Depth Psychotherapy With Transgender People
By Lin Fraser Ed
Adapted from the Opening Plenary -HBIGDA Conference- Gent, Belgium 2003

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.

Filed under: Psychotherapy on August 27th, 2007