Psychotherapy is not a prerequisite for referrals for medical interventions and in many ways, is independent of the assessment and evaluation requirements of the SOC. Psychotherapy involves a deeply interpersonal and subjective relationship between two people, the client and the therapist, focused on the needs and goals of the client during a usually transitional (in the broadest sense of the word) period of their life. This involves a process of (Pfafflin, 2007) listening closely: acknowledging the distress, fears, and hopes of the client and together exploring the direction to take. This may, under some circumstances, include assessment and referral, but does not do so in a substantive way.

The transgendered person seeks therapy for the same reason as does anyone else, to sort out difficulties within a compassionate, safe, nonjudgmental and neutral environment. Yet, the transgender path involves a unique journey, one with quite specific potential obstacles. The transgender specialist knows a good deal about this particular path and can help the client negotiate the difficulties and along the way.

Specific challenges include finding and hearing one’s authentic voice, and learning to express an identity and negotiate relationships independent of external pressures, both from the wider community and even from within the transgender community. With more available choices and individual variation along the transgender path, the importance of the safety within the therapy relationship to sort out myriad options cannot be overestimated.

A major aspect of healthy identity development involves being seen and mirrored authentically, and for the transgender person, this may occur for the first time in psychotherapy. An identity does not develop in a vacuum, yet for many transgender people, their sense of self in a gendered way has developed internally and in secret and hasn’t had the opportunity to be in relationship. The therapy environment provides:

• a space to develop the client’s authentic narrative
• a space to be seen, heard and mirrored, without stigma, with compassion
• a space to retrieve the lost soul
• the instillation of hope, one of the foremost tasks of psychotherapy

Depending upon the situation and the needs of the client, a good therapist is a mirror , a guide, an ally, an advocate, a steadying hand and a stable consistent image that can be internalized during the therapy and beyond. The benefits can last indefinitely.

Lin Fraser EdD- from paper on Psychotherapy in the Standards of Care

This article presents an introductory model for doing depth psychotherapy with transgender (TG) people. It is a developmental model based on a combination of: a) contemporary psychodynamic psychosocial and gender identity theory, b) Jungian theory and c) transgender narratives, the life stories people describe in therapy.

The model operates from the assumption that the trans self can be a legitimate, authentic self rather than, as has been suggested in earlier theory, a false-self or complex. In other words, this is a non-pathologizing, trans-affirming model of TG identity and therapy. It includes the strengths and problems that might emerge from the unique path of transgender identity development and also describes how these concerns might be addressed in therapy. It also addresses a therapeutic stance as well as counter transference concerns.

Issues that emerge in psychotherapy with transpeople are the same ones that emerge for anyone else, issues of self and self-in-relation, issues of identity and issues of relationships, issues of autonomy and connection, issues of identity and intimacy. For the trans person, however, these issues are both psychological and physical because this condition is both a mind and a body condition. (a mind that doesn‘t fit the body), complicated by an unknown etiology. Also, like anyone else, the trans person has inner and outer issues, inner psychodynamic issues and “out-in-the-world” issues having to do with negotiating identity with external reality.

In this paper, I‘ll be discussing these issues as they emerge across the lifespan and as they emerge in therapy, from the perspective of pre, during and post-coming out phases of TG identity development.

What I hope to do in the process, is leave the reader with things to think about, things I‘ve seen and thought about, culled from 30 years of practice from a depth psychology perspective, all in San Francisco, that can then be applied to the reader‘s own theoretical framework.

Cultural Shift

But first, I want to mention the wider context from which this clinical thinking emerges. We are in the midst of a cultural shift regarding the “Transgender Phenomenon”. This is the latest of shifts in which people themselves, who were defined by a dominant culture that put them in categories of inferiority, objected and redefined themselves. It began with the civil rights movement, then moved to the women‘s movement, then gay and now trans. In each situation, a protest emerged against pathologizing. For example, with women, standard psychodynamic theory held that women had an inferior superego with a lower capacity for moral development, an inferior soul or none at all (Freud, SE 1964), less cranial capacity, which led to poor reasoning. Moreover, women were seen as less grown-up, more childlike, like blacks. Gays have been in the same position, being defined as other and inferior. And now trans, have been inferred, like women, blacks and gays, via sexism, racism and homophobia, to have an inherent inferiority, with the added dimension (like gays until approximately 30 years ago) of psychopathology attached to the prejudice.

But.. the tide is turning, at least in some areas of the world, certainly in San Francisco, and among younger people who are more comfortable with gender diversity and fluidity

As clinicians, we are responding to both the human rights concerns, and to what we hear and see in our practices, the lived experience of TG people, fitting the theory to the people and not the other way around.

Background and Theory

My initial contact with transpeople was 30 years ago when one of my first clients was a transwoman several months pre-genital surgery who came to my clinic to work on her anger issues. Her gender transition and surgery approval preceded our work together allowing us to focus on other issues. That gave me an opportunity to learn from her about transsexuality (the term used at the time) unencumbered by assessment concerns. We continued our work through her surgery and several years post-operatively and both she and her surgical program referred many people to me.

As a civil libertarian drawn to depth work and with a mushrooming gender practice, I had no problem with trans people defining their bodies and gender expression. Nevertheless, I took very seriously my responsibility as the referring person to physicians for irreversible medical feminization and masculinization as outlined by the Standards of Care (SOC) as well as, of course, the responsibility required of depth psychotherapy to help people on their individuation path.

My interest in serving trans people has led me in many directions over the years, studying various theories, writing my doctoral dissertation on the condition, reading and traveling widely with my work in mind, spending two years at the SF Psychoanalytic Institute, being under the supervision of several Jungian analysts for the past 28 years, and of course, participating since its inception in 1989 in BAGA (Bay Area Gender Associates) peer consultation group as well as listening to hundreds of my clients’ stories over the years . The approach I describe in this paper is a brief overview of what I’ve learned.

Back when I first started seeing people, the analytic literature was limited, and what existed pathologized the condition (see, e.g., Bak, 1968; Fenichel, 1930; Greenacre, 1969; Greenson, 1966, 1968; Person & Ovesey, 1973, 1974, 1976; Stoller, 1970, 1971,1972, 1973, 1975). Although informative, useful and interesting, these theories didn’t necessarily fit the breadth and depth and surprising psychological health of many of the people sitting in my office. Although a critique of the literature is beyond the scope of this paper, based on what I was seeing, much of the literature, insightful though it was, seemed to be trying to fit people to established theory rather than the other way around. Nor did it apply to everyone. Many transpeople, aside from a mind-body mismatch, seemed quite healthy given the challenges of their outer world. Also, many transpeople complained that therapists operating from the psychodynamic theory that the trans self is a failure to separate, a defense, false self or even a psychosis and never potentially a healthy part of the self had harmed them.

That said, we don’t need to throw the baby out with the bathwater in terms of psychodynamic theory. If we remove the explicit or implicit psychopathology from trans identity, if we just shift assumptions and suspend disbelief, this theory can be very useful in understanding and helping the trans person in psychotherapy.

For example, the following (Westen, 1998) are some current concerns of contemporary psychodynamic thinking that might be useful in working with a trans person:

• A focus on the development of identity and the importance of relationships, seeking to understand how an individual develops a coherent identity, a strong sense of self, and a sense of connectedness, including a capacity for empathy,
• How early patterns of relatedness that develop in childhood continue throughout the lifespan,
• How adaptive unconscious processes and defenses work,
• How the role of representations of the self and others learned in
• childhood, create both distortions and healthy relationships and
• How a relational therapy based on insight, empathy and compassion can modify either unconscious or painful processes.

Psychotherapy from a Jungian perspective is about fostering individuation, “being who the person is meant to be” (Wheelwright, 1982) and addresses questions of meaning and expansion of consciousness. What that‘s about is helping the person develop a healthy self and finding meaning in relation to their own ego (the self with a little s); to others, intimate partner, family and community; to work; and to the Self (with a big S, that some call God or Higher Self).

Individuation is uniquely challenging for TG person because in order to be who they were meant to be, the person must challenge societal norms, expectations of family and loved ones, what others tell them they are meant to be. They must challenge the generally accepted certainty of the stability of biological sex and gender, what most believe to be fixed and immutable.

The Jungian perspective works well with TG’s, however, because it is not as concerned with cultural rules and conformity as are most perspectives and is more about developing who one uniquely is in the larger world. Jungian theory is also not so culture bound, can be contextual and relational, opening a wider frame in which to connect with the Self.

Jungians are also not particularly concerned with pathology. Jung said Freud took care of that (Bolen, 2004) leaving space for him to focus on health and possibility. And today, contemporary psychodynamic theory can do the same.

Finally, in terms of the therapist stance, the bottom line, in my experience is to believe the person. Like in any good therapy, skilled clinicians assume that the other is an authority of their own experience.

This therapist stance, then, is one of no preconceived ideas. The therapist and client collaborate on a journey in search of the client’s truth. And, again, as in any good therapy, the therapist’s examination of his or her own beliefs, in this case, about gender, transgender, immutability of gender identity and sexual orientation is important. What is seen clinically may be surprising and challenge preconceived ideas about sex and gender and even the sense of what constitutes an integrated self. The importance of keeping an open mind cannot be overstated.

Using this approach, what has emerged in my practice over the years is that although depth psychotherapy can help people enormously on their individuation path, it doesn’t seem to have as an outcome a cure of trans feelings (other than in a few isolated cases). Depth work helps more in terms of helping people live a more authentic trans life or in understanding how the trans identity developed over time. Once stabilized, it appears more like part of the authentic self rather than a complex for most people. It seems indeed, to be, who the person was meant to be.

