Abstract

Gender Specialists are trained professionals, paraprofessionals, or peer-support care providers who are trained to work with the transgender population in the mental health field.  These specialists need to understand not only the psychosocial and psychiatric aspects, but also the various steps, processes and issues (i.e. physical, medical, and economic) that arise for the transgender client.  It is important that not only Gender Specialists and transgender individuals understand the complete transition process, but every engaged mental health counselor that works with a transgender client needs to be aware of the progression as well.  Each step has procedures that need to take place; this includes the assessment process, pre-operative counseling, hormone therapy, the life-test, gender reassignment surgery, and post-operative care.  These are the key methods that the transgender client will go through in their transition development and according to the Harry Benjamin International Gender Dysphoria Association; they require the help of a counselor to attain nearly all of this process.

Introduction

With the emergence of numerous psychological concerns in therapy over the years, one may perhaps suggest that counseling the transgender individual is even more of a challenge than perhaps any other concern in this field of study.  In order to understand the transgender individual and their mental health requests, a therapist should not only concern themselves with the various matters that could arise in the counseling sessions, but they should conduct an in-depth assessment of who transgendered individual is as a human being and what concerns they may have with their identity.

To comprehend and appreciate the transgender individual, the therapist needs to recognize the semblance of the transgendered person not only through text on how to counsel them, but through individual accounts from transgendered persons.  With the amount of time given to complete this undertaking, some therapists may perhaps find it complex to recognize the nature of transgenderism in a short period of time.  As a result, therapists would probably need direction from specialists in the field of transgender counseling in addition to reading of various peer reviewed articles and texts.  With an assortment of issues that can present themselves throughout the path of an individual’s transition, the inexperienced therapist may find it easier to refer the client to a more qualified therapist in the field and then decide to gain the information needed in assisting such individuals.  With the evolution of medical science, it is no wonder that the field of psychology is seeing a rise of individuals needing the assistance of professionals in determining if complete gender reassignment surgery is appropriate for them or if a less radical procedure (e.g. only hormone treatment) would be in order.

Gordon Allport once said that “the goal of psychology is to reduce discord among our philosophies of man and to establish a scale of probable truth” (1955), and in one of his previous texts he relayed that “general psychology…selects a single attribute or function that can be conveniently isolated for study” (Allport, 1937).  By looking at underlying issues that the transgendered individual may be dealing with, we can see that the matter at hand most likely would not be transgenderism but could be any number of other factors.  William Wundt (1937) understood that psychology examines the complete content of experience in its associations to the subject.  Consequently with this consideration, we see that there is probably more to a clients yearning to transform their gender identity than just gender reassignment surgery; this can involve any number of mental health concerns.

There are various processes in the transition of a transgendered individual that take place, with each individual being as unique and individualistic as the non-transgender individual.  For transgendered individuals these processes include pre-operative psychotherapy, the assessment, hormone therapy, the commitment to a life change process, life skills training, gender reassignment surgery (or sex reassignment surgery), and post-operative psychotherapy, which includes the termination of the counseling process or the continuing counseling process.  It is through these processes that the transgendered person needs to make steps in order to discover themselves in their best state of being.  For that reason, it is no surprise that we see the need to counsel each of these individuals with a more open mind and complete understanding, to beware of our biases, and to be cautious and  aware of our own manifesting countertransference issues that could surface for even the most culturally sensitive and experienced therapist. 

The belief of who a transgender individual is, without looking at the subject matter from the psychological perspective, could easily consume a number of pages that would address various thoughts and ideas on the subject matter and would become increasingly inapplicable to the matter at hand. It is for this reason that the ideas that are to be presented here will be on the basis of counseling and the complete transition process of the transgendered individual.

 

Narrative

The transgender individual is more than what one thinks of when we talk about transsexuals.  The term transgender extends to include approximately 100 various sexual identities that include drag kings and drag queens, two-spirits, androgynous, intersexed, transgenderists, transvestites, and transsexuals, just to name a few (L. A. Sausa, Ph.D., personal communication, October 15, 2008; Transgender Glossary, 1994/2008).  It was during the late twentieth century that two pronouns were adopted as gender-neutral pronouns during this trans-liberation movement.  These two pronouns, ze or sie in place of she or he and hir in place of him or her (Feinberg, 1996; Stryker, 2008), have not taken hold in today’s cultures, and may not become prominent words in society for many years (1996). Many also “feel their gender identity to be that of a ‘third gender’” (Parlee, 1998), leaving some individuals wondering what pronoun should be used to refer to them in conversations.

