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Transgender Emergence


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Journal of the American Academy of Child and Adolescent Psychiatry, May 2006 v45 i5 p627(4)

Transgender Emergence: Therapeutic Guidelines for Working With Gender-Variant People and Their Families. (Book review) Kelli Harding; Michael J. Feldman.

Full Text: COPYRIGHT 2006 Lippincott/Williams & Wilkins

Transgender Emergence: Therapeutic Guidelines for Working With Gender-Variant People and Their Families. By Arlene Istar Lev, C.S.W.-R., C.A.S.A.C. Binghamton, NY: The Haworth Clinical Practice Press, 2004, 467 pp., $69.95 (hardcover), $39.95 (softcover).

When a child is born, one of the first phrases an expectant family waits to hear proclaimed is "It's a boy!" or "It's a girl!" But what if, because of one of a number of different congenital anomalies of the reproductive system, the child's genitalia are ambiguous? In this book, Arlene Istar Lev tries to expand the reader's conceptual understanding of the "natural" occurrence of gender variance in humans and opines that current treatment for ambiguous genitalia is considered a "psychosocial emergency," with the need to "immediately assign a male or female sex to the child and perform surgery to make the appearance of the genitals mirror the assigned sex" (p. 355), even when no "medical emergency exists" (p. 356). The emergent gender assignment is purportedly based on two problematic theories of development: (1) that individuals are "psychosexually neutral at birth" and (2) that "healthy psychosexual development is dependent upon the appearance of the genitals" (pp. 356-357). The book's discussion, although notably lacking commentary by physicians on current medical practices, is an otherwise thoughtful look at gender identity formation in children and young adults as well as families' reactions to those developments, hence the transgender emergence or that "developmental process whereby gender-variant people examine themselves and their identity, within a context of compassion and empowerment, and progress to an authentic and functional sex- and gender-identity congruence" (p. xx).

One of the great joys of psychiatry is the opportunity to view the world from the vantage point of another person's life experience, and although many books present a thorough overview of the topic they propose to cover, few offer the reader an experience that extends beyond the content of the pages. Transgender Emergence does just that. The unprecedented amount of curiosity and comment generated by the title from patients, colleagues, and complete strangers on the subway helps one understand in part a component of the experience of transgendered individuals and a reminder that the experience of sexuality and gender does not occur within a vacuum but within the context of family and community systems and their not always supportive reactions. Transgender Emergence presents a lengthy but thought-provoking synopsis of the complex issues facing the many categories of gender-variant people, which include "transsexuals, cross-dressers, masculine-identified females, feminine-identified males, MTFs [male-to-female], FTMs [female-to-male], transmen, trangendered women, intersexed, and other differently gendered people" (p. 399). The book is intended for a broad audience and would be informative reading for gender-variant patients, their families, and clinicians interested in furthering their knowledge of human sexual development over the life span and provide "informed psychotherapy and family therapy" (p. 1). (Parenthetically, Chapter 5 is fascinating reading for those seeking to understand elements of the antipsychiatry movement.)

Few things in life are absolute, and the introduction serves to remind (and challenge) the reader to reconsider the binary categories of male and female genders. It provides a broadminded and compassionate framework for evaluation of gender identity and gender roles by asking the reader and clinician to approach the subject not as one of disorder or dysfunction, but rather as one of individuals whose symptoms might be related more to being different and despised in a judgmental and stigmatizing society in which such behavior is often viewed as immoral. From the introductory epigraph from Elie Wiesel's 1986 Nobel Prize acceptance speech challenging the reader to "never be silent whenever and wherever human lives endure suffering and humiliation," the book takes the tone of an urgent mission to educate readers and promote tolerance and understanding of the transgender experience as a normative human variation in sexuality, as opposed to pathology in need of being "fixed." In addition, the introduction attempts to define and explain the development of problematic terms that are emotionally and politically gender laden, including the term gender-variant itself. This section, although interesting and informative overall, is in places constrained by a series of caveats and a politically correct desire not to offend. (The glossary in the back of the book is more straightforward and helpful for fast term clarification; however, the absence of "gender-variant" in it is peculiar.)

The book is subdivided into three parts and an appendix. Part I covers "Theoretical Understandings of Transgenderism," which includes an overview of the role of the clinician in working with patients with gender variation introduced by a series of useful vignettes of how someone with gender-variant distress may come to a mental health practitioner's attention. For example, "The clinician's phone rings and the woman on the other end is distraught because she just found a suitcase filled with women's clothing and pictures" (p. 25). The author notes that "few helping professionals are actually trained in gender identity concerns" (p. 28), often leading to the use of a medical model that traditionally infers that there is something to be fixed or cured about individuals whose "basic dilemma involves having a sex or gender identity that doesn't match their physical bodies" (p. 29). Guidelines for gender specialists are offered in approachable table form, as well as through comments on the development of the concept of gender dysphoria. An overview of the therapist's role as gatekeeper in sex-reassignment surgery and hormone replacement is discussed, in addition to working with families to help create an environment of support and advocacy for individuals desiring to "live true to their own nature" (p. 54) despite social and cultural repercussions for doing so. In an attempt to normalize often-stigmatized behaviors, transgenderism is discussed in an eye-opening historical and cross-cultural context from the ancient Greeks to Native-American culture to Joan of Arc. Chapter 3 (particularly the beginning) is a well-organized and excellent discussion of the four components of sexual identity (natal sex, gender identity, gender-role expression, and sexual orientation) and contemplating these as a biopsychosocial phenomenon "whereby the component parts of self--biological, psychological, and social construction of culture--intersect and interact in complex ways to create an integrated whole" (p. 79). Lev also reviews the relevant human biology and current controversies regarding intersexed populations (estimated to be 1.7%-2% of the population) and surgical alteration at birth. The chapter builds a case for considering categories such as male and female, man and woman, masculine and feminine, and heterosexual and homosexual not as absolutes but instead as traits on a spectrum. The book is a rallying call for a model of self-actualization and empowerment for transgendered individuals and at times is overpoliticized and potentially alienating to the clinician, especially a physician, reader. A case in point: the challenge to the clinician to decide to be "social control agents or harbingers of social change and social justice" (p. 109) through their work with patients. Although one could argue that no sphere is truly free of politics, it appears a boundary crossing to advocate the intentional introjection of personal political views into the physician--patient relationship.