This is not to say that trans people don‘t bring extraordinarily rich and complex inner worlds into the therapeutic milieu. The reality is that many have extraordinarily complex internal lives that are often quite complicated and quite difficult to sort out. Many are candidates for long-term depth work, including work with the unconscious. Dream interpretation can be especially useful for assessment of the client’s inner world.

The range of what the therapist might see includes a spectrum of cross-gender identification. This spectrum includes the more conventional or stereotypical full cross-gender identity but also includes partial, even fragmented parts that may appear compartmentalized. These parts may have functioned potentially defensively early in their development but once stabilized are usually not reversible and can progress to a full cross-gender identity.

The point I‘m making is that depth work doesn’t generally lead to a disappearance of trans feelings, on the contrary, it can rather lead to an uncovering of them or in the case of bigendered people, to a way to manage a psyche that houses two selves or two sexual orientations, one towards others, and one towards an inner image of a crossgendered self. Various outcomes can be seen in terms of outer expression of gender identity.

What is important for the therapist to remember is that, according to the 2001 SOC, the “overarching treatment goal is lasting personal comfort with the gendered self in order to maximize psychological well-being and self-fulfillment”.

Transgender Identity Development & Psychotherapy

That said, and as an overview, I want to briefly take you through the life path of a composite TG person from a developmental perspective and then address the main psychological issues that, as a result, might emerge in therapy. This is just a template because the clinical picture can be quite complicated depending upon age at onset, degree of transgender feelings, life experience including significant relationships and the many other aspects of a persons‘ life that affect identity.

As I mentioned before, for the transperson, the primary concerns are the same as for everyone else, how to develop a healthy self and self-in-relation, how to experience empathy, trust, develop the capacity for intimacy and live an authentic life.

The unique challenge for the TG person, and this is probably the most important precursor for later psychological issues addressed in therapy, is that the developing trans self is hidden from others. Hence, the person develops that self in secret and alone and then to avoid stigma after coming out, often hides again. For many, then, their unique history remains secret throughout the lifespan. Thus, the developing gendered self is both unmirrored and unsocialized at least in a gendered sense.

This secrecy is changing as the culture changes. As people move out of a binary system of gender, trans and other gender-variant people are able to live more authentically. Nevertheless, all of us, including trans people live and must learn to negotiate in a binary world, probably more so for a trans person even though they might not fit the binary.

Early Life

The developmental task according to a variety of theorists (see, e.g., Ainsworth, 1978,1979; Bowlby, 1969, 1973, 1980 Erickson, 1963,1968, Waters, 1995) is to develop a sense of a separate self along with basic trust and the ability to attach.

In terms of identity development theory, we all begin to have a separate sense of self between the ages of 6-18 months, in what Lacan calls the mirroring stage of development (Kramer, 2002). We see ourselves in the mirror of others who care for us; in fact, the self is constructed in mirror relationships and with others (Goldman 1993,2005; Lacan, 1949; Winnicott, 1958, 1971). Accurate mirroring is required for the development of a coherent self (Kohut 1971,1977,1980, 1982). A separate identity is also constructed in the actual mirror, when we see ourselves in the mirror, and say, “hey, that‘s me”(Kramer on Lacan, 2002). For most people the gender that is mirrored by others matches our own self-concept.

In terms of gender identity theory, male and female gender identity differentiation develops early usually before the age of 2 and aside from being human, is the bedrock of identity of a person‘s sense of self. If it‘s one thing one knows, it’s that we’re a boy or girl. Society mirrors that sense of self, strengthening and teaching us about our gendered self-concept.

The process involves a separation from (for boys) or identification (for girls) with mother (Chodorow, 1978,1994) and this developmental task must be resolved prior to developing a healthy capacity for intimacy. The developmental tasks can be quite different for boys and girls. Boys have a particular challenge in separating from their primary caregiver (Pollack, 1995), since it‘s more difficult to disidentify than to identify which can lead to relational difficulties down the road. Nevertheless, most developmental theories concur that this separation and identification, both in close relationships and in society, however challenging, is important for the healthy consolidation of gender identity.

For the TG person, this process is even more difficult. The gendered reflection is wrong. Why this reflection is wrong is unknown. Although researchers and gender experts suspect a biological etiology for the condition, the jury is still out (see, e.g. Bockting, 2005; Coleman, 2005; DiCeglie, 1998; Green, 2004;). Lev, 2004; Roughgarden 2004; Zucker & Bradley 1995).

What is known is that the trans person feels trans or cross-gendered at the core of their being and it is this subjective feeling of gender that defines their experience. (SOC1991) This subjective sense varies from person to person in terms of definition, degree, age of onset, ability to articulate, whether partial or whole, etc, but most people have a vague awareness of its existence from an early age at least in retrospect. Hence, negotiating separation and or identification in terms of gender can be quite confusing. For example, for the developing trans person, how does one identify, or disidentify and with whom does one do this? Many transpeople report feeling confused, not necessarily having a name for the problem, (that will come later), but generally just remember feeling that something is very wrong (with them) in trying to identify with their biologically same-sexed peers.

And in listening to their stories, it seems that they don’t fit into either male or female standard developmental gender identity theory because the authentic self isn’t mirrored.
Their resolution, then, to this confusion, is to develop the gendered self along dual and parallel lines, one as the self that society mirrors and one that is kept inside and secret. There is a) an internal sense of self that does not match the body that develops in secret over time that nobody sees, that is invisible to others and is thus unmirrored and b) a false gendered self that society does mirror. Thus, two developmental lines co-exist and develop over time; the person is developing a gendered self that is unseen while society mirrors someone else.

From a depth-oriented perspective, the central psychodynamic question becomes: How does the self develop when it is unseen? In fact, when other people see who the self is not, and actually validate, reinforce and mirror, what is experienced as a false-self, at least in a gendered sense.

And, then, how does that invisible self learn how to relate, to connect? To trust others?

I think it’s obvious, from a developmental perspective, how difficult this task might be for the young transgender person. Major contemporary object relations theorists (Winnicott, 1958; Kohut, 1971,1977) expound upon the problems that emerge from faulty mirroring, especially its role in the development of a false self. In fact, much of good psychotherapy in general provides a corrective for faulty mirroring (Bolen, 2005)

The good news, of course, is that the TG person as a human being, is, of course mirrored, and thus the essential self can and does learn trust and relatedness, Nevertheless major distortions can and do occur as a result of the unintentional, but quite faulty mirroring of the gendered self.

Given this situation, then, for the developing trans person, what happens early on, that later might become issues in psychotherapy?

• The young person might become shy/isolated/introverted/depressed/ /mistrustful/ a good actor/ reactive rather than assertive, and very lonely.
• They might also develop a rich internal fantasy world with a good deal of compartmentalization and self-sufficiency. They could also have difficulty locating a core sense of self and try to be someone else, maybe even becoming hypermasculine or feminine, trying to please. They might learn to mistrust their own feelings.
• Typical feelings might include feeling like an alien, or worry about being crazy or “I‘m the only one”, with common defenses of splitting, as the only way to cope. Others might experience numbness, repression, memory problems, or even dissociation.

Generally, what is seen are all the things that occur when one has a shameful secret, but in this case the secret is one’s self.

Adolescence and Pre-transition

Aside from self and identity issues, body issues emerge during adolescence. This is the time of the betrayal of the body when secondary sex characteristics emerge. This involves giving up hope of the dream that “I really am or will grow up to be a man or a woman”, that somehow this will occur despite evidence to the contrary.

With the body-hatred can come, especially toward gendered body parts, a dissociation, and the development of a lifelong experience of a disembodied self. Many experience themselves as “all-mind”, some even have an identification with the character DATA from Star Trek or being “a machine” or an “alien” Some develop their minds at a cost to their bodies. Many are very smart and some develop an interest in computers rather than people. Life can feel “like a science fiction movie” when the body parts develop so very wrong.

Many are quite shy, feeling “I don’t fit in”, are perhaps socially awkward, with some FTM’s finding a place in lesbian culture, MTF’s in gay or “geek”culture. Many feel isolated, and report little dating. Some are asexual or continue to develop their sexual self in secret. Some are hypersexual “at least someone can enjoy this body”. Some may become fetishistic and become sexually hyperactive with the self. MTF’s may fall in love with an image of the self as a woman and can become quite solitary.

Some might develop a relationship with the mirror and do their own mirroring since no one else will. Others carry around a picture of themselves in the preferred gender role prior to transition, similar to carrying a picture of a loved one during a separation as a means to stay connected and attached (Watson on Bowlby, 2002) However, in this case, the attachment is to that part of themselves that can then function as an internal security blanket even if it can‘t yet be expressed out in the world. Hence, they learn to do for themselves what they can‘t get from the outer world.

Some MTF’s experience a splitting between their male side (logos) and female side (eros), with all their erotic energy bound up in, in a Jungian sense, an Aphrodite archetype (Bolen, 1984) within themselves that is idealized, while their male presentation is concrete, rational and inhibited. Some have few sexual partners and experience difficulty with sex and intimacy, because the body is wrong. If they are sexually active, many become adept at sexual role-playing, describing dissociation from gendered body parts. Most experience guilt and shame and feel the isolation of living with a secret

Nevertheless, this is also a time of finding images that matter, especially representations of other trans people. In the words of one of my trans colleagues, it’s a time of developing a self and keeping the hope alive by “searching for tidbits”. Many make good use of imagination and tell themselves, “I can really do this”. It’s a time of developing resilience and patience.

