Gender Transition, Hormones, and Gender Affirming Surgery: Gatekeeping versus Trans-Affirmative Collaborative Care

Clients who consult with me about transgender issues represent a diversity of gender and sexuality, and each client experiences a personal and unique set of issues. Many clients are seeking a resolution to the incongruence they feel between their birth sex and their gender identity, gender expression, and gender roles. Sexual orientation that was once understand may be in question when someone begins gender transition and has new experiences of themselves as a gendered and sexual person. Gender identity concerns are just dawning for some; others have resolved to seek guidance to help resolve their gender issues after years of being afraid to talk to a psychotherapist about it; and others only seem to need help to access medical care, such as cross-sex hormones and genital surgery. Some trans men and women seek counseling for help with challenges after gender transition, such as overcoming fear, difficulties in dating and social relationships, avoidance of emotional intimacy, and to improve relationships with loved ones.

When clients first come to consult with me, I recommend that we first reach a shared understanding of the gender and/or sexual concerns. I suggest that we discuss how gender and sexual issues emerged throughout your life from childhood to the present, so we can understand the path that your life has taken thus far. Then, we can agree on the goals for our work together. Clients often have specific goals, such as deciding whether to consider gender transition, learning how to develop a healthy and balanced self-concept as a transgender person, or obtaining referrals for hormones and gender affirming surgery, such as "top surgery", metiodioplasty, or vaginoplasty.

I also want to understand the psychological issues that might also be causing problems in your life. Sometimes clients have problems with depression, anxiety, obsessive or compulsive thoughts and behaviors, suicidal thoughts, shame, guilt, couples or marital conflict, and concerns about coming out to family, friends or at work..  Internalized negative beliefs about non-traditional gender and sexual expression, (internalized transphobia) can cause intense life long psychological suffering. Gender diversity, no matter what we may call it (e.g., transgender, transsexual, cross-dressing, androgyny, etc) is not a perversion, a psychological disorder nor a pathology.

I believe that the reason transgender persons struggle with gender and sexuality is because of the heterosexist beliefs in our culture which stigmatize gender diversity. As children, we are raised in a heterosexual culture with rigid beliefs about what is acceptable and normal for men and women. We learn at a young age what are acceptable gender roles and behaviors for our sex, and we internalize feelings of guilt and shame when we know we want to be and act like the other gender.  The suppression of gender and sexual expression can cause prolonged depression and anxiety that can be resolved through therapy.

My experience has been that transgender persons are more susceptible to depression and anxiety than the average person. Transgender persons often experience multiple stressors that can increase the vulnerability to depression and anxiety.  Depression and anxiety can be effectively resolved through transgender sensitive therapy, but sometimes medications are needed. However, many transgender persons do not have a psychological problems of this sort, such as depression, and do not need psychotherapy. I do not believe that people with transgender issues necessarily need therapy.

People who are transitioning and who would benefit from sex hormones and gender affirming surgery do not necessarily want or need psychotherapy. However, I do believe that counseling is an effective method to resolve the gender and sexual issues discussed above and as a tool for self-understanding that can improve the quality of life. When a client wants sex hormones and/or gender affirming surgery, and we conclude that there are no serious problems functioning in life, I do follow the 
WPATH (formerly Harry Benjamin International Gender Dysphoria Association) Standards of Care in making referrals to physicians and surgeons.

Many non-transgender providers of psychological and medical care assume that the desire to be the opposite sex is a psychological disorder.  Unfortunately, the DSM-IV equates gender dysphoria and gendered diversity with a  psychological disorder.  Nevertheless, the SOC
 are a specific set of medical guidelines that psychologists, psychotherapists, physicians, and surgeons are expected to follow in providing healthcare, such as administering sex hormones and making decisions about genital surgery, to transgender people.

Clients who are transitioning from one gender to another often are unsure about what if anything to tell their employer and co-workers. There can be fears of discrimination and job loss.
Many clients are worried and anxious about how their gender issues may affect their relationships, the people they care about and love, their family, spouses, and children. There can be fears of rejection, abandonment, and anger. There can be fears about stigmatization for self and the family within important social contexts, like school, church and the neighborhood.
I am committed to honesty, clarity, and collaboration in consultation with clients. I clearly explain my understanding of the issues and my recommendations for counseling goals, and collaborate on a making an agreement for services that makes sense to both of us. I believe in equalizing the power in psychotherapy and consultation through educating clients, carefully listening to and understanding clients, and collaborating in making decisions. I believe that these qualities are essential in working with transgender issues because of the history of the abuse of power by gate-keeping professionals. In order to work together productively, my clients and I must have a consensus on our treatment goals, the frequency of sessions, and the methods of counseling. When I am held to specific professional behaviors by legal regulations, medical standards, and professional ethics, I inform clients ahead of time whenever possible.