individual (our affiliation to a gender), just as Brain Sex is our Love Map—how we identify our love/sex partner.
When our gender Self Map does not match our Physical Gender (genitals), along with our society providing no niche or role (although most other societies do) for this varied gender expression, a conflict usually develops. Although gender folk’s combination of the five gender factors is just as natural as any other, it is not perceived as “normal” (what you are supposed to be or do) in our society.
Because a child’s greatest desire is to be normal (like everybody else), they create an artificial self which meets this goal. They are often so successful at this that they not only fool everyone else but themselves as well — at least part of the time, in some way.
I have gradually come to the conclusion that for most physically male gender folk, the male persona is an artificial construction produced by the early adolescent individual (ages 12 to 15) in order to fit in and be like everybody else. For the physically female person, there is a separate and different, but still consistent pattern, which I will address in a separate writing.
Once created, physically male gender folk live in this role — a 3-D personality with its own goals, likes and dislikes, values, hobbies, etc. Although indistinguishable from the “real thing,” it isn’t themselves. It is an artificial creation for them to be able to fit in. But, as the nagging reality of the deception becomes harder and harder to suppress, one has to express their true self somehow, in some way.
For most, dressing is the obvious compromise. If one cannot be female, one can at least express femininity. But the more one expresses one’s true self, the desire for more becomes greater. Some individuals continue expressing themselves more and more, others panic and purge only to start again later.
One's transgender classification (crossdresser, transgenderist, transsexual, etc.) is due to how each individual adjusts to first, the conflict between their natural female subjective gender (Self-map) and their need to be “normal,” and later to how and how much they resolve the conflict between their female subjective gender and their “male persona.” There is no objective “best solution,” only a subjective, personal best solution, which may change over time.
After years or decades of living, working and building within their male persona, it is often too “expensive” to give up the life, perks, family, etc., one has built up—in order to go back to basics and have an emotionally 12 year old girl grow up—and live in a once male 40+ year old body.
Therefore, while all gender folk need to transition, not all need to use hormones, let alone surgery. The only person who truly knows where and how far to go is the transgendered person, themselves. But even they cannot do it alone. When one has spent decades fooling everyone, including oneself, it is difficult to tell what is true and what is smoke and mirrors. As we need a reflection to see our own face, we need a knowledgeable, experienced helper to see our true self.
How does one find such a helper? —With great difficulty, I’m afraid. In my opinion, a psychotherapist’s role is to be a helper, a teacher, and a guide. To help the transgendered with those areas and conflicts resulting from a lifetime of living a double life, one inside or hidden from others, one out in public. The therapist needs to be a teacher in making available all the accumulated knowledge, skills and choices one has as well as clearing away the myths, lies and misinformation. And as a guide, the therapist aids the client through the social, legal, medical and emotional mine fields toward one’s true self. Here are some must have’s you will need to find in your helper.
your helper knowledgeable and up-to-date about transgender needs and
While gender folk have problems and need psychotherapy, and marriage and family counseling like any other group, transitioning, itself, is not psychotherapy. Transitioning is being given the tools and knowledge to ask the questions whose answers set them free. The old artificial male persona falls away piece by piece, revealing underneath a brand new self. The new self may be female or just more feminine. Whatever transitioned people may appear to others, to themselves they are happy, and sometimes for the first time, whole individuals.
I am pleased to say that those who have stayed to complete their transition with me have all become both happy people and very happy with their decision to transition. Never have I had so many people use the word “giddy” to describe themselves and their new life.
However far one is able to go toward dismantling the male persona and allowing their naturally female subjective gender to develop, one generally seems to have the following three levels of transition:
1. Recognition that one's Brain Gender is different from one's Physical Gender —This first phase comprises the majority of transgendered persons (75 – 95%) and can take the form of seeing one's self as a "woman trapped in a man's body," a need to express one's "feminine side," etc. This stage is mainly concerned with physical/surface changes such as crossdressing, passing, makeup, wigs, etc. In this first part, many gender folk don't even venture from their own home in female attire or restrict their expression to undergarments (bra, panties) in public. They often have a juvenile (before age 15) and later, an adult phase. There is often years or decades between the two phases. This level is filled with confusion, conflict, guilt, panic, and purging. The so called "Primary Transsexual" is an individual who never constructs a male persona and therefore never accepts their male genitals or challenges their female Self Map/subjective gender.