In years prior to the Internet, Christine Jorgensen and her 1950’s successful “sex-change”served both as a role model and gave people a name for their condition. Other trans pioneers, such as gay FTM Lou Sullivan, started trans organizations offering people a place to meet and to receive accurate information about their condition.

Today, thanks to the ubiquity of trans people and information online, information and contacts are widely available. Many join chat rooms and talk worldwide. The trans community, continually growing, even when virtual, offers a respite to the loneliness and isolation many trans people face before coming out.

(Nevertheless, as an aside, I think we need to take a closer look at the resilience and strength of the trans person during this pre-coming out period, because a question might be, how does a person develop a stable sense of a gendered self without being mirrored by others? Trans people can and do. One would actually expect more trouble than we see. Hence, trans identity could be a laboratory here for studying the development of ego strength, imagination, and hope).

Coming Out

People often come to therapy just prior to coming out. Many report that they “can‘t stand it any more”, that the pressure keeps building and they need to find out how to live with their trans feelings. They come to therapy to sort out how or whether they can accommodate these feelings in an authentic way. They come to find out where they can live most comfortably on the trans spectrum, to find out what is right for them, and whether or not to transition fully.

Therapy can take a very long time as the person sorts out the varying inner and outer pulls, trying to balance their trans condition with demands of the outer world, and the needs of other people in their lives. They are trying to sort out who is their authentic self and how much it needs to be expressed in the outer world.

Many come to therapy needing help with assessment, while others come for help with transition, having already made the decision that this is the only authentic path. Many have spent years in self-analysis and are quite sophisticated psychologically. Hence, some need more help sorting out their inner world (who am I?) while others need help dealing with their outer world, work, family and friends (I know who I am, but how do I live out in the world in my authentic gender?) Those on the latter path usually need referral letters for medical masculinization or feminization as well as support during transition.

Coming out is also time of negotiating love and work. Many ask, “Who will love me or accept me at work? Where do I fit in the outer world?” Transition involves a loss of the old self as well as some relationships. It involves dealing with discrimination, and stares, “feeling like a freak” and potentially losing all that matters to become who they feel themselves to be. Some may feel that even though they know that they are trans, transition is “just not worth it” although most feel they don’t have a choice.

For example, one MTF, who has wavered regarding transition for a very long time, and in the process has separated from a spouse, is convinced that he can‘t make major contributions in his field as he is currently doing because “she”would not be taken seriously. But if she doesn‘t come out, she asks herself, can she ever be comfortable in a male body and identity. And so it goes, back and forth, sometimes for years.

For those who do transition, this is a time of a second adolescence. Unlike other adolescents, however, the trans person has the advantage and wisdom of chronological age but without the benefit of peer support. The impact of starting the appropriate hormones is sometimes overwhelming, but a sense of rightness usually occurs. Many psychological and physical changes occur with medical masculinization and. feminization.

Transition is a very self-focussed time “The space that it takes up in psyche” can look selfish to others. Meeting other transpeople to build up authentic self-representations is important.
People are dealing with both relief and fear, especially around stigma and rejection. For the transperson this coming out process is very visible and there is no hiding.

From the perspective of identity construction, what is seen and mirrored may produce difficulties. The person in transition often looks unusual which may produce alienation. What is experienced may not match the inner image and the reality of the presentation may involve giving up the dream of being like a genetic man or woman.

Nevertheless, the person may be experiencing rightness in their gender and later their body for the first time.

Some may be experiencing a shifting sexual orientation and gender role that may be unexpected while learning how to be in new role without normal socialization. Many are experiencing a sped up adolescence from an image heretofore held only in fantasy, without the normal adolescent friendships and social feedback. Hence, they experience a lack of mirroring again.

Therapy

The key therapeutic tasks are first, to see and mirror the person in their appropriate gender, either fully or partially. This can include mirroring both genders at times or to be fluid along the gender spectrum when clinically appropriate, to hold all options and outcomes in the room. As the therapy progresses and the gender stabilizes, the task is to help the person relate authentically.

The therapist, not unlike relational depth psychotherapy in general, especially in the beginning of the work, is working in the pre-oedipal arena of attachment, separation and individuation. During this period of development, empathy and mirroring is needed for a person to develop a coherent self, without which it develops a false self as described in an earlier section of this paper.

According to Kohut, (1971) through the technique of accurate mirroring, the client feels seen, heard and understood. Empathy and mirroring are required to address early developmental deficiencies, providing a therapeutic corrective. Winnicott writes “Psychotherapy is not making clever and apt interpretations; by and large it is a long-term giving back what the patient brings. It is a complex derivative of the face that reflects what is there to be seen. Even when our patients do not get cured, they are grateful to us for seeing them as they are, and this gives us satisfaction of a deep kind.”(Goldman on Winnicott, 2002).

This may be especially true with trans clients. With trans people, the therapist is often the first person to really see the authentic self, even before it actually emerges, to know the secret, literally helping the person come out.

For the trans person, there is tremendous relief in just telling their story as well as hearing their own story for first time. It may be the first time that in telling their story in a nonjudgmental environment, that they get to see themselves in their own image, and not somebody else’s.

Moreover, some, once they‘ve started coming to therapy in the preferred gender, will never let the therapist see them in the previous role, often going to great lengths to come to therapy dressed as their authentic selves. And they will visibly cringe if the therapist uses the old name or the previous pronoun. For example, one client whom I have seen for a number of years is a CEO of a successful company in her male role. Rather than let me see “him”, she does phone sessions with me when her schedule won‘t allow her to come in as herself. She hopes to transition someday, but in the meantime, it matters that I see her and relate to her as she sees herself.

An important point for the therapist to remember is that this emerging self is very vulnerable and should be treated with great care. This self is young, fragile, and inexperienced and has been hidden, precious, and protected. It has been a lifelong fantasy, and can be full of guilt and shame and quite untrusting. It can be easily shamed, may be maligned and seen as a freak outside the office, even hated and subjected to violence, and certainly subject to rejection.

The therapist and client need to hold the possibility of the shared projection of the dream but also hold the possibility of its loss or at least some of it as the authentic self emerges. Coming out can be a tumultuous time. With coming out, there is often pressure to move quickly, like a “tempest in a teapot” and the person is often quite self-focused and absorbed. If they move too quickly it can be like a bull in a china shop, which can lead to damage. Or be like a too early birth that once started, can‘t be held in the womb, but then suffers from prematurity.

Relational and trust issues are central. With some people, the therapist needs to be quite interactive, not just reflective, because the self has been so protected. One useful image is helping like a midwife with a difficult birth. An attitude of extroverted feeling can be helpful, many MTF‘s, appear to be introverted thinking types.

In terms of the body mismatch, the therapist provides information, support, and referral for hormones and surgery (SOC 1979, 1980,1990,1998, 2001). The effect of hormones can be unexpectedly dramatic, albeit desired. Sharing knowledge of how others have negotiated the transition path can predict and facilitate the way for the newly transitioning person. The therapist can also provide information on shifting sexual orientation and model an appropriate gender role presentation.

Sometimes the therapist may widen the transference and include both loved ones and in some cases, even the work environment in the therapy.

The therapist may be asked to do consultation with employers or provide trainings for co-workers to facilitate transition in the workplace, and, once again, this can be done within the context of the therapy with certain clients as long as potential risks are discussed.

Although it is beyond the scope of this paper, loved ones are also asked to make a major transition in terms of identity and their place-in-the-world. Making the decision to transition has not only a major impact on the trans person, but on their loved ones as well. It may be appropriate to widen the transference in specialized cases and with fully informed consent, to include loved ones in the therapy. Usually, however, appropriate referrals are made to other specialists.

In some cases, people may feel that even though they know that they are trans, transition is “just not worth it”, although most don‘t feel they have a choice. Others learn to live more comfortably in their biological sex with an acceptance and understanding that their trans feelings are a part of who they are. Most, however, transition partially or fully.

No matter the location on the trans spectrum, the therapists‘ task is still always to see, but also to contain and to hold (like for others during transitions). The office is both a holding environment and place of safety for this in-between period that takes up so much space in the psyche. It is also a container that protects the person from moving too quickly or in extreme cases of putting oneself in danger. For example, one person in my practice who was living in a fundamentalist Muslim society felt compelled to cross-dress and go outdoors knowing that if caught, she could be jailed or even beheaded. She was in constant contact with me via the Internet (as well as seeing a local psychiatrist) and the virtual office provided enough of a holding environment to contain her need for being seen until she could return to America and transition safely.

In a more general sense, the therapist needs to hold both or all the possibilities of where the person could land, or in some cases, even never really land on the gender spectrum, but instead maintain fluidity.

Some are no longer fully transitioning, but finding their place on the gender spectrum that feels most comfortable while others, recognizing that their gender is fluid and open to change over time never do stabilize. Others settle on a bigendered life, where they alternate personas, and potentially widen formerly rigid archetypal patterns as they experience more options and spend more time out in the world developing a self or selves.

The therapist will be faced with exploring options that don‘t fit a binary system of gender with a mix and match of body/gender expression and will also be challenged regarding both a theory of a unitary gendered self or stability of sex/ gender and sexual orientation over time. Some people will change sexual object choice as they transition, others won‘t and others will live in a state of partial transition. Occasionally, a transwoman will opt to keep her penis, a transman might choose to have lower surgery, but opt to keep his vaginal opening but might rename it, some will identify as trans, others won‘t, some will prefer cross-sex pronouns with no bodily changes.