The histories of the transgender individual, specifically the transsexual and transvestite, have little records, if any, prior to the twentieth century.  Even the label transvestite has been rejected by many of the transgender population because the term “invokes concepts of psychological pathology, sexual fetishism, and obsession, when there is really nothing at all unhealthy about this form of self-expression” (Feinberg, 1996).  Although there are several identities under the transgender umbrella, the transsexual has a strong mind-set of having erroneously been born in the wrong body, often from childhood onwards (Zhou, Hofman, Gooren, & Swaab, 1995).  Roger E. Peo (as cited in Emerson, 1996) once defined gender identity as one’s internal perception of one’s self as either a man or a woman and Shirley Emerson said that “in our culture, gender identity is assumed to be consistent with a person’s genetic sex (1996).

With years of being afraid to let people know about their feelings and desires, and the possibility of threats or even death, transsexuals have had to worry about being who they are.  It has only been in the last thirty to forty years that transgender’s have been coming out and letting people know who they are.  With coming out has come heartache, struggle and even the fear of becoming martyr’s for what they believed in.  To understand more about the transsexual and those included under the transgender umbrella we, as the non-transgender individuals, need to recognize the history and their stories.

In 1654, Christina, Queen of Sweden, chose to take on the name Count Dohna and dressed in men’s clothing.  This is the first known account of a female changing her name as well as her identity completely from female to male.  The earliest person in history known to change only her identity from female to male (FTM) was Joan of Arc when she believed that the Saints Catherine of Alexandria and Margaret of Antioch had spoken to her about helping to fight in the Hundred Year’s War in the late 1420’s and early 1430’s before her death (Riddle, 2008) The transsexual male to female (MFT) was first written about in Abbe Francois Timoleon de Choisy’s memoirs in 1676, when she attended a Papal inaugural ball in female dress (Transgender History, 2009).  Until this time in history there had been very little, if any manuscript, written about such things.  Much of this was most likely due to the societal taboo associated with the transgender identity over the last three or four thousand years (Hotchkiss, 1995).

During the late eighteen hundreds we read of instances of “crossing the gender border,” (Elkins & King, 2006).  When individuals were participating in this behavior, they were described in terms of ‘masquerade,’ ‘disguise,’ or ‘impersonation” (2006).  Even through the 1930’s, there were “masque” balls in cities such as New York, which followed the coined term of masquerade (Feinberg, 1996), and it was during these masque balls that one could be arrested for dressing “inappropriately” in the clothing of the opposite gender. 

The first time we are actually aware of any terminology for the transgender identities is in 1919 when Magnus Hirschfeld coined the term “transvestite,” (Brown, 1998/2007; Liv (Site Admin), 1999/2009).  The following year Jonathan Gilbert published a book entitled “Homosexuality and Its Treatment’ in which he tells of the story of Dr. Alan Hart’s FTM transition in 1917.  Eventually in 1931, Hirschfeld coined the new term “transsexual” (1999/2009).  Throughout the 1930’s and 1940’s advancements in the field of endocrinology were being made and 16 cases were reported to have some sort of gender surgery prior to 1953 (Feinberg, 2006).

Sadly, due to the ignorance and misguided individuals, transgender people have had to fight just to stay alive in many cases.  On November 14, 2008, in Syracuse, New York, a young MTF transgender named Lateisha Green was standing outside a house party when she was shot and killed.  Originally the killer shot her because he thought that Lateisha was gay.  With the Gender Expression Non-Discrimination Act awaiting in the New York state senate, it would make it a hate crime for someone to attack another person because of their gender or gender expression.  The Matthew Shepard Act at the federal level also did not provide protection for the transgendered individual if they were to be attacked.  Miss Green needlessly lost her life for the reason that someone hated her because of who he thought she was.  Thanks to the expansion of the Matthew Shepard Act in April of 2009, when Dwight DeLee, Lateisha’s murderer, went to trial on July 13, 2009, he was found guilty and convicted of first degree manslaughter as a hate crime just four days after the trial had begun (Human Rights Campaign, 2009; The Lateisha Green, 2009).