Part II covers "Diagnosis and Assessment" and includes two chapters, the first a well-written re-examination of the nature versus nurture debate through discussion of different frameworks, including the biological, psychoanalytic, cognitive-behavioral, and feminist perspectives, and their often problematic etiological theories of gender, sex, and gender-variant behavior. Particularly enlightening (and troubling) is the section on John Money's 1966 "John/Joan case," which supposedly became "the index case for the surgical alteration of intersexed children" and was "lauded as substantiation for the theory of psychosocial neutrality of infants" (pp. 116-117). The case involved a male baby identical twin whose penis was accidentally destroyed in a routine circumcision and was sexually and socially reassigned as a female. Early reports, using his brother as a control, claimed the child was well adjusted living as a girl, providing "proof that gender identity was malleable" (p. 117). Long-term follow-up, however, showed the child never successfully adapted and, following penis reconstruction, is now living as a man. Also discussed is the often ill-fitting classification of gender variance, which calls into question the use of etiologies and categories as "not the best way to understand gender-variant people" or "to serve those who seek services" (p. 146). Chapter 5 sets the framework for revisiting mental health's grim legacy of at times legitimizing society's stigmas (including sexism, racism, and homophobia) by the creation of pathology through classification. In contradiction of the author's earlier broad-minded style in the introduction, in this chapter, the author presents a troubling and one-sided view of the DSM as a "tool of social and political control" (p. 147). At times, Lev implies prejudicial intent on the part of the DSM collaborators, rather than yet another item to be viewed in its appropriate historical context. (The author even mentions suspiciously the amount of revenue gained by publication of the DSM, as implicit proof of wrongdoing.) Although the DSM certainly is an imperfect work in progress, the zealous bias in this chapter makes the reader distrust the quality of information presented in other sections. The author, who has intriguing points to make, loses the effectiveness of her information and the potential for a wider audience by presenting it in such a skewed manner.

Part III addresses treatment issues, including compassionate advocacy and honoring gender diversity by listening to gender narratives for the understanding of experience. Chapter 6 asks the reader to "sever the associations of cross-gender identity with mental illness" (p. 185) and presents an empowering view of gender expression in therapy. By presenting mental health symptomatology as "sequelae to living in a gender binary world in which they do not fit" (p. 203), Lev minimizes the potential for common mental disorders, transgender or not. (Of note, there is limited discussion of substance abuse or behaviors that put one at risk of communicable diseases such as HIV.) In addition, the author problematically states that "mental health problems should not be determining factors in providing medical treatments" (including hormone replacement and elective surgery), with anecdotal data and an overly simplistic view of complex medical decision-making. Chapter 7 focuses on the actual "transgender emergence" and a six-stage developmental process people experience while coming to terms with their own gender issues, including awareness, reaching out and seeking information, disclosure to significant others, exploration of identity and self-labeling, exploration of transition and possible body modification, as well as acceptance posttransition. Identification of these developmental stages is useful as a guide to help clinicians recognize a pathway for patients from self-hatred to self-respect and gender congruence.

Chapter 8 focuses on developmental stages for family members coping with transgenderism and is particularly applicable to child clinicians working with families. Chapter 9, relating to transgendered children and youths, is initially somewhat repetitive because much of the book is already focused on themes of development, but the gender-variant child/youth as an early expression of transgenderism is attention grabbing. Chapter 10 provides more intriguing bioethical discussion regarding intersexed individuals, or those with genetically ambiguous genitalia at birth, as well as reported medical treatment protocols for sex assignments at birth. Appendixes include the International Classification of Diseases system, as well as a useful review of common intersexed conditions, and a guideline for clinicians writing letters of recommendations for hormones.

In summary, for clinicians interested in gender identity formation Transgender Emergence is recommended reading as a comprehensive and thought-provoking, although one-sided, overview of topics related to people struggling with gender issues, as well as a useful guide for working with patients and families. It is at best a lively, compelling text peppered with useful tables and enjoyable quotes that is in itself an experience. The book, although overpoliticized, has an important message of education and tolerance of the transgendered experience as a normal variant of the human condition and as such would be a remarkably good read for those often feeling disenfranchised by society at large. Although unfortunately diluting her message by grandstanding and repetitiveness, the author does courageously attempt to bridge the gulf between therapists and transgendered individuals by promoting therapy as beneficial for those struggling with gender concerns. Perhaps Audre Lorde's quote is the most effective at conceptualizing what is important about this book: "It is not difference which immobilizes us, but silence. And there are so many silences to be broken" (p. 240). Transgender Emergence is a spirited attempt to break the silence of stigma.

Kelli Harding, M.D.

Michael J. Feldman, M.D.

Columbia University

College of Physicians and Surgeons

New York

DOI: 10.1097/01.chi.0000215533.44778.5d

Disclosure: The authors have no financial relationships to disclose.

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Updated: 1/20/07