The range of permutations, once the person identifies as trans is quite varied. Many people, as they explore their preferred gender role, do tend to transition more and more fully, but not all. Much depends on, aside from an internal self-representation, their social context, age and community.
Nevertheless, even though the therapist might be seeing that which might be new, the therapy is really not much different from other depth work.

In other words, the therapist maintains the same stance of compassionate neutrality that would be used in any good therapy, paying attention to counter transference and all parts of individuation process. The contents of the unconscious, as illuminated by dreams can be very helpful in helping the person sort out permutations because they often have few external images to follow.

Also, it‘s a time of mentoring. Many experience relational naivete in general and especially in their new gender role. For both the therapist and the trans client, feeling-in-connection is paramount. Relational issues become more important during this process of building a self. Developing more capacity for empathy becomes more salient in this phase.

The trans person now has the opportunity to consciously construct a self. They have the opportunity to live authentically without the constant feeling of wrongness and can thus become less self-conscious and more relational. Many become more outer oriented because they feel no barriers for the first time, once they have discarded the inappropriate shell. Many report feeling more connected and less self-focused as they practice and build a new gendered self that is seen and mirrored in the world.

The therapy can also focus on the issues that emerged in childhood as a result of faulty mirroring, toward integrating the parallel developing selves as well as addressing the other various sundry issues that might emerge.

Post-transition and later

This time is one of ongoing individuation, consolidating a sense of self. More issues of love and work emerge in the new gender role. It‘s also a time of bodily integrity along with the growing realization that the early fantasy cannot really come true. Sexual issues continue, longing for a real penis or vagina and coming to terms with the lifelong fantasy vs. reality. Many continue to ask, Where do I fit? Who will love me? Should I tell? Not tell about my past? Shifting sexual orientation is often a surprise. Many find partners, which can sometimes be another transperson. Some learn to accept celibacy and solitude.

Issues of meaning become more important during this phase. It is a time of expanding the self, potentiating undeveloped archetypal patterns in the new gender role.

This is a time of authenticity vs. feelings of fraudulence. If they fully transition, some ask,Am I going from one closet into another?
How can a person be authentic if they can‘t tell the truth? The issue becomes: Authenticity vs. avoidance of stigma. “if you truly know me, you‘ll reject me or at the very least you‘ll treat me differently, differently than you would if you thought I was genetic- so I‘ll lose the dream” And, they‘re right. Some then say, “But if I‘m not truthful, I‘m still a fraud”. So this quandary becomes an ongoing dilemma throughout the lifespan.

Most do find resolution although the paths aren‘t the same. Some lean in one direction of the conflict and stay in stealth mode. Others lean toward the other and tell the truth, but never then, really experience their lives the way they‘d like to, unless they have truly embraced their trans or 3rd gender status. Most tell the truth to a few close friends, but not the larger world.

Post-transition can also be a time of longing and disappointment. Some MTF‘s mourn the loss of youth in the appropriate gender role, the loss of being a pretty maiden. It can be a time of grieving for lost opportunities and a wish they had transitioned earlier. And it can be a time for grieving lost relationships.

For FTM’s, growing up to be a man rather than remaining a boy can be difficult. Many look quite young and don‘t look like men and some want to remain boy-like because of negative socialization associated with manhood. Others worry that they look younger than they are and will be treated accordingly. Some experience a continued sense of invisibility because they pass so well.

But for many, this period is indeed a time of relief, and satisfaction, that they are finally right with themselves, whether the outer world can fully accept them or not.

The therapy continues to address questions of meaning as well as continuing work on issues not addressed in earlier phases of the work. As integration progresses, the spiraling and returning to the same issues that occur in any therapy process continue.

Outside of the office, the quandaries posed by discrimination and misunderstanding, can lead the therapist to activism. Many become educators, to help change the culture to accept and hopefully someday normalize gender variation

For the transgender person, the lifelong task becomes coming to terms with and accepting reality as they continue on the path of individuation. It means learning to experience pride in a job well done, finding meaning in their unique path, the wisdom of knowing both or the spectrum of genders, and feeling good about their unique perspective and journey.

I‘d like to end with the following quotes that demonstrate some of the points made in the paper. They are quotes from people in my practice said during the weeks I was preparing the talk that became the basis for this article.

SIX YEARS POST-OP MTF
Not a day goes by that I don‘t realize that I‘m different
You always know that you‘re not genetic- “the holy grail”
But..
That‘s what I‘ve been given
And I have to deal with it
The fact that I‘m not 100% female
But there’s no doubt in my mind
That I did the right thing
And it’s getting easier
More people accept that I got here via a different mode than they did-
But I AM here

10 YEARS POST-OP FTM
From the moment I made the decision-
(On Interstate 80 in Richmond-after first appointment with you)
I knew it was the right thing to do
I’ve never regretted it
Never had second thoughts about it
Never wished I’d done it differently

Why?
Because I know who I am
I’ve always known who I am

But I was held back by fear based on how I was raised-
Thinking- this was something I could never do
The breakthrough came when someone asked
Have you ever talked with someone with experience in this area?
In a roundabout way I found you.
It was the ACT of coming down here- and talking to you-
It’s like being afraid of water- and then taking the first step
I don’t remember what happened in the session
But on the way home-
Myself being a conservative Christian
I really felt RELEASED
God was saying-
It’s OK
best way to put it- I felt released
my family, my religion- they felt it wasn’t OK
And from that moment on-
Never a doubt
Never a regret
Never a 2nd thought
I went full time June 5, 1992

TWO YEARS CROSSLIVING MTF
With coming out-
The challenge is letting go of the desire (to be a real woman) and to be OK with who I am
And feeling safe with who I am
There’s an issue of safety
In claiming who I am
People might be violent
But I don’t want to live in a queer ghetto
Anytime I make a step of outing myself
There’s a part of myself that lives
But another part dies (the part about really being a woman)
Because there’s more denial pre coming out- the fantasy is I really will be a woman
Part of coming out-
Allows me to believe in my dreams- but it never really happens
I hope that I can change the way I see myself and that others can, too
I’m not a man, wish I was a woman, but I’m in-between- so.. I’m still the same as I was before in that sense-
and I need to construct something artificial to live in the world
so I ask myself- why did I do this-
if the dream can’t come true?
But now, at least people SEE me-
And they understand more of who I am
It would have been easier if I could just come to terms with living in male body space-
It makes me angry that this life I’ve been given and the WORLD gives me
only these choices
Some people say we’re the future, I’d rather not be the future, I’d like to be the present
Because even with surgery- I’ll be different from every other woman
My body reminds me of how much I lack
My gender is a carrot that’s right out in front of me-
Like infinity- I get so close
But never there
All I know is I get closer
But I’ll never arrive
I’m coming to accept these feelings and my anger
But there are so few role models out there
And many that are aren’t healthy role models
And many are more afraid than I am
So; how do I deal with it?
I remember:
I’m not my body
My spirit is genderless
Timeless
Transcendent

I have to let go of the boy from the past
And the image of the girl, too.

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————————————————————————
[1] Homosexuality was removed from DSM as a mental disorder in 1973.

[2] The International Guidelines of the Harry Benjamin International Gender Dysphoria Association for the care and treatment of gender dysphoria. Therapists are responsible for assessment and referral of qualified individuals to physicians for hormones and surgery.

[3] Classification, assessment and management of gender identity disorders in the adult male: A manual for counselors, University of San Francisco, 1991.

[4] Herb Wiesenfeld PhD from 1977-1980; Crittenden Brookes M.D./PhD from 1980-1985 and Jean Shinoda Bolen M.D. 1985-present.

[5] Bay Area Gender Associates (BAGA), an ongoing peer consultation group of licensed mental health professionals with a specialty in transgender conditions that has been meeting for the last 15 years.

[6] The Transgender Phenomenon/Psychodynamic Viewpoint, Plenary Talk at HBIGDA Conference, Gent, Belgium, September 2003.

Lin Fraser EdD/MFT/NCC

Distance Certified Counselor/Member WPATH

Private Practice San Francisco, California

Abstract:

This paper provides background and exploratory material about ethical and clinical considerations regarding the use of etherapy in the care of transgender clients. A brief overview of the literature, its applicability and extrapolation to transgender clients, the rationale for etherapy, clinical and ethical considerations, both general and specific to transpeople, are described. Included in the discussion is an online psychotherapy case and commentary involving a Saudi-based American male-to-female transperson and a San Francisco therapist.

Key Words: etherapy, e-therapy, online therapy, web-based therapy, telehealth, transgender

Author Information:

Lin Fraser EdD/MFT/NCC/DCC

2538 California StreetSan Francisco, Ca 94115

linfraser@aol.com

http:/linfraser.com

415-922-9240

Introduction

Thia paper provides exploratory and background information about ethical and clinical considerations regarding etherapy (e-therapy, web-based therapy, online counseling, cybertherapy, telemedicine, on-line therapy, distance counseling, ecounseling, telehealth etc.) in the care of transgender clients. By way of background, I have recently been certified as a distance credentialed counselor (DCC#553) and have a thirty-year subspecialty as a licensed clinician doing psychotherapy with transgendered people and their families.

The training and written test for this distance credential was essentially a series of questions demonstrating: 1) the ability to apply and extrapolate evidence-based knowledge about etherapy to the applicant’s area of planned online practice i.e. the case for etherapy 2) knowledge of clinical and ethical concerns applied to etherapy, their myths and realities 3) how to conceptualize and think about an actual online clinical case and 4) knowledge of how and where to access information about continually changing legal, ethical and clinical considerations, both specific and general, in this growing, changing and often confusing environment. In my case, my area of focus was providing ethical online therapy for transpeople, hence the information included here is current, but may have updates by the time of publication. Although my credential is American with the potential for global certification, the conceptualization/way of thinking described in this paper is universal.