Standards of Care and DSM Criteria

The transgender individual faces a list of various steps to complete their transition from the gender they are born with to the gender they feel they were supposed to be.  In order to achieve their desired results, the Harry Benjamin International Gender Dysphoria Association (HBIGDA) introduced the Standards of Care (SOC) for Gender Identity Disorders in 1979.  They have been revised five times to meet today’s standards, with the latest edition having been revised in 2001 (Meyer III, M.D. Et Al, 2001).   In the SOC, the World Professional Association for Transgender Health, Inc. (WPATH) explains the areas of focus on gender identity disorders, which include Epidemiological Considerations, Assessment and Treatment, Psychotherapy, Requirements for Hormone Therapy for Adults, the Real-life Experience, Surgery, and Post-Transition Follow-up.  They state that the universal objective of psychotherapeutic, endocrine, or surgical treatment designed for individuals with gender identity disorders is a lifelong individual reassurance with the gendered self in order to get the most out of their overall psychological welfare and self-fulfillment (2001). The HBIGDA SOC is included in Appendix A.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) did not have a diagnosis for transgenderism or transsexuality prior to their release of their DSM-III.  It was only in this third edition that the American Psychiatric Association used the term transsexualism for the first time, making it a mental disorder in the mental health and medical field (1980).  This terminology again was changed in the DSM-IV (1994) to GID, or gender identity disorder, in which there were three classifications, Gender Identity Disorder in Children or Gender Identity Disorder Not Otherwise Specified (NOS), 302.6 and Gender Identity Disorder in Adolescents or Adults, 302.85.    Because of this definition, many people believe that transgender people are mentally ill, however some authors believe that having a transgender identity is not in and of itself being “mentally disordered” (Israel & Tarver, 1996; Melby, 2009).  “Regardless of the stage of life in which individuals with gender identity disorder find themselves, the key root of their cross-identification behavior is the conflict over their biological sex role and their perceived sexual identity” (Kirk & Belovics, 2008).  Various people consider that gender identity, or the individual ideas of being a man, woman, both, or neither, is fixed in biology, although what the genetic “cause” of gender identity may be, has by no means been established (Stryker, 2008).  The DSM criterion for gender identity disorder is discussed in the HBIGDA as part of the understanding of transsexualism as well as being included in Appendix B.

With a new interest in treating the transgender individual through therapy and medicine, as well as the advancements that have been made over the last thirty years, ideas on how to treat transgender individuals are expanding every year.  In 2004, Aaron Devor, a professor of sociology at the University of Victoria, proposed a fourteen stage model of transsexual identity formation built upon Cass’ model of homosexual identity formation (cited in Devor, 2004).  This model is included in Appendix C and is a profound source to assist the Gender Specialist in counseling the transgender client.

Many people believe that removing the diagnosis of GID from the DSM in the fifth edition, scheduled for release in 2012, and would be a move compared to the likes of the removal of homosexuality from the DSM-III (1980).  Although this would be more acceptable among the transgender population, the problem with doing so would ultimately be grounds for insurance companies to deny any kind of assistance in the mental health of the transgender client or any physical treatment for their transition.  Without any assistance from ones insurance provider, many transgender individuals would not be able to get the help that they need in order to become who they truly are due to the high costs of hormone therapy and surgeries.

 

Assessment Process

With the Harry Benjamin SOC, we see that the requirement for both hormone therapy and gender reassignment surgery for the transgender client is to undergo psychotherapy for a minimum of three months before undergoing hormone treatment and a minimum of two years for the gender reassignment surgery.  When the transgender client first begins the process of searching to establish their gender reassignment, it is with the SOC that engaged mental health professionals need to assist them the most. 

Through their initial visits the therapist needs to complete the traditional assessment process as they would with any other client.  This may seem simple enough, but there are more areas of interest that the therapist may want to look at.  It is important that the therapist build a therapeutic rapport with the client, discuss the clients’ needs, goals and expectations, and evaluate the client’s history, objectives, and their psychological concerns along with their consent to care (Bockting, W.O, Knudson, G., & Goldberg, 2007; Hansen, Rossberg, & Cramer, 1972/1994; Israel & Tarver, 1996).  It is in this relationship that the therapist’s perception and understanding of the client’s behaviors are not only realistic but that their feelings are genuine and their behaviors congruent (1972/1994).  It is also vital that the therapist take a culturally sensitive approach to working with the transgender client (Gainor, 2000). 

Like any other field of study, transgender counseling can be more beneficial when done with a Gender Specialist or Senior Gender Specialist.  In their book Transgender Care, Gianna E. Israel and Donald E. Tarver II, M.D. (1997) explain the work of both of these specialized fields.

“The Gender Specialist may be a professional, paraprofessional, or peer-support care provider.  The Gender Specialist is an active practitioner in psychotherapy counseling, or education directly oriented toward gender-identity issues.  It is recommended that care providers interested in establishing themselves as Gender Specialists undergo a minimum of two years of direct supervision or consultation with a practicing Senior Gender Specialist who is recognized as having advanced experience in providing consultation to peer practitioners.

The Senior Gender Specialist is a care provider who has actively practiced as a Gender Specialist for five years.  Senior Gender Specialists are deemed appropriate to provide assessment and evaluation letters, as recommended for Genital Reassignment Surgery.  At their discretion, Senior Gender Specialists may also provide training, supervision, or consultation to Gender Specialists.

