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Journal of the American Academy of Child and Adolescent Psychiatry, May 2006 v45 i5 p630(2)

Transgender Emergence: Therapeutic Guidelines for Working with Gender-Variant People and Their Families. (Book review) Stephen Koder.

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 (paperback).

Transgender Emergence is a tour de force. Arlene Istar Lev, a therapist with a background in social work, specializes in the field that most mental health professionals refer to as gender identity disorders. Her book is an admixture of literature review, historical review, therapeutic guide, clinical wisdom, popular psychology, social advocacy, and political rallying cry. This made the process of reading and reviewing it a daunting task.

In terms of content, the scope of the book is comprehensive. The author provides a preface and introduction that offer a clear overview and statement of her clinical philosophy. Part I covers theoretical understandings, commencing with modern clinical theory, and then provides a historical perspective before offering her own deconstruction of sexual identity. Part II examines etiological theories and classification systems. Lev then offers a postmodernist critique of diagnosis in the field of gender identity. Part III is the major section of direct clinical relevance, in which the author proposes models of the stages of "transgender emergence" and also of the family adjustment to this process. Lev proceeds to examine the research and clinical issues concerning children and youths who identify themselves as being, or wishing to be, of the opposite gender to their sex of birth. The book finally advocates an accepting and supportive approach to people born with intersex conditions who do not necessitate immediate surgical intervention on purely medical grounds. There are three appendixes and a glossary, all of some use to clinicians, especially nonmedical ones.

The theoretical content is brought to life by the author's passionate clinical politics juxtaposed with illustrative case material. Her writing demonstrates a deep commitment to improving the lot of people who are struggling to survive within aliminal, marginalized, and socially stigmatized condition. Lev infuses her text with a zeal for effecting change in the cause of respect of the individual and tolerance of difference at the individual, family, societal, medical, and legal levels.

The book argues the case for transgender liberation, along lines similar to those of the women's liberation and gay liberation movements. Gender and sexual orientation are portrayed as potentially fluid aspects of individual identity and as largely socially constructed. Lev proposes that those who do not feel their gender to be stereotypically identified with that of their biological sex may benefit from the services of a therapeutic "midwife" to assist the realization of the individual's authentic self. Obstetricians need not apply.

Ironically, Lev's propsychotherapy but antipathologizing posture would disenfranchise most of the readers of this review from working in the gender identity area. She conflates the concept of mental disorder with mental illness to support her liberationist position.

There is no doubt that the author has read broadly, with more than 500 references cited. However, she quotes selectively and is critical in a political rather than a scientific sense. For example, several times throughout the text she quotes Fausto-Sterling's (2000) controversial estimate that 2% of the population has some type of intersex condition, yet juxtaposes this only once with a more clinically realistic figure of 0.1% (Blackless et al., 2000). The latter is immediately followed by another estimate of up to 4% prevalence (Preves, 2002). None of these studies is treated with critical analysis, yet Fausto-Sterling's 2% figure is chosen as being closest to the truth. Such a figure represents a significant number of people and implies gross medical neglect and/or a social conspiracy to ignore their fundamental needs and rights.

Through much of the text, there is reference to major clinical protocols from the Harry Benjamin International Gender Dysphoria Association and the Royal College of Psychiatrists. Unfortunately, neither is included in the appendixes. The book contains substantial repetition of content within and between chapters, many of which are able to stand alone. This could be rectified in a second edition, which I very much hope to see in the coming years. Lev has written an important and challenging, perhaps revolutionary, volume. It leaves the reader feeling a little battered but better informed and more sensitized to the clinical, human, and political issues surrounding gender identity. I emerged more enthused and better prepared to practice in the field, despite being a child and adolescent psychiatrist.

Stephen Koder, M.B.B.S., FRANZCP

The Children's Hospital at Westmead

Westmead, NSW, Australia

DOI: 10.1097/01.chi.0000215534.52402.dd

Disclosure: The author has no financial relationships to disclose.

Blackless M, Charuvastra A, Derryck A, Fausto-Sterling A, Lauzanne K, Lee E (2000), How sexually dimorphic are we? Review and synthesis. Am J Hum Biol 12:638-645

Fausto-Sterling A (2000), Sexing the Body: Gender Politics and the Construction of Sexuality. New York: Basic Books

Preves S (2002), Intersex and Identity: The Contested Self. New Brunswick, NJ: Rutgers University Press

Named Works: Transgender Emergence: Therapeutic Guidelines for Working with Gender-Variant People and Their Families (Book) - Book reviews

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