The purpose of this paper is to briefly cover the points listed above so that the reader will have a more informed understanding of the usefulness of etherapy in the care of transgender clients. Included in the discussion will be a Case Study that will examine and illuminate the points/topics under consideration in this new modality. This paper will not include a discussion of the efficacy of online evaluation and referral for hormones and surgery, as this remains an area needing further study and research specific to our community and can’t be extrapolated from known data.

Definitions/Methods of Delivery of Services

Etherapy (e-therapy, cybertherapy, e-counseling, online therapy, distance counseling etc.) normally refers to the provision of mental health services through electronic media. (APA, 2007) or “to the use of psychotechnologies to deliver therapeutic dialogues at a distance” (Maheu, et.al, 2005, p.5).

The main differentiating factor from traditional face-to-face- (f2f) is the medium by which the therapy occurs (Derrig-Palumbo & Zeine, 2005). In this case the medium is electronic, but the provider of services could be the same person. It is the method of delivery of service, rather than the service itself that distinguishes etherapy from more traditional f2f.

For example, the description of the distance-credentialed counselor on the Center for Credentialing and Education (2007) website is as follows:

A Distance Credentialed Counselor (DCC) will be nationally recognized as a professional with training in best practices in Distance Counseling. Distance Counseling is a counseling approach that takes the best practices of traditional counseling as well as some of its own unique advantages and adapts them for delivery to clients via electronic means in order to maximize the use of technology-assisted counseling techniques. The technology-assisted methods may include telecounseling (telephone), secure email communication, chat, videoconferencing or computerized stand-alone software programs.

Technology-assisted methods can be either synchronous or asynchronous and can be supplementary as well as complementary to f2f. Synchronous delivery methods include such interactions as real time Chat, IM (instant messaging) and Video Chat, text-based phone and or telephone (VOIP such as Skype). Asynchronous methods include email, via the Internet or phone.

Although it is beyond the scope of this paper to discuss technical considerations, it is presumed that any therapist providing these services will get the training necessary to be comfortable, knowledgeable and ethical using any of these delivery methods.

The Case for Etherapy

Timing and Access

The proliferation of the Internet concomitant with the burgeoning worldwide trans community online has set in place an ideal avenue to develop outreach and care online. One of our goals and missions is to advocate and provide care regardless of demographics (Brown, 2007). One problem of our population has to do with access. Many are geographically isolated and live in places where they may be stigmatized or even criminalized. The Internet knows no boundaries and has the capacity to reach even the most inaccessible of people as long as they have electronic access.

The infrastructure allowing fast, easy access is growing worldwide including in developing countries. It behooves us to provide care when and where we can and with the Internet, we can expand our clinical reach. Emphasizing this advantage, the dedication page of a seminal handbook on online therapy, states “for those who suffer from emotional distress and need better access to care” (Maheu et.al, 2005). Moreover, even where therapeutic care is accessible, access to competent specialists providing transgender care may be limited. Via online connections, specialists can provide care virtually anywhere either directly to the client or indirectly via training, consultation or supervision to local therapists who may be providing the f2f care.

Readiness and Appropriateness of Transpeople for online therapy

Moreover, etherapy has been shown to appeal and especially help a certain type of individual (Fenichel, et.al, 2004, Derrig-Palumbo & Zeine, 2005, pp 87-89), attributes shared by many members of our population. One criterion is technical comfort, if not a level of expertise. The exam for distance counseling included a comparison of the relative technological sophistication of both the target population (transpeople) and the provider (me) delivering the services. In this situation, the clients far outpaced the provider. Our population is known to be tech savvy and has already developed worldwide connections online.

What is missing in fact, is not the connections among transpeople themselves, or their knowledge of how to use electronic media, but the provider’s ability to provide ethical clinical services to them. It behooves us, I believe, to learn the clinical and technical skills to provide these services.

The knowledge, information and delivery models are already in place to provide ethical online psychotherapy to an ever-expanding global trans community. The mechanisms exist to deliver services and provide training to local licensed clinicians and/or community –based mental-health facilitators. The systems are already in place, we need to learn how to utilize them to expand our reach.

Moreover, trans people as individuals are highly motivated and want care from knowledgeable providers (Rachlin, 2002). Many transpeople won’t access therapy concerned that uneducated providers might misunderstand, pathologize or even harm them. What is anecdotally known is that many are highly intelligent, psychologically savvy and knowledgeable, having examined themselves for years, often alone and in secret (Fraser, 2003), and are thus candidates for depth work with a competent therapist. Many are quite comfortable with the written word and could benefit from text-based therapy.

Even for those who speak a different language, simultaneous translation of text is available online so that culturally competent clinicians could work with those who speak a different language.

Moreover, what is also known about web therapy is that it often appeals to those who are stigmatized and might otherwise not reach out for services due to fear or shame, certainly descriptors of a subset of our population. (Dellig-Palumbo & Zeine, 2005. p. 87).

Finally, the accessibility, ease, confidentiality and safety of the Internet foster a sense of safety and ability to self-disclose.

Convenience and Flexibility/Increased Containment

Another advantage of etherapy is that multiple modalities and delivery methods are available depending on preference of the client and creativity of the therapist. This offers possibilities to mix and match modalities, offering convenience, flexibility and individualized treatment. Each delivery method has its advantages (Ainsworth, 2001, APA, n.d., CCE, n.d., Dellig-Palumbo & Zeine, 2005, ISMHO Clinical Case Study Group 2000, among others) and the therapist can learn to utilize each most effectively depending upon preference, experience and the needs of the client.

A definite advantage for both client and therapist is mobility and continuous connection. The provider is free to be mobile as is the client and yet continue the work. With those who are doing f2f in combination with etherapy, knowing that the therapist is somewhat accessible when either are away for long periods or even in between sessions (this is at provider’s discretion and is part of the frame) reduces acting out behavior and other manifestations of anxiety. In this increasingly globalized society, a very mobile-therapist and client can maintain connection, contain sometimes very difficult material, and continue the work.

Also, online psychotherapy can be more convenient and flexible than f2f. A client can contact the therapist on their own time from wherever they wish. And the therapist can respond likewise within the agreed-upon frame.Moreover, the writers’ experience is that people really appreciate the ongoing connection and never take advantage of it, in fact the opposite occurs, the perceived ongoing connection actually reduces emergency contacts.

Finally, online therapy provides accessibility to clients who may be of limited means, a not unimportant concern, within the trans population (Whittle 2006).

Myths and Realities/Clinical and Ethical Concerns

Concerns about etherapy tend to fall into one of two categories, clinical or ethical/legal.

Clinical

Clinical concerns about etherapy relate to concerns about connection, relationship and the therapeutic alliance, and issues of risk management (confidentiality, emergency, identity of client).

The primary clinical resistance to etherapy relates to the inability to actually see /be in the same room with the client, hence being unable to visually discern nonverbal communication and other nuances central to f2f therapy. Moreover, many believe that mutual physical presence is necessary for the exploration of underlying considerations, not to mention the basic tenets of psychotherapy, such as the therapeutic alliance and the intersubjective connection that allows the client to feel safe. It is believed that this connection can only occur in the physical office.

Depth therapy considerations such as the development of a transference and immersion into deeper levels are presumed to only occur in the actual physical presence of a caring, nonjudgmental empathic other. Many people worry that somehow cyberspace seems limited and mechanical given the nature of the intimacy of f2f psychotherapeutic relationship.

The evidence, both from the literature (Fenichel et.al. 2004, Suler, 2007) and in the case described below, does not support these concerns.First, as technology advances, more online work will include video either by phone or computer, alleviating the concern about lack of verbal cues. (Maheu, 2005). Second, the efficacy of the written word should not be underestimated and text-based communications for certain clients (and providers) can be a powerful modality for the psychotherapeutic relationship. Concerns related to the therapeutic connection central to therapeutic alliance and moving to deeper levels are not borne out by those who have actually experienced the power of etherapy. (Fenichel et.al. 2004, Suler, 2007)

For example, as will be demonstrated in the case study in this paper, this ongoing connection in cyberspace allows a very protective and strong holding environment. Growth doesn’t necessarily operate on a schedule and some of the deepest revelations occur outside scheduled sessions. The felt experience for many is that the therapist is as close as the screen. It’s this sense of connection rather than the actual physical contact that seems to be important and is borne out by those who practice etherapy. (Suler, 2007) This connection between sessions can contain difficult material and allow the client to go deeper more quickly.

A detailed discussion of clinical concerns is beyond the scope of this paper. At this point, much of the literature is descriptive and often involves case studies of this evolving practice, with the recognition that more data based research is needed.

One excellent resource is a series of white papers, developed by ISMHO’s Clinical Case Study Group (ISMHO, 2000a), who presented a series of cases to each other over a three year period and then developed some conclusions about online therapy based on their shared experience and ongoing case consultation. These white papers, available online, contain valuable information, compiled by established leaders in the field. One article assesses a person’s suitability for online therapy (ISMHO, n.d.), another suggests clinical principles for the online provision of mental health services (ISMHO, 2000) and another, on the myths and realities of online clinical work, dispels such myths that therapy needs to be f2f, talking and/ synchronous. (Fenichel, et.al., 2004).

For those interested in more technical articles, with comprehensive lists of journal articles, Marlene Maheu’s 500 + volume titled The Mental Health Professional and the New Technologies with 37 pages of tiny font references may be of interest (Maheu et.al 2005).