Care providers who hold advanced degrees in psychology, medicine, sexology, clinical social work, or other medical or mental health fields may become Senior Gender Specialists following two years of active practice while receiving consultation in a role as a Gender Specialist.”

In order to start the therapy needed for Gender (or Genital) Reassignment Surgery, the assessment needs to cover not only the basic information of individual and family mental health history, but also their some childhood history, physical health history, sexual/ marital history, and their transgender identification and the history involved with such.  A sample assessment or Gender Identity profile is included in Appendix D.

The assessment should be done in the early stages of counseling, no later than the fourth or fifth session, in order to determine any issues that will need to be addressed in treatment.  It is this assessment of gender concerns that involves a detailed history of transgender identity development and gender expression (Bockting, W.O, Knudson, G., & Goldberg, 2007).  This assists the client in developing trust and rapport with the psychotherapist.  It is through this assessment that the therapist finds if there are any key mental health issues at hand, such as schizophrenia, depression, anxiety disorders, adjustment disorders, addiction, or post-traumatic stress disorder, to name a few (Israel & Tarver, 1996).  Devor (2004) explains that each of us has a deep need to be witnessed by others for who we are and that we all desire to see ourselves mirrored in other peoples eyes as we see ourselves.  When these messages received in return from others are not equivalent of how one feels within, an assortment of psychological distress and maladaptive behaviors can result.

Through the assessment, the therapist can find the issues most important to the individual in order to treat the client in the proper fashion and not just address surface issues.  With gender identity being the more common reason that a transgender client sees a therapist, it is common that other issues are of more concern and need to be acknowledged appropriately in order to allow further gender identity treatments to take place.

 

Pre-Operative Psychotherapy

After the assessment has been completed, which should be within the first three to five visits, the therapist discusses the treatment plan with the client and makes a plan to address by agreement the more prominent issues at hand.  The issues that should be covered in sessions should be discussed with and approved by the client to ensure a direction and purpose for the sessions. It is in this stage of treatment that the client understands the issues with which the therapist is working to help.  Through treatment, the therapist promotes the clients understanding of both the risk factors, such as a higher risk of cancer or cardiovascular disease, and the consequences, such as the loss of relationships, entailed in the process.

In the course of the psychotherapy, the therapist is able to identify how early in life the client realized a difference in their gender identity and the factors that may have created this realization.  Usually one’s ideas as male or female are established early in life (as cited in Parlee, 1998; Harré, 1991).  This is found to occur during Erik Erikson’s initiative versus guilt stage of development (Berger, 1980/2006) and Jean Piaget’s preoperational stage (1980/2006).  It is during this age frame of three to seven years of age, in which individuals dealing with gender identity typically come to the realization that they were born in the wrong body.  The criteria listed for GID are descriptive of various individuals who experience conflict between their gender as assigned at birth and their gender identity, which is typically developed in early childhood and comprehended to be decisively established by age four, which agrees with both Piaget’s  and Erikson’s stages as mentioned above.  Nevertheless for some transgender individual, gender identity may remain rather fluid for many years (WPATH Board of Directors, 2008).   

During the therapeutic process, it is important that the client-therapist relationship work on many factors that may be connected to the feelings of gender identity, and that each one should be addressed at the appropriate times.  Some of these possible issues are substance abuse, black-market hormones, rejection, suicidality, depression, gender-based discrimination, loss of friends and family, and disclosure, which requires forethought and communication skills (Israel & Tarver, 1996; Top 10 Things, Unknown/2009), as well as medical, emotional, family support and employment risks.  On the other hand, the benefits that result from the transition are peace of mind to the client, the ability to complete the individual’s change of identity, including physical, social, mental, emotional, and the governmental identification changes to match the individual’s new identity, and the final gender reassignment transition (Yvette, personal communication, September 9, 2009).

Israel and Tarver said that “although we discourage the diagnosis of gender identity disorder as it is defined by the DSM-IV, we agree with the DSM-IV listing of the mental and biological issues that should not be confused with the evaluation of gender-identity concerns” (1996).  It is because of these many concerns that HBIGDA has required that any individual seeking gender reassignment surgery needs to seek a mental health professional for a minimum period of two years before their gender reassignment surgery and a minimum of three months before commencement of hormone treatment (Meyer III M.D., W., Bockting Ph.D., W. O., Cohen-Kettenis Ph.D., P., Coleman Ph.D., E., DiCeglie M.D., D., Devor Ph.D., H., et al., 2001).

