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This article has been published in The True Spirit Conference Brochure, February, 1999, and Transgender Tapestry, Issue #90, Summer 2000. Being a GOOD Gender Therapist I have an image indelibly etched in my mind: I'm watching the Wizard of Oz on television as child, and remember when the merry travelers first reach the Wizard's castle in Oz, after a long and perilous journey. They are met at the door by a gatekeeper, who opens the peephole and says, "Go away." Therapists working in the gender community are often viewed as this gatekeeper was - a powerful figure that can determine entry, and must be convinced, cajoled, bribed or tackled into allowing admission. Clients often come prepared to their first session, armed with more clinical reading material than any other client population. On their first visit, they often present with a description of "gender dysphoria" literally lifted from a medical textbook. They are either terrified of me because I have the power to diagnosis them, or furious at me because they need me to diagnosis them in order to receive the medical care they desire. Developing a healing and trusting relationship that starts from the premise of power and exclusion is a challenge. How can I be a gatekeeper who is a gentle door'man', warmly inviting an often scared and vulnerable client in to my office, offering a safe haven from judgment and diagnosis? Clients are right to be wary. Most therapists are ignorant of issues of transgenderism, and have had virtually no training on these issues. Many therapists that have studied gender issues believe it to be a disorder and an illness; a few refuse the yoke of gatekeeper, and approve all requests for medical referrals on principal, ignoring ethical guidelines. Therapists working in the gender community are placed in an untenable position, -- caught between the requirements of western medicine's bureaucratic machine on one hand, and the burgeoning trans liberation movement on the other. The medical model creates categorical systems and labels gender folk with words like "gender dysphoria" and "gender identity disorder", and outlines arbitrary distinctions between erotic cross-dressing behavior and "real" transsexuals who deserve surgical intervention. The trans political community denies any model that diagnoses disease, and insists on access to available medical treatments on demand from a system that inherently infers an illness model. The politics of a liberation movement, however liberating, do not often bear witness to the intensity of very personal human pain in the face of gender confusion. The decision to come into a therapist's office is rarely an easy one; it often represents a change, a step, and a move forward. I find that most trans folk who make an appointment, show up for a first scheduled appointment -- unlike the general population of therapy clients. They almost always arrive anxious but motivated to "get to work." The next task is to figure out what the "work" is. I am a therapist. What this means to me is that I am a professional with experience and expertise in understanding something about human pain, and assisting people to live healthier, more productive lives. I am a family therapist who believes that people are interconnected in a web of others; I see that our actions and decisions impact one another. I am also a feminist, a social worker and political activist, which means that I see important implications in why people experience the kind of pain they do. I cannot limit myself to psychological explanations of human behavior, but am committed to seeing the social and political ramifications of oppression. These parts overlap inside of me, synthesizing a working analysis of my professional obligations. I believe that living in a bipolar gender system is no less than tyranny. I believe that everyone has a right to their own gender presentation and expression, and that everyone has a right to access appropriate and expert medical care. I believe that our culture is at the beginning of a revolution and that the transgender movement is at the forefront of a truly feminist, non-sexist and liberating social transformation. I also believe that we, all of us, are deeply wounded from the ravages of this racist and patriarchal society. I believe that those of us who are "different" -- racially, culturally and genderly -- suffer greatly. At it's worst the system kills us, institutionalizes us, and abandons us to poverty. At its best, we can heal; we can deconstruct the patriarchy's lies, we can reinvent ourselves in our own image. Good therapy is a tool that can help this process. That I am a gatekeeper in undeniable - I have the power to write referral letters to endocrinologists, or not. I have the power to diagnosis people with mental illnesses, and who among us is not afraid that of some outside authority's power to decree us "mad." On one hand, I can write a supportive referral letter for a client who I've only met once or twice, who presents as a competent and articulate adult, who identifies as transsexual and desires hormone treatment, and explicitly denies needing therapy -- and the professional community will judge my ethics. According to the guidelines of my profession, the nature of this person's transsexuality obliges me to three months of assessment and some kind of on-going therapy; the diagnosis of transsexuality defines a mental illness that requires treatment. On the other hand, if I refuse to write a referral letter for a client who wants to take hormones without his wife's knowledge, or is clearly exhibiting psychotic symptoms and I am concerned that she is unable to examine the consequences of these decisions, have I abandoned the political call to arms of the trans liberation movement? As a gatekeeper, I am expected to ensure that nobody slips through the system and has surgical or hormonal procedures that do not meet the procedural guidelines. I am aware that too often these guidelines have not really been developed to protect the clients, but to protect the medical profession from being sued. However, I am also aware that many clients are not aware of the impact of these kind of decisions on their lives; as a helping professional, I have an obligation to help people assess whether their choices will relieve their pain or increase it? As a therapist (not a lawyer or surgical physician) I need