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By Arlene (Ari) Istar Lev

Gender Loving Care

Posted By on June 30, 2009

Gender Loving Care: A guide to gender-variant clients
By Randi Ettner

W.W. Norton & Company, 1999 ISBN  0-393-70304-5

Published in In The Family Magazine, November 1999.

There are scant resources available addressing the therapeutic needs of transgendered and transsexual individuals, and sadly many of the books that exist are seeped in a medical model perspective that is more pathologizing than empowering.  Therefore, I picked up Randi Ettner’s new book with caution, and read it with a skeptical eye.  I was pleasantly surprised.  Surely, there are things to criticize but it important to first recognize the strengths of this book and there are many.

Ettner does an excellent job opening her book with recent advances in the biological and medical explorations of gender identity development.  I found myself reading her bibliography with enthusiasm; her review of this literature — and her translation into readable terminology — is a real contribution to the field.

The chapter called "Effective Psychotherapy" gives an excellent overview of the obstacles that impede clinicians from competent therapy with trans clients.  Ettner debunks many myths about these populations, including separating issues of gender dysphoria from sexual identity.  She also separates issues of sexual abuse trauma from gender concerns.  She strongly encourages therapists seek consultation and supervision regarding client care.

Most exciting of all, Ettner clearly recognizes the diversity of gender variance, avoiding the trap of the limited categories of "transvestite" and "transsexual" which can exclude many gender dysphoric clients.  She says, "An overzealous application of the medical model … may lead to rigid trajectories, generic treatment protocols, exaggeration or lying of the part of the patient …  Psychoeducational models that emphasize choice, uniqueness of individuals, and informed decision-making serve to depathologize gender variance while empowering individuals (pp. 71-72)."  This is exactly the kind of thinking that clinicians must develop in order to serve this population with skill and compassion.

However, Ettner herself falls into certain traps based on current medical model mythologies that are disappointing to have repeated. It is obvious that her experience working with male-to-female (MtF) transgendered people is more extensive than her experience working with female-to-male (FtM) identified individuals, as is common in this field.  She states that FtM’s present with fewer diagnostic uncertainties than MtF’s, and that by the time they seek therapeutic assistance they have a "well-consolidated male identity."  This minimizes that many transsexual men struggle with various elements of gender dysphoria, sexual identity confusions and body dysmorphia before they come to terms with an FtM identity. 

Ettner states that "… male items of clothing possess no erotic properties" which I found to be ludicrous.  The attempt to depathologize female cross-dressing by separating it from fetishism only serves to deny the eroticism of masculinity.  For some people, women and men, trans and otherwise "male" clothing is highly erotic.  Females who wear male attire pay a high price in this culture and Ettner does not seem to recognize that the totally cross-dressing, manly looking female is harshly stigmatized.  This might come from her lack of involvement with the lesbian community and with the experiences of butches, stonebutches, and other masculine females, as well as FtM’s and transmen.

Although I commended Ettner on the thoroughness of her section on current biological theories of gender dysphoria, I am personally not drawn to these theories as an explanation of gender variant behavior.  I am leery of identity being defined by genes, or endocrine systems; civil rights and clinical support should not depend on whether behavior is innate or chosen.  I believe that people simply have a right to their own gender expression, and sometimes the search for "biological causation" hampers the therapeutic process of self-acceptance.

Randi Ettner has done an excellent job clarifying the distinctions between sexual and gender identity, and for beginner therapists (or clients) struggling with separating these variables, this book is an excellent start.  However, although these distinctions are essential to an understanding of gender variance, the waters quickly become muddied when dealing with issues between couples when a partner is transitioning.  Within the lesbian community these issues are paramount right now, as some FtM’s are transitioning gender within the context of previously lesbian identified relationships. Lesbian identified women who are partnered with transmen, that are neither lesbian nor women identified are struggling with powerful identity issues.  Clearly, we are at the beginning of an understanding of how these identities overlap, superimpose, obscure and conflate with one another.

Issues of transgenderism are not well understood.  Not within the clinical community, not within the lesbian and gay movement, and not within society at large.  Randi Ettner’s book is an important contribution to a growing body of literature on gender variance.  My criticism is that it just doesn’t go far enough.