During the mental health treatment process, there are many possibilities for helping the client in their mental health needs, including, but not limited to: individual counseling, self-help and social support groups, and group psychotherapy.  Also it is important to help the client’s immediate family members and spouse individually, or conjointly if they so desire, in order for them to be able to understand the gender reassignment process and so that they can discuss any issues that they may have about their loved one as well.  Besides family therapy, it may also be important to the spouse/ partner to be involved in relationship therapy along side the transgender client, in order for them to be able to focus their effort on issues in their relationship regarding the transition process.

 Because of the limited amount of time that the therapist has with the client, it does not allow them to be there for the client through all facets of the gender reassignment, but it is imperative that they become acquainted with each of the physicians involved in the client’s physical health care.  Through the psychotherapeutic process, the therapist helps the client going through the gender reassignment treatment to remain mentally well.  There are many guidelines recommended concerning mental health treatment are have been included in Appendix E. 

 

 

Hormonal Therapy

With hormone treatment being the first step that is taken after psychotherapy treatment has begun, the therapist not only needs to be involved in the client’s mental health, but should remain in contact with the physician in charge of the hormone therapy in order to assist in the monitoring of potential concerns with the clients mental and physical health.  This is extremely important as the client begins this part of the treatment as there are many new concerns that can come into play.  These can include, but are not limited to, cancer, including breast cancer (MTF), higher lipid levels, mood changes, heart disease, acne, and male-pattern baldness (FTM) (Israel & Tarver, 1996).  For the treatment of hormone therapy, it is important to understand the many difficulties that the client may face through this stage of the process, as these may be indicators to future concerns. 

For many transgender individuals, the hormone therapy is sometimes the only treatment that they will receive; therefore it is vitally important to closely monitor their mental health.  With the increase of estrogen in MTFs and testosterone in FTMs, many side effects can come along with these hormonal differences.  Transgender hormone administration may play a causal role in depression and therefore should be monitored closely by both the prescribing physician and the therapist.  Other concerns with hormone therapy are cardiovascular health, cancer, risks involved with smoking after hormone treatment has begun, as well as the client’s diet.

One of the key factors during all stages of the gender reassignment process is finances.  This becomes an important issue in hormone therapy as most insurance companies will not cover hormone therapy for gender reassignment issues.  Since this becomes a major concern, the probability of the transgender client obtaining black-market hormones is not uncommon.  Sadly the problematic issue with black-market hormones is that if the client is having an adverse reaction to the medications or their dosage needs to be re-regulated by their physician, it goes unnoticed thus becoming a major health matter.  In the end, black-market drugs can ultimately develop into higher costs for the client due to additional costs associated with additional physical and mental health issues.  It is advised that the therapist help keep a close eye on the client’s hormone use and advise them to keep their regularly scheduled appointments with their physician in order to maintain appropriate dosages and hormones for their treatment.  The hormones and their individual dosages are listed in Appendix F.

From Fantasy to Reality: the Real-Life Test

After the transgender client has been in psychotherapy treatment for approximately one year, and after they have begun hormone treatment, the next process is moving from the temporary lifestyle of cross dressing to the permanent lifestyle changes and commitment to the new gender.  This process, although not necessary in all transgender treatments, is a vital step for the transsexual in order for them to realize their new individuality and transition from a temporary state of self to a permanent state of altered gender identity.

When the client has been cross dressing in the past, this has been a temporary identity change or acting out.  At some point the client needs to realize and act in a permanent fashion as a transsexual.  Many of the areas here consist of experimenting with their looks, a new self expression and an exploration of who they desire to be after their transition is complete.  It is important that the client realize the importance of this change and make a complete commitment to their new identity.

According to Israel and Tarver (1997) and HBIGDA (2001), this process is known as the real-life test.  It is a term used to illustrate the phase from beginning to live in role, to the time when he or she has been doing so long enough to be considered a suitable candidate for aesthetic or Gender Reassignment Surgery (1997).  Apart from the SOC  by which a real-life test protocol is defined, few specialists believe that care providers and transgender individuals place too much importance on the quantity of time one must expend living “in role” preceding the  recommendations for surgery.  The real-life test however is essentially designed to care for and reduce the risk of non-transsexual and unprepared individuals from undergoing surgical procedures and incurring physical, psychological, and/or social injury.

There are other changes that occur through the process that can change the transgender individual’s lifestyle choices, their relationships, sexual partners, and even their sexual identities.  For example, family relationships are challenged by many transgender clients’ families because of fear or the lack of understanding.  This is important for the client to help their family seek therapy as well in order to keep the lines of communication open during transition process.  Although this is usually considered a part of the pre-operative psychotherapy, many transgender clients choose to wait until they have begun hormone treatment or the real-life test to inform those that are closest to them.