It is important to recognize that information is evolving as more people practice and publish. The case study in this background paper on Revision7 is an addition to this tradition and is the first to my knowledge on the applicability of etherapy to a transgender client. Nevertheless, a quote from Case Study Group offers a direct parallel and might sound familiar in terms of the issues presented:

Several unique advantages exist in online work. Many have been described in the literature already, such as access for the homebound, geographically isolated, or stigmatized client who will not or cannot access treatment. One of our case presentations illustrated vividly not only the possibility but also the advantage of Internet-based therapeutic support. A pilot in the military, exploring sexual orientation and afraid of the potential impact of “coming out” and jeopardizing a military career, demonstrated how seeking help online was reassuring to the client in terms of confidentiality. The absence of geographic boundaries allowed the client to select a therapist who appeared to have the expertise and understanding needed in the client’s particular situation (Fenichel, et.al 2004).

From this case and the information herein presented, it is hoped that the reader might be able to imagine the clinical possibilities inherent in the cyber therapeutic connection as well as the multiple modalities it affords to individualize treatment /offer choice and potentially even offer more creative delivery of clinical services than more traditional f2f.

Another clinical concern has to do with risk-management, issues such as security, confidentiality, emergency backup, and reliability regarding the identity of the client. These can be resolved via encryption, a plan for what to do in an emergency, providing links to local services and the provision of an emergency local healthcare contact. Identity can be established via credit card payment and other software. As described in the above case, confidentiality may actually be increased via online rather than f2f for the kinds of concerns our clients present.

Ethical/Legal

The primary ethical/legal issue under consideration has to do with who can practice and where does one practice etherapy? Where is the therapy located? Where exactly is cyberspace? Much discussion concerns the legitimacy of crossing state, national and international boundaries or if boundaries even exist in cyberspace? The bottom line issue is how is the consumer protected?

This paper has, as an underlying premise, that people considering practicing etherapy, will be certified, licensed or otherwise covered by their regulatory boards to practice f2f therapy and etherapy (where the regulations are clear) and will provide this information to clients as part of the informed consent process.

For example, the provider’s website might include links to appropriate licensing and regulatory boards, as a way to verify their credentials. It is also presumed that, as in f2f, the practitioner will have familiarity with the ethics of their respective practices. The practice of etherapy far exceeds the various state regulatory and licensing boards ability to keep up with its exponential growth. Hence it falls upon providers to not only stay current with their respective regulations, but to also understand the thinking upon which ethical practice is based. Problems of licensing reciprocity exist and the location of cyberspace is generally undefined.

As an overarching principle, then, the reader is advised to stay current with their particular licensing board, professional association and country’s regulations as well as the thinking of those in the vanguard of this rapidly evolving medium. At a minimum, by keeping abreast of current information, a considered and knowledgeable decision about whether to participate can be made.

As an overview, the various regulations available today can be confusing, still unclear and contradictory. For example, Fenichel, in April 13, 2007 e-mail to the ISMHO membership addressed the “thorny problem of US licensing” saying that

The short version of the topic is that the patchwork of 50 states sets of rules now in place does not seem like it can remain standing—it is anachronistic, so it seems, out of step with the reality of how people interact with the world these days, often facilitated by the Internet.

Moreover, one’s particular state or even country’s governing body may not approve of what may be considered quite ethical from one’s professional association.Rules range from a commonsense approach such as the NCC Code of Ethics from the 1990’s that advises the clinician to use their best clinical judgment based on an extrapolation of ethics from f2f to online work or the American Psychiatric Association’s position statement on the Ethical Use of Telemedicine:

The APA supports the use of telemedicine as a legitimate component of a mental health delivery system to the extent that its use is in the best interest of the patient and is in compliance with the APA policies on medical ethics and confidentiality (APA Ethics Committee, 1995).

to a highly restrictive regulation, where, under such and such a license, the clinician can only practice etherapy if licensed in the location where the client is physically located. Hence, in this latter case the location of the therapy is where the client is located. Some countries (Italy, I believe, is one) do not allow the practice of etherapy at all. Others are quite liberal, like Britain, for example, that offers reimbursement for etherapy services provided by clinicians living both inside and outside the UK as long as they hold a UK certification (Personal e-mail communication, 2007). The US now has a CPT code (0074T) for online consultation with an established patient (Kraus, 2004).

Discussions are in place about a global credential (Clawson, 2007,p.4).) and the writer holds a national counseling credential and a distance counseling certification. Even so, their applicability in some locations remains unclear.

Maheu and her colleagues have drafted papers including principles, statements and philosophy for an international convention on telemedicine and telehealth (Maheu, et.al., 2005, appendix d – p. 451).

In general, regulations are slowly catching up to practice. In America, rural states are in the forefront, because their consumers desperately need access to services. “There are no national laws forbidding a therapist to treat someone outside of his or her state of licensure, though some state boards have taken a stand on where the therapy takes place” (Derrig-Palumbo & Zeine, 2005, p. 53).

To date, no legal case has been tested or tried to untangle the myriad regulations; hence services are provided without any certainty as to how a lawsuit might be played out. One case in California, (Zack, 2007) has recently emerged as a potential test case. A physician in Colorado prescribed medication (Prozac) online and across state lines to a person in California through a server in Texas without physically examining the person. The patient later committed suicide and was found to have had Prozac in his system. The writ petition against the doctor is a felony complaint about practicing without a license in California. Much discussion on the ISMHO (International Society of Mental Health Online) forum and elsewhere is ongoing as to whether this may become the “test case” with potential applicability to etherapy.

The reader is referred to the ISMHO website for articles and interesting and ongoing international discussions about ethics, liability and legality of providing etherapy.

Most discussions of ethics and codes of conduct seem to concur on a few general principles. First, as an overview, is the importance of maintaining a clear understanding of the ethics statement of one’s own professional organization, both in general and then specifically about etherapy if such standards exist. General considerations usually include, maintaining licensure, providing informed consent, maintaining an ongoing consideration of what is in the client’s best interest, providing access and nondiscrimination policies and operating within ones level of competence and training. These are underlying ethical considerations for all therapy, including etherapy. The therapist needs to be regularly asking whether what is being provided is in the best interest of the client and are they competent to provide it? Then, in terms of extrapolation to etherapy, for this particular client, given their particular situation, is etherapy the best available service? And is their condition within the therapists’ area of expertise or could they access more effective services elsewhere?

Certainly given these universal ethical parameters, the case for etherapy exists for trans clients due to the aforementioned accessibility problem and limited available expertise.

Aside from general ethical considerations, the therapist also needs to understand specific regulations and standards having to do with etherapy. Many professional associations provide versions of such. These are usually subsets of their ethics statements such as APA, APA, NCC, CAMFT (in America).

It is also important to check local and country laws, regulations, to see if any exist regarding etherapy. What may be found is a good deal of confusion, so each provider needs to consider carefully his or her own circumstances.

A major question in the DCC credentialing exam had to do with the ability to access information and knowledge of how to stay current. Links to useful websites will be included in the section following the case study.

As an example of current legal thinking about etherapy, included below is some commentary from an avoiding liability bulletin distributed by the writer’s liability carrier. It is written by Richard Leslie, J.D, an attorney specializing in the intersection of psychotherapy and the law. The following is his prudent advice regarding online informed consent and insurance coverage

Online Therapy-Disclosure(March 2006, Volume 1)…Whether or not required by state law or regulation, therapists who practice online therapy (e.g., intrastate) would be wise to make certain disclosures to the patient prior to the commencement of online therapy, and to obtain the patient’s written and informed consent prior to such treatment. Of course, if there is an applicable state law or regulation, therapists must follow the law or regulation in all of its detail. Since it can be reasonably argued that online psychotherapy can be considered new, innovative or experimental, it would be wise and prudent to obtain written informed consent, even in the absence of a state requirement.

One of the disclosures that is often required or, at a minimum, advisable, is a description of the potential risks, consequences, and benefits of online therapy. In one state, the telemedicine statute leaves it to the practitioner to determine what those risks, consequences and benefits actually are. Consequently, disclosures in that state and in other states will vary (where not specifically mandated) depending upon the technology used, the level of sophistication of the therapist and the patient/client, and the nature of the services being sought and rendered.

Certainly a disclosure about how confidentiality will or may be affected by services being provided over the Internet, and what steps the therapist will take or has taken to make sure that the communications between patient and therapist remain confidential, would be important.The patient should also be informed about how session records will be kept and how they may be retrieved or copied, to the extent that it differs from traditional record keeping practices. If therapy does not involve synchronous audio and video communication, but rather, written communication only, additional disclosures about the nature and process of the written communication should be considered. A therapist might also disclose the possible lack of certain clinical information about the patient because of the inability to see what might otherwise be seen in face-to-face therapy, and the possible consequences thereof (Leslie, 2006).

Online Therapy- Insurance Coverage(October 2005, Volume 1)Therapists and counselors often ask whether or not their malpractice (professional liability) policy covers them if there is a claim or lawsuit for alleged negligence in the performance of online therapy sometimes called Internet therapy or e-therapy). Because the answer to the question may vary from insurer to insurer, therapists should review their policy to see whether or not there is any exclusion or limitation pertaining to online therapy. If there is no limitation or exclusion, then coverage should exist (Leslie, 2005).

As an example, my insurer added my distance counseling credential to my policy for an additional seventeen dollars.

Case Study

What follows is a case from the writer’s practice that addresses the issues and considerations, both ethical and clinical, described in the previous sections. My client, “SH” has given permission to discuss her case, “ You also have my full consent to use all relevant documents regarding our therapeutic interactions, including hand written notes and copies of emails in any future paper, presentation, or publication regarding our telehealth activities (SH, 2005).