2. Accepting one's True Self— This stage is much more varied than the first, and has less emotional turmoil. This is the stage where one begins to accept their female self in some way and to make lifestyle changes to accommodate this acceptance. One may only accept the need to appear female, still denying their female true self (crossdresser) or begin to accept their true female self, but concentrating on a superficial physical level of change (transsexual, transgendered).
The self-identified crossdresser may begin to bring his significant other into his dressing, begin going to crossdresser meetings and events, or even going out into public. Those individuals more accepting of their true self will start to look for help in physical transitioning, such as hormones, electrolysis, and surgery, as well as wigs, makeup and clothes.
The major insight lacking at this stage is that they are still under the control of the male persona with all of its unnatural fears, drives, expectations, and knowledge. Even their view of their "female self" is his view, not their freed and autonomous female self. They are still trapped in the belief that physical form alone determines gender.
3. Becoming one's True Self — This is the last but unfortunately least experienced part of transitioning. This is the stage when that little girl trapped inside an artificial male persona in order to fit in, breaks free, grows up and has her own life — often with markedly different values, temperament and interests.
It has been my observation that the female subjective self needs little help in growing up and developing if the overpowering weight of the male persona is removed from it. The individual has spent years, decades developing, reinforcing and living in this male role. Dismantling the male persona takes a great deal of time, effort and outside help. In those individuals identified as "transsexual," their subjective sense of happiness and success is directly parallel with the degree they have dismantled their male identity, not on their age, physical size, hormones, surgery, etc. Another interesting aspect of a female subjective gender with a male physical gender is the concept of Sexual Orientation. To classify a M/F individual as either homosexual or heterosexual would be equally false. If one views their gender as that established by their subjective gender, then having sex with a physical/ subjective female would make them homosexual (lesbian). But, if one viewed their actions from their physical gender, they would be committing a heterosexual act. In other words, no matter which gender they have sexual relations with, they are simultaneously committing both a homosexual and heterosexual act. (See What is Gender and Who is Transgendered for details.)
My method for transitioning I term “Informed Decision Making.” In this, the client makes their own decision to go down whichever road they choose and how far, upon being given the information and insight needed to do so. I find most gender folk focus on their dress and body at first not realizing that the whole persona changes during successful transitioning. This is why physical transitioning (clothes, makeup, hormones, surgery) is only a minor part of the whole transition process. Values, lifelong hobbies, musical tastes, temperament, and goals, can and often do change. The new self which emerges from under the male personality often grows into a person no closer to the male persona than a sister. It is often a rebirth in slow motion (it takes one to two+ years). One becomes their true natural self, which is far greater than just a change in physical gender.
But, while transitioning offers great promise, there are also great dangers if one does not use care in choosing who they listen to and ask for help. All too often individuals in transition, or for that matter, those who feel they have arrived, become a collection of disparate traits and cosmetic changes instead of a complete package. Naturally, some individuals are stubborn and refuse to accept any guidance and support. But the real culprits that hold many from achieving their best are often the treating professionals themselves.
Many times providers remain ill informed about transgender issues or worse, remain uncaring and expect the transgendered client to fend for oneself. They never aid or foster an informed consumer’s mind-set. Who’s best interest is served when a provider is often unprepared to provide the client with the broad based understanding needed to make the proper choices?
If an individual happens upon “professionals” who offer no guidance or sense of priority while making available hormones or surgery with little or no life-style preparation — a disaster may be in store. The individual’s future happiness is threatened when the outcome of such “professional” intervention may be a bearded, baritone post-op lady with large breast implants but little or no training or understanding of how to walk, talk, or sit, let alone a strong sense of “female-self.”
In an area such as gender, where myth and ignorance often exceed knowledge within the professional community, it is only expected that the lay persons in need should be confused, frustrated, and uninformed. The transgendered often begin life feeling as if they are the only person in the world to have such a problem; that something is wrong with them - and not just in society’s view. When at last they try to be themselves, to throw off sometimes decades of deception, frustration and denial, they are often both fearful and resentful. So much of their life is felt to be “lost,” and naturally there is an eagerness to get on with their “new self,” right now! Unfortunately, many gender folk have collected a lot of “excess baggage” in the form of a marriage, family, children, and educational/professional development that doesn’t properly translate to one’s desired gender status. And just like society as a whole, the transgendered individual may focus far too much on the physical aspects of gender, down-playing or even missing the mental, behavioral, social and emotional aspects. Their male persona is not realized or appreciated, let alone its need to be dismantled.
When it comes to gender, our culture is genitally obsessed. What’s between your legs and on your chest determines your gender (sex). Body form and plumbing are all our society sees and therefore all the transgendered person may be aware. Actually, most conventional wisdom regarding sex and gender is incorrect. (See What is Gender and Who is Transgendered for details.)