Another possible change is that of sexual identity.  Sex is not who one is as an individual, it is a part of one’s identity in relationship to others, for this reason, many therapists have confused sex and gender for many years and this should be corrected in the fields of psychology, sociology, and medicine. Generally people experience sexual orientation and gender identity as two separate things (APA, 2008). Sexual orientation refers to one’s sexual attraction, while gender identity refers to one’s sense of oneself as male, female, or transgender (2008).  The transgender client can have any number of the various sexual identities, including homosexual, heterosexual, lesbian, bisexual, nonsexual, or asexual.  There is no rhyme or reason as to what causes ones sexual identity to change in some transgender clients, but many transgender’s have had a sexual identity of heterosexual prior to their transition and after their transition have become homosexual or lesbian, bisexual, nonsexual, asexual or remained heterosexual. 

Life Skills Training

Life skills’ training is a process of the transition that is not distinctly discussed in the literature, although it is mentioned in the transgender community.  This process consists of learning new skills that identify the transgender individual in their new gender expression.

For MTF clients, there are basic skills that one needs to learn in order to pass as a female.  Some of these include, learning how to shop for women’s clothing with help from a style counselor, which includes how to properly know ones own bra size, what colors and styles of clothes to wear and how and where to shop responsibly, how to apply makeup properly, learning how to walk as a woman, and voice coaching.  Although these seem like miniscule skills that one needs to learn, to the transgender MTF they are very important.  If one is unable to pass as female, there is the fear of being fired from one’s job, being discriminated against in public situations, or being beaten, tortured, or even killed.

For the FTM transgender, some of these basic skills include, voice coaching, dressing in more masculine clothing, and learning to walk in a more masculine way.  The voice coaching for FTM is not as big of a need as it is for MTF as the testosterone will start to thicken the vocal chords causing the client to begin speaking in a lower register.

Gender Reassignment Surgery

For the transsexual individual gender reassignment surgery, for at least part of this population, is the final step to the completed transition process to the client’s new identity.  This process involves a multitude of various surgeries for the male to female transition compared to the female to male transition.  To understand this population better, we need to know that not all transgender clients undergo surgery.  The estimated numbers, although these numbers are most likely lower than actual transsexuals, total  approximately 10,000 to 12,000 MTF transsexuals and 5,000 FTM transsexuals (Ulm, 2009) and approximately 400,000 transgender individuals in America (Kennedy, 2008).  Comprehending these numbers on a more understandable scale, Ulm and others say that male bodied people who become women are approximately one in 11,900, while female bodied people who become men are roughly one in 30,000 people (Currah, Juang, & Minter, 2006; Rohde, 2009; Transgender, 2009; Ulm, 2009), although these numbers are continuously changing as more and more transgender individuals are coming “out of the closet” about their transgender identity.  With these figures, it is estimated that in a city of approximately 125,000 people, there would be roughly 11 MTF transsexuals and 4 FTM transsexuals. 

There are two different types of surgeries available for both FTMs and MTFs, aesthetic surgery and the genital reassignment surgery.  According to Israel and Tarver (1997), it is virtually impossible to fulfill the real-life test, which was discussed earlier in this paper, and be fully functioning in the capacity of a new gender identity without some prior surgical intervention.

For the MTF clients, there is the option for breast augmentation surgery.  While interviewing Amanda in her personal communication (September 12, 2009), she said that she chose breast augmentation for two reasons; the first was to remain off the hormones in order to continue to have sexual intercourse using her male anatomy, and two because of the possible side effects of hormones.  The second option for breast enhancement without hormone treatment is silicone injections.  This has become one of the most unethical procedures towards MTF transsexuals, as it has been declared illegal by the United States and in most countries with similar food and drug precautions due to its (silicone) ability to migrate through the body causing dangerous side effects to major organs. Unfortunately, unscrupulous and deceitful doctors and other practitioners preying on the transgendered community have been found to continue to offer this form of treatment (1997).  There are several other aesthetic surgeries for MTFs, including tracheal shave, voice augmentation, false rib removal, rhinoplasty, face lifts, acid peels, chin reductions, forehead lifts, brow shaves, electrolysis (hair removal), cranial reconstruction surgery, and hair transplants.

For FTMs, the earliest possible and most common surgery is a bilateral mastectomy or chest reconstruction, which can be completed after a minimum of three months of psychotherapy treatments.  Part of the reason for such an early timeframe for this surgery is due to the higher risk of breast cancer when testosterone treatment has begun.  Dermatological treatments have become common as well in the FTM population due to severity of acne scarring from the hormone treatments.  Although there are many other types of aesthetic surgeries available, these have been seen as the most common procedures being performed in the early stages of the transgendered client’s transition.  Douglas Ousterhout (cited in Israel & Tarver, 1997) says that “the procedures being completed need to be chosen on an individual basis.”