SH, then MH, an American living in Saudi Arabia contacted me via email in March 1998 and asked for an appointment during his (she was living in male-role at the time) home visit to the Bay Area. I saw him in my office in May. He was experiencing rather intensifying progressive gender incongruence and needed therapy to sort out his conflicting struggles. Married and the father of two (almost grown) children, and working overseas with no contact with any kindred spirits, he was becoming more and more depressed and agitated. The pressure on his psyche was intensifying and he was filled with guilt and shame. He was considering medical feminization, even though the consequences of a speedy transition could be quite dire from his perspective, and potentially quite dangerous if he went out dressed in Saudi. We saw each other several times before his return to the Middle East and he asked if we might continue the work via email.

This was my first introduction to etherapy in my own practice, although, over the years, I had worked with established clients over the telephone as time and distance considerations required. I had also recently joined a listserve about etherapy so I had some sense of the issues and concerns involved. MH was seeing and had been seeing a psychiatrist in Saudi since 1996 and had been in therapy with others in the past, but his psychiatrist had no knowledge of gender issues. I felt that as long as he continued to see his local therapist, and if the local therapist agreed that ongoing email contact between M and me might be helpful, then I would be willing to work with him on a trial basis and evaluate its effectiveness as we went along.

We discussed the tentative frame of the therapy, such things as fee structure, my availability, response-turnaround time of communications, contact information of his psychiatrist and next of kin, security of email etc., and agreed that these arrangements might evolve or change as the therapy progressed.

What I couldn’t have known at the time was that this would be the beginning of a whole new clinical experience, rich with depth and possibility. Although much less was available then in terms of knowledge regarding ecare, the thinking concerning how best to help from a distance has not really changed. The issues that were confronted are the same, as they would be confronted by anyone with their first eclient. Moreover, trans specialists are used to being ‘cutting edge” and on the forefront of new and challenging theory and developing new standards and therapies to meet the needs of an evolving population. The challenge of etherapy is no different.

Due to a confluence of factors, this first case proved efficacious. My client turned out to be ideal for this kind of work, technically savvy, much more so than her therapist, and she knew how to encrypt our communications. She was intelligent and actually quite brilliant with the written word. She was (is) psychologically oriented with the ability to connect experience and dreams to feelings as she wrote. She was literate and knowledgeable about symbols, attributes important to the type of Jungian work I do. Moreover, she was capable of a transference, and we were able to create a holding environment in cyberspace, which was especially important given the danger of being trans in Saudi.

These things I didn’t know of course initially. What I did know is that we had made a connection in my office, I felt there was a therapeutic alliance and that responding to her request would not harm her given that she had local backup. After our first session, even while she was in San Francisco, she (then he) emailed me her initial dream (very important in Jungian analysis) which contained strong imagery suggesting that her entire world was crumbling/ that the status quo as he knew it was tumbling down and he woke up crying.

So, the therapy began.

I checked my MFT licensing board in California and although they do now, at that time, they had no information on online counseling. I also checked the National Certified Counselors Ethical Standards (I’m also an NCC) for online work and they delineated a common sense approach recommending that as this is a new modality, the counselor needs to apply the same ethical principles as they would to f2f and then they listed the common sense principles.

As it turned out, the American Psychological Association (I’m a clinical member because my doctorate is in psychology although I’m not licensed as such in California) had its annual convention that summer in San Francisco, and I attended a three-day workshop in telehealth. By this time, I had been communicating online with SH several times weekly and was aware that it seemed to be helping. I shared this case to the attendees and workshop leaders, including the group leader, Marlene Maheu PhD, a psychologist in the forefront of the telehealth movement (see Maheu et.al, 2005), and to an APA attorney and APA ethicist. What they told me applies today and can help any new etherapist learn how to think conceptually.

First, what is most important as a bottom line (and this seems to be true in all clinical ethics-see links in the next section.) is what is in the best interest of the patient? Is providing etherapy to this person at this time in their best interest? In this case, clearly the answer was yes because I had an expertise she could not find in Saudi.

Two, does she have informed consent? And what does informed consent mean in etherapy? This may differ depending upon one’s professional association, but in the next paragraph, I’ve included S’s informed consent, which covers most bases.

Three, the lawyer said in terms of legal precedents, the best application would be the comparison to telephone therapy which at APA, required an f2f visit before commencing ongoing telephone work. In terms of case law, I was on solid legal ground as long as I saw her f2f first and then again from time to time. Current ethics do not require f2f contact; nevertheless an introductory f2f still makes common sense to me, although that may not always be feasible in terms of the trans population. In general, as mentioned before, it’s best to check one’s own specialty ethics, legal and licensing (state or country) regulations regarding how to proceed in your jurisdiction. Although there has been no test case as yet, the defense or prosecution will refer to case law.

Four, they suggested that I keep good records and seek ongoing consultation. With etherapy, one has a full transcription of the therapy so good record keeping is quite easy as is consultation. I had (have) both individual and group consultation, the latter being with Bay Area Gender Associates (BAGA), an ongoing consultation group of licensed therapists specializing in transgender identity issues, and I kept all apprised of the therapy on an ongoing basis.I reported the information I learned at the conference to SH, then MH, and s/he sent me the following “informed consent”

Dear Lin Fraser,

Please let this email be for whom it may concern verification that I, MH, an American citizen born on —- -, 194_ in ———, ——— do give fully informed consent to Lin Fraser of San Francisco, California, to practice gender identity therapy with me as a client via internet email through a new and experimental process sometimes termed “telehealth”. I understand that this is a new and somewhat unknown form of therapy, and that therapeutic outcomes are not guaranteed to be the same as might have occurred through the process of face-to-face therapy sessions. However, due to my remote living and working situation (in Dhahran, Saudi Arabia), and the complete lack of any alternative gender identity therapy in this country, nor any adjacent countries, I approached Lin Fraser by email early in 1998 to set up an appointment for me at the end of May. During our first two sessions in her office I asked her if she would be willing to counsel me as her patient via email when I was back in Saudi Arabia. She agreed to this arrangement, and we have been communicating on a daily basis since the beginning of June. We plan to have face to face sessions whenever my presence in San Francisco is possible, but due to my living in Saudi Arabia, this may only be possible a very few times per year.

Sincerely, MH

The therapy progressed over the next 6 months with numerous emails back and forth, much struggle on her part and a deepening of the internal work. Inclusion of the etherapy dialogue and progression is beyond the scope of this paper, but the text was as powerful and in many ways more powerful than f2f. There was more time for thoughtful reflection, and allowed a savoring and settling of the work during and between communications.

Per our initial agreement, I asked her to reflect upon and evaluate the work. Here are her words verbatim in December 1998:

Dear Lin, This is a brief personal evaluation of the therapy relationship we have had from early June through today (December 4, 1998) and my personal feelings as to the effectiveness of the process, how I feel it has benefited me.

I believe our tele-counseling process (“telehealth”) has been extremely effective in my situation, more so than much of the counseling I have experienced directly with two different psychiatrists face-to-face during the past fifteen years or so. If nothing else, it certainly has put me in a “journaling mode” like I’ve never experienced before, knowing that you would be reading my thoughts within a few hours, most of the time every day during July and August and September when I was going through heavy identity problems.

And now during a time the “problem area” seems to have shifted somewhat to the transition of our family unit, my relationship long term and future with my wife, TH, and both disclosure and the transition of my relationship with my son and daughter.

As far as I know, there are no psychiatrists or psychologists in this country (Saudi Arabia) with experience or skills such as you have and are able to draw upon in working with gender issues like mine.

You have been able to help me by being a constant and consistent listener and artful questioner. While I know you have often expressed some frustration at not being able to interact more directly and to visually see my body language as we dialogue, I also realize that there are some things that can be gotten into even deeper through writing words with feeling and care, sort of a verbal meditation, done in silence, fully focused. These include complex feelings and observations that are felt while being articulated.

Not a whole lot different than face-to-face therapy, I suppose, where certainly over 50% of the process is verbal (some might disagree).

We also of course should not discount the transpersonal dimensions, since I sit and meditate and think of you and my issues.I really believe that Internet email, which we are using as your communication medium between Dhahran and San Francisco, is highly effective in this dialogue, more so than traditional “snailmail”. One knows that the other person in the dialog will likely read what you have just said within a few hours, sometimes within minutes. This makes it a real “conversation”, almost like face-to-face but with the time-speed slowed down quite a bit.

Anyway, to be more specific, I feel that the following developments have been highly important to me during the past six months of telehealth gender therapy:

1. I feel I have transitioned from a state of great doubt, confusion, anxiety and emotional turmoil due to conflicting “identity feelings” to a state of relative peace, clarity of objectives, and a strong new sense of a single identity (through acceptance of my conflicted female feelings).

2. I have arrived at a clearer understanding and feeling of self-identity than ever previously in my life, as I am more able to accept more of my male and female elements simultaneously and/or in sequence, as situationally appropriate.

3. I have learned that it is possible to “slow down” the speed of my transition (which always is pressuring my psyche to “accelerate” the changes), to consolidate them and pause and digest them, and only then to go forward, and to use the emerging, though highly inexperienced/immature feminine elements of my psyche to shift my concern from exclusively focusing on myself, to being able to think more about others and how they feel and how they are impacted by my gender shifting.