to have some kind of criteria to determine who is capable of making decisions about gender transition, and who is in need of emotional healing before they are able to make life altering decisions. We can argue about one's legal rights to medical care, and we can (and should!) discuss who gets to 'keep' the gates, but can we really argue that human beings in pain are not always able to make decisions in their best interests, and that one of the tasks of the therapeutic professions is to help people sort this out. Clients seek out therapy for gender issues for different reasons. Adults seeking services for themselves are often of two categories. One group is people who have been dealing with some level of gender confusion since early childhood (or less occasionally for a number of years in adulthood), and are seeking "help." They explicitly seek out my "expertise," either want me to diagnosis them as a way to label their pain, or are hoping that I will not be able to do so and thereby somehow free them from a condition that plagues and obsesses them. These people are classically what the literature calls "gender dysphoric:" i.e. their gender differences are causing them tremendous pain, and they want some relief. Sometimes I am the first person they have ever spoken to about this; often I represent the first attempt to do "something" about it. The other group who seek out therapy for gender issues are people who know themselves to be genderly different - either transsexuals or transvestites who fit the prescribed diagnostic criteria in the DSM, or people who do not fit into any medical classification system, yet know themselves to be trans. This group of people are often less closeted and more articulate about their identity. They are often in less emotional pain, and clearer about their options. Sometimes they also want help - help managing a resistant wife, or confusion regarding coming out to parents, or help coping with fears about how this will impact their careers or financial stability. Sometimes they just want a damn referral for hormones. Sometimes it is appropriate to just give the damn referral. Other times, it seems appropriate to question some of the unexamined issues in a client's life, to see that they have considered the impact of their decisions on loved ones or employment. Other times people are exhibiting bona fide mental health problems, possibly totally separate from their gender issues, but more likely a direct result of the oppression and pain of gender difference. Telling a person in pain that they are "oppressed" does not always eliminate their pain. Referring someone on to hormones or surgery can increase the confusion and pain in someone's life and exacerbate other mental health issues. Exercising good judgment is the expertise of the therapist. Being a gatekeeper does mean I have the power to lock the gate and keep people out -- it also means I have the power to let people in. Either way, it is a small part of the work I do. I am a therapist and therapy is about helping people to make healthy, empowered decisions to live their lives in the most freedom and happiness possible within the confines of an oppressive system. At the end of the Wizard of Oz, you may remember the scene when Toto pulls back the curtain behind which the wizard is hiding. The wizard says, in what I think of as one of the great moments of cinema, "Please ignore the man behind the curtain." Therapy is about opening up this curtain. Therapy is not magic; the therapist is not a wizard. And most certainly this is not Oz. Any therapist who is hiding behind diagnoses and clinical interpretations is just hiding behind a curtain. Any good therapist will open the curtain, and show you his or her face. Gender folk have inherited a binary system in which they do not fit, and becoming whole is no easy task. The work of healing, of deep healing, is the best work we can do. Not because transgender people are gender dysphoric or mentally ill, but because the system is crazy making, and gender transgressive folk have a right to heal at the root of their spirit. Indeed, it has been suggested that coming home to one's true spirit is a shamanistic journey. In most spiritual traditions before undertaking a spiritual quest, one seeks out a guide. One client calls me a "transition assistant," and indeed this work is about assisting and guiding. I think of a guide as a skilled person who is prepared for all circumstances, and knows the diversity of the terrain. Guides do not necessarily know everything that will be encountered, and cannot know the inner path of the seeker, but they can often sense when danger is near, or know how to prepare shelter in a storm, or lead the seeker to water. I learned many years ago to never go camping without carrying matches in sealed plastic bags. When clients are drenched in the rainstorm of job loss, partners' abandonment, complicated medical problems or authoritarian doctors, I can pull out my matches and build a fire. I can provide a warm fire, and listen to their pain, and then listen some more. Being a "good" therapist requires myriad skills. I can advocate for clients, and help them build up the strength they need to advocate for themselves. I can be the voice of expertise in talking with family members. Often I can use my professional power to help people receive other services they need; sometimes I must use my professional power to push clients to examine issues they would rather ignore. I am often a fashion consultant. There is nothing more important in the therapeutic relationship, than finding a therapist who provides a safe space, and feels comfortable to you -- someone you can trust with your truths. You do not need to settle for a bureaucratic gatekeeper to present a false self to who will judge and diagnosis you. You can find a guide to travel with you on a sometimes perilous, but often exhilarating journey. You deserve nothing less. Next: Guidelines in Seeking a Therapist Copyright ©1998, Arlene Istar Lev Arlene Istar Lev CSW-R, CASAC is a family therapist who specializes in working with the gay, lesbian, bisexual, and transgender communities. She is the founder and Clinical Director of Choices Counseling & Consulting, and adjuncts at SUNY Albany, and Vermont College of Norwich University. She can be reached at 321 Washington Ave., Albany, NY 12206. 518-463-9152. |
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