Genital reassignment surgery itself is the most prominent procedure the transgender client is concerned with during the transition process.  It is important that the client complete a minimum of two years of therapy with a psychologist or psychiatrist (or in some cases it is recommended from both) before undergoing this major step in the process.  The two main reasons for this are, 1) to not rush into making a decision that they are unable to reverse after it has been completed, and 2) to protect the physician from a malpractice suit by performing a surgery that the client was not prepared for.

The genital reassignment procedures include the removal of the gonads and genital removal as well as reconstructive procedures such as hysterectomy, oopherectomy, salpingectomy, vaginectomy, genitor-phalloplasty, and metoidioplasty for the FTM individual; or orchidectomy, penectomy, genitor-vaginoplasty, or labioplasty, which is completed no sooner than three months after genital reassignment surgery for patients who desire it (Schrang, 1997) for the MTF individual.  There are two options for surgery when considering the genitals which include the complete genital reassignment surgery or a gonad-removal surgery in which only the reproductive glands are removed.  Both HBIGDA (2001) and Israel & Tarver (1997) have given the SOC and recommended guidelines stating that either of these types of surgery requires a minimum of two years before either surgery can be completed.  These procedures and their definitions can be found in Appendix G.

There are several concerns after surgery with health related complications beyond the traditional surgical procedure.  After the GRS, FTMs have a greater risk than MTFs with health related concerns.  This is usually in part to the fact many FTMs do not complete their transition and maintain their female reproductive organs.  This main risk is not only in part to common causes of cancer or other health issues, but the increase in testosterone can raise the chance of cancer related health problems in the ovaries and cervix.  This was the case for Robert, a FTM transsexual who did not have his ovaries removed and eventually passed away from cancer because doctors were afraid to treat him until it was too late (Cola, 1999).  His documentary was released two years after his passing to tell his story (Davis, K., 2001).

Post-Operative Therapy, Termination in Counseling and a Continuing Process

Although post-operative counseling, like the life skills training, is not clearly defined in the majority of the literature, it is strongly recommended that the transitioned transgender client complete their therapy after their transition.  Many issues that may have been resolved in pre-operative counseling may or may not show up again and new issues at hand may need to be addressed.

Israel and Tarver (1997) suggest that the responsibility of the Gender Specialist does not finish with pre-surgical therapy, evaluation, or providing a letter of recommendation.  A competent Gender Specialist will recognize the need to present post-surgical follow-up and its necessity for the client.  Through the post-operative mental health check-in, the Gender Specialist provides an opportunity for the individual to talk about his or her recent experience, and can recommend additional resources and options for the client, should difficulties arise in the future.  This is best to be completed within the first month after their GRS and this one session is provided by some Gender Specialists, not all, as a courtesy session which creates the additional incentive for post-operative client to seek support with any difficulties that they be having as a result of surgery.

It is at this time that the therapist will determine if other factors, such as post-traumatic stress, loss of family or extended-family support, housing, or employment, complications with identity related documents and governmental issues with documentation, depression, adjustment, or anxiety, or any number of these may present for further therapy (Carlson, 1996/2002; Israel & Tarver, 1997).  It is during this time that the client can receive any additional counseling that may be needed.  At this time the therapist can also help the client and work with other organizations that may be beneficial in these areas as well.

Should no other concerns arise after the GRS, the therapist can help the client move on through the termination of therapy in agreement with the client.  This termination is not only dependant on the counselor, but also on the client as they see their ability to move forward without the need for therapy.  This is not dependant on only one or the other, but on both the client and the therapist and should be agreed on as to a timely manner to terminate the counseling process (Hansen, Rossberg, & Cramer, 1994).  The termination process is one that can be complex because of feelings of ambivalence about it.  The client equally wishes to be liberated from the counseling process and is sometimes apprehensive about parting the process as well (1994).  It is because of this that the counselor emphasizes the fact of ending the counseling process carefully and not just abruptly as to not further impede any unresolved issues. 

In their book, Counseling: Theory and Process, the authors discuss the termination stage of counseling as  having three primary functions as presented by Ward (cited in Hansen, Rossberg, & Cramer, 1994).  These three functions consist of: 1) evaluate the client’s readiness to finish the counseling process and merge their learning, 2) resolve any outstanding emotional issues and bring the relationship involving the client and counselor to a close, and 3) to make best use of the client’s transfer of learning and enhance his or her self-reliance and confidence in the capacity to retain the transformation.