The most important service a professional can provide for the transgendered individual is to provide the knowledge, support and resources needed for a series of “informed choices” as to what, how and where their transformation will take them.
Today quality gender based services are becoming increasingly available, although they are still geographically spotty. While some regions of the country are very “gender knowledgeable,” others are not so gifted. Even in areas with minimal professional services available, the dynamism that a conscientious and self-aware gender support group can provide is tremendous. But sometimes support groups and Internet “chat rooms” can be counterproductive, if the blind are leading the blind. All too often those with the least knowledge and most misinformation are the most eager to share their “insights”—not as an opinion, but as “fact.” When a transgendered individual who is new to the community comes across these self-appointed experts, they are often swayed by this mis- and dysinformation. Even with the gender community’s growing size, knowledge base and opportunities, groups of individuals suffering from the consequences of misinformation and the quick-fix mentality are living in a small world of their own—still trying to influence others along the same ill-fated path. Group knowledge, resources, and a desire for personal growth are essential. While the transgendered now can take a long overdue control of their destiny, one should keep in mind that success is heightened by “informed choice,” not just choice.
Counseling, though, need not be weekly. In fact, very few of my clients receive weekly sessions after the first few months. Of course, the more intensive the effort, the quicker one will reach their goal. But counseling more than once a week doesn’t seem to help — unless there is more than one problem being worked on, such as transitioning plus marriage problems.
For example, let’s say Mary (who was Bob) has recently come to accept she is transgendered, and has a wife, Betty, who she cares for, and three children ages seven, nine, and twelve. Mary is a successful engineer at a large company making a very good wage. Her wife does not work outside the home.
Mary has several problems to solve. One — what does “transgendered” mean to her? Two — how does she now relate to her wife who is fearful and upset? Three — how, when and what to tell the children? Four — what should she do about work, friends, family, etc.?
The first problem is part of transitioning and by far the most important. As Mary answers, “What does being transgendered mean to me?,” the solution to her other questions will become clearer and clearer. But at some point, as Mary gets to know and accept herself more, she and Betty will probably benefit from couple/marriage counseling as there are many issues between them they need to resolve.
Because a person’s core personality often changes greatly during transition, making too many decisions too soon is a mistake. At the beginning of transition, Bob’s values, goals and baggage (personal responsibilities, etc.) are still in charge — at this stage Mary is only a gleam in Bob’s eye. It takes time to tear down the walls and fill in the gaps. As Mary is learning and growing, Betty needs to be brought along too — at least as far as she is willing or capable of going. Remember, this a very trying time for the spouse as well as the transgendered person. The partner’s whole life is being turned upside down and she has no control over it. The partner often feels betrayed, angry and frustrated. Betty can even see Mary as her enemy, her competition. But, the more and the sooner a knowing, experienced professional is brought into the picture, the easier it is for both parties, and the better the outcome for everyone. Betty’s willing cooperation is needed for best dealing with the children, family, and future living arrangements.
With Betty brought into the process, as Mary’s transformation continues they can decide as a couple what their relationship and living conditions will be. Not always, happily, but truthfully with everyone’s needs acknowledged and discussed.
If Mary realizes she must transition fully into a female body and role, they are now positioned to deal with this together including the telling of children, family and friends. Often a completely new job description is called for upon transition — sometimes because of the difference in Bob’s and Mary’s personality and values, and other times because a woman is not as accepted or respected in the old employment. And, of course, sometimes the prejudice of the employer leads to a loss of job. But, I have found that prejudice is the least common reason for job change if the transition is done correctly on all levels — emotional and psychological as well as physical. In fact, over the last few years, I have experienced very few negative reactions from employers, family and friends towards my transitioning gender clients. So few that I have began to feel that most negative reactions stem from gender folks not being given good help during transition rather than the transition itself. The exceptions to this rule are often spouses and best friends, because in both cases, the very basis of the relationship are often threatened by transitioning.
There is a global need for all gender folk, whether CD, TV, TS or TG to transition, although the road taken and the distance traveled may vary greatly from individual to individual. Transitioning is much more than a physical/superficial journey. And transitioning in itself is not psychotherapy but a rebirth of an individual long buried under the layers of society’s imposed expectations. Like all births, it can be long, difficult, very painful and full of doubts at times. But who can deny the joy and expectation of a new life, a new beginning, even if the death of the old is needed to give room for the birth of the new?
This Site may also be accessed via www.tgcare.com
Care Health Information Archive