Previously I was of course concerned, but with a much greater emphasis on fear (terror actually) and shame and tremendous guilt at “what I was doing to myself and how it would destroy both me and my family”. Those feelings of fear/terror/guilt kept me paralyzed, unable to act with “skillful means”. Now I accept S, and have experienced a vast polar shift from feeling “transgendered and damned” to feeling “transgendered and proud” (probably a sign of major immaturity here! But it feels good at this point!).

And feeling at peace with myself internally, I feel I have the solid inner foundation upon which to take a firm, stable stand to nurture, rebuild where necessary, and preserve where appropriate, our previous family relationships (I mean the intimate emotional/marital relationship with my wife primarily, but am entering the process, with your help, of including my children in the transition which must proceed from disclosure).

I think that all I want to say on the issue that you asked me to comment on, i.e. “could I provide an evaluation of our telehealth gender therapy process?”

Of course there are additional side benefits from this telehealth that are obvious, particularly that of having the entire therapy dialog/process (or 90% of it) in electronic text files for present and future reference during therapy and possibly later for research, ability to scan electronically for issues and patterns of resolution, etc.

Hope that has been enough for an A grade in “evaluation reporting”!

Hugs and a warm smile and a simple “thanks Lin!” “S”

After this quite comprehensive evaluation, the therapy continued via email until S returned to the States the following spring and we moved into a rather traditional f2f psychotherapy that was deeply enriched by the etherapy that had preceded it.

Over the next few years, she did transition. She completed medical feminization, went through an ultimately amicable divorce and is now happily partnered with another transwoman. She is close to both her ex-wife and children, is successfully employed and sees me occasionally as needed.

In her latest exchange (April 3, 2007) she talked about her happy relationships with her partner, her delight in her children, one married, one engaged, her upcoming retirement and move to a lovely new home, and her deepening spiritual commitment. Her only reference to her trans identity was the following:

On Palm Sunday I led the procession with Fr.______ at my side, the priest in front, as we sang a processional chant in Latin. A lot of irony here, as I first met Fr. ___ at the ancient monastery of ______, near _____, in _____, back in 1992 with my young family (I, as M, had a red moustache at the time). I don’t think he realizes that S used to be M, but one never knows with these monks…

Lots of interesting times in the life of S, no! No end in sight. I wish you and your family a joyous Easter!

S

Commentary on Case

From the foregoing, it is evident that S does indeed have a rich and fulfilling life, but given her situation when she first sought consultation, one wonders what the outcome might have been without etherapy. S describes it as a “lifesaver”.

Although she was a particularly good candidate given her technical and verbal prowess, the issues that emerged in her case are perhaps typical of many trans people living in remote areas where clinical expertise is unavailable.Moreover, although the etherapy part of her therapy is from 1998-1999, conceptualization, ethical issues and how to think clinically are the same today. What I went through would be similar for any beginning etherapist. For example, as the case evolved, I consulted ethical and clinical experts regarding pertinent information that was then available from APA, CAMFT and NBCC and sought ongoing clinical supervision, both group and individual.

Even though the thinking was less evolved than it is today, the process is the same, checking with licensing and regulatory boards, keeping abreast of ethics and maintaining consultation among colleagues, both more experienced and peer.

Moreover, more options exist now allowing synchronous communications such as IM, text or video chat rather than just the asynchronous format available in 1998. Hence, etherapy can be multimodal and individualized, offering both the advantages of a real conversation as well as the slowed-down quality and time for reflection allowed by asynchronous email.

An extensive discussion of clinical considerations as they apply to etherapy and specifically to this case as an illustration of distance work with a trans client is beyond the scope of this paper. What is presumed is that the reader can extrapolate for him or herself the general clinical issues involving both the frame and the process. The following will only be a very brief discussion of both.

The frame would include such things as screening. S was a particularly good candidate for etherapy as she was highly motivated, was comfortable with computers and text-based communication; she was psychologically oriented and could connect her feelings to both her conscious and unconscious experience. Moreover, she had the capacity to reflect and journal. She was responsive to the type of therapy I offered.

Other therapists of course, have other orientations, and the literature suggests most orientations can be adapted to etherapy (Derris-Palumbo & Zeine, 2005, pp5-38).

Other issues pertaining to the frame include informed consent (Griffin, 2006), security, confidentiality, encryption and other technical considerations. Arrangements need to be be made regarding emergency local backup, and links to local services, payment and fee schedule, frequency and length of contact, etc.

In terms of the clinical process, her commentary actually says it best and points to the potential power of etherapy. There is little to add, she mentioned many of the points suggested in the literature, the power of written word, the deep meditative process that can occur, the unbroken intersubjective client-therapist connection, the potential for containment for unhealthy impulses and the reality of the virtual office as a holding environment.

What is inferred in the “evaluation” is the strong transference that can also develop, even without the therapists’ physical presence. As an example, S told me that she had kept for months and referred to repeatedly (she put it on her mirror) an encouraging note I had sent to help her through a particularly difficult day. She also imagined me in her daily meditations and still calls on my image during conflict. In terms of countertransference, I held her just as strongly as any of my people in f2f work, sometimes more so. I wrote to her, both in response to what I felt she needed, but also when the muse struck.

The location of the therapy was both diffuse and everywhere, yet felt boundaried and nonintrusive. I responded at my own pace, respecting what I knew to be her needs, but also, since this had been discussed as part of the frame, in consideration of my own.

Basically, what her commentary describes is clinical evidence for the extrapolation and application of what is known about the benefits of etherapy to a trans client. Her descriptions of the benefits she received match descriptions in the general literature, with the addition of the benefits both typical and specific to trans identities. These include the slow consolidation and integration of a unitary gendered self, a movement from conflict, confusion, and guilt to clarity of objectives and relative peace, the development of a capacity to slow down the process to allow integration, a beginning sense of safety, and more of a capacity to consider the feelings of others.She also mentioned the usefulness of having the complete record of the therapy available then as a written review as the case progressed, an identification and discussion of what has happened during the work, goals reached and its potential use in the future. This complete record has been of obvious use in the preparation of this paper.

How to Stay Current/Links to Further Information

Even though clinical considerations may have changed little in the intervening years, much is evolving in terms of ethics, regulations, laws etc. Online therapy is growing exponentially and information about it is evolving.

As mentioned earlier, one requirement for any etherapist is the necessity of staying current. To keep up with this shifting information, information on the web is regularly updated. The reader is here referred to several excellent websites and forums. These include links to online professional associations, current information on ethics and the law, information about how to get more education including CEU’s, as well as general references in the field.The links below include only a smattering of the many websites available, but the list is inclusive of those referred to in this paper.

Two websites have been most useful; one is the International Society for Mental Health Online, which has links to several of the papers referred to earlier and other useful links regarding etherapy. One section includes a link to a member’s only forum, which offers threads to many interesting discussions on topics of interest to etherapists. For those interested in practicing online therapy, membership in this organization is recommended.

Another good website, is http://etherapylaw.com described on the website as “A clearinghouse for information on legal issues in online counseling”. This website, although very recent, and still evolving, covers legal/ethical issues pertaining to therapists. It is updated regularly and has been developed by one of the pioneers in etherapy, Jason Zack PhD, a psychologist who is currently a 3rd year law student at Penn. His website has received numerous accolades on the ISMHO forum. The ethics section on this website has links to many organization’s (ACA, APA (Psychology), NASW, AAMFT, ISMHO, APA (Psychiatry), ACTO) code of ethics, ethical principles and/or codes of conduct, both in general and specific to etherapy. It also has an international section that will cover issues of interest to non-American members. The following is a link to Canadian Psychological Association’s code of ethics for online therapy .

Several pioneers, such as Michael Fenichel PhD, Ron Kraus PhD & John Suler PhD have useful websites and also offer CEU’s in the field. Suler’s work has been particularly influential regarding the clinical/psychodynamic considerations described in this paper. He has written a classic in the field, an online book The Psychology of Cyberspace and offers CEU’s on the book, CEU’s Psychology of Cyberspace that includes a blog companion to this seminal work.Kraus’ company, OnlineClinics has a useful and general ethics code Guidelines for Mental Health and Healthcare Practice Online that covers many of concerns articulated in this paper.

Information on the national credentialing process for online therapy is on the Readyminds counselor credential website.Finally, an extensive list of articles on etherapy has been compiled by Azy Barak PhD, an Israeli pioneer and member of the ISMHO Study Group, entitled References Related to the Internet and Psychology. Another extensive reference list has been compiled by Marlene Maheu et al in her book, the mental health professional and the new technologies and she also has good informational website on telehealth and e-health.

Suggestions for Further Research

Ethics and efficacy of etherapy for hormone & surgery referralsOne issue that clearly needs further research is whether a clinician can ever make a competent assessment for a referral for medical masculinization or feminization without f2f work.While it is clear that the trans population is ready and can benefit from the provision of etherapy by competent knowledgeable clinicians, what is not clear is whether evidence exists that can be extrapolated to assessment and referral for surgery and hormones. Although literature exists supporting Internet assessment (Hyler, et.al. 2005), the data doesn’t offer enough of a parallel to draw conclusions for our purposes. Further research is needed in this area and we need more data specific to our field. At this point, “relying solely on web-based contacts with consumers as the exclusive basis for evaluation or referral is risky at best for both providers and consumers and does not meet the minimum Standards of Care guidelines promulgated by this organization” (Brown, WPATH website 2006). Therefore, this issue is beyond the scope of this paper, which has been limited to the efficacy of psychotherapy.More knowledge, more specific information and experience is needed, most likely gathered amongst trans providers.

Clinical

Etherapy clearly can be a useful modality for psychotherapy with transgendered people. It offers opportunities for multiple modalities and potentially enhanced and expanded, creative, tailor-made delivery of services