In the termination process, it is important to inform the client that this does not mean that they can never be seen by the counselor again.  Albeit, this may be the end of this portion of counseling, the therapist should inform the client that their office is always open for them to come back to at any time to work through any issues that they may need to address in the future.  Just because the client-therapist relationship has come to a close at this time of their transition, it does not mean that they are not allowed to consult the therapist in the future for any circumstances that may arise in their lives.  If the client feels that the counselor would be better suited to help them with a situation they are unable to face alone, they should feel welcome to visit the therapist at a later time.

Ethics

            Once again, there was no real definitive literature on the topic of ethics; however, due to the nature of the subject, it is good to be reminded of some of the ethical principles for therapists.  A few new principles can be added to the therapists ideals from various research and literature for future use as well.  With very little being discussed in relation to ethics in the literature, there are some rules of thumb not only for the counselor but for the client as well when it comes to ethics.

“There are merchants and care providers who prey on transgender individuals who are closeted or unaware that other resources exist.  The unscrupulous (counselors and physicians) take advantage of a transgender person’s sense of desperation,” (Israel & Tarver, 1997).  In the interviews completed at the end of filming the movie “Transamerica,” Felicity Huffman believes that “it is not a transgender issue,” in regards to the film, “it is a human issue” (Tucker, 2005).  Just because the transgender individual is seeking the assistance of a therapist for their mental health, as well as trying to find authenticity through GRS, this does not mean that they are individuals that are worth trying to deceive every dime out of them because of who they are, or for who they desire to be.

Care providers encountering transgender issues, not only for the first time, are advised to keep in mind that it is the provider’s liability to pursue the ethical and professional guiding principles customary for their area of expertise, and to guarantee that the transgender client is taken care of with the same dignity, respect, and quality of care unmitigated to others, regardless of how atypical an individual’s requests and thoughts may seem (Israel & Tarver, 1997).  “Awareness of the ethics codes is crucial to competence in the area of ethics, but the formal standards are not a substitute for an active, deliberative, and creative approach to fulfilling our ethical responsibilities” (Ethics Codes &, 2009).  With this in mind, psychologists and psychiatrists should adhere to either the American Psychological Associations “Ethical Principles of Psychologists and Code of Conduct” (2002) or to the American Psychiatric Association’s “The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry” (2009).  A copy of the American Psychological Associations Ethics Principles is listed in Appendix H. 

Conclusion

Transgenderism is not always a painless path to follow (Hotchkiss, 1995), and transgender individuals, as well as their loved ones have often been an underserved community that are in need of empathic, comprehensive, and clinically competent care providers who are not there to judge or try to mislead them in any direction.  With the knowledge that has been presented in this paper and through the research undertaken, any motivated mental health care professional or counselor will be able to come to the same knowledge and level of empathy and compassion that is needed to counsel these clients.  The knowledge that has been obtained in this research, although extensive in some areas and minimal in others, would be an excellent source for the person seeking to become a Gender Specialist.   As a result of this research, appropriate terminology is now properly understood and unacceptable terminology was corrected and should be explained to individuals interested in becoming a Gender Specialist as well as the transgender client, their loved ones, and throughout the educational system.

The entire transition process, when looked at prior to the research, can seem not only daunting, but also seems very complex.  After reading about the process and studying the fields of psychology or psychiatry, one should be able to assist a transgender individual throughout their transition with a positive outcome.  This will also help the therapist to challenge their own stigmas and be able to confront their own feelings and fears.  To say there is no challenge in this field would be a lie, as no therapist has all of the answers.  The challenge in this area of study is that it is still new in the field of mental health that many more issues need to be explored and understood in order to resolve the possible psychological consequences for the transgender client.

Many patients need to take time due to the cost of the entire process, which can run into hundreds of thousands of dollars in some cases.  Likewise it is also important that the therapist does not try to extend the psychotherapy sessions longer than needed. With economic restraints taking their toll on many transgender clients, the therapist needs to be more empathic and understanding when it comes to recommended time lines that they may give to the client.  With a typical time frame of two and one half years from the beginning of the counseling process to the completion of post-operative psychotherapy, it is also important not to set specific time frames and to allow for other issues that may need to be addressed prior to any further treatments. 

Finally, it is imperative to understand that post-operative counseling is just as important as pre-operative counseling.  With almost no literature on post-operative counseling, it is important that further studies are necessary to understand this part of the transition process.  With the various areas of study within the topic of transgender transitioning, it is highly recommended that further research be completed for the Gender Specialist and for transgender clients and their families.

References have been removed as well as the appendices having been removed as well due to length of information. In all there were a total of  53 references for this research.