Home Up Welcome Contents Questions? WHY? Wanted to Know Telling Awsome Courage To Be Suicide Links Gender Identity School Rejection Nicole's Story Being Bullied Female to Male Alone DISCOVERY For Parents Risk Reduction Therapists Shame Sinful?Through The Looking Glass



Through The Looking Glass

A Look at the Literature Available on Counseling Transgendered Individuals

There has been an increased focus on diversity and multiculturalism within the counseling field. However, the transgendered population has not been given much attention in research and in counselor training. Discussions of issues relating to the transgendered are rare and information available in articles is scarce. This means that a significant section of the population is being poorly served by the counseling community. Ettner (1999) suggests that those experiencing some sort of gender dysphoria can be conservatively estimated as 3-5% of the population. Others suggest the percentage to be greater. My personal doctor, a rural general practitioner, estimated that over 10% of his patients could be considered transgendered in some form. Historically, and to some extent currently, the assessment, treatment and research tends to pathologize the transgendered. For the most part, mental health practitioners’ views about transsexuals, cross-dressers, and others with transgender status have "not been informed by objective empirical research" (Fox, 1996). Therefore, counselors are ill-prepared to meet the needs of such clients (Raj 2002). My personal experience, and what I have heard from members within the transgendered community, is that often it is the client who educates the therapist, at the client’s expense.


It is useful to begin this discussion with an examination of the terms. Very simply put, sex is between the legs and gender is between the ears. Transgendered is an umbrella term referring to those who experience discord between sex and gender. This can be seen as a continuum with an almost infinite variation in the expression of the gender variance. However, three general groupings can be discussed. The crossdresser (CD) is dual gendered male and female. This is exhibited by dressing in clothing of the opposite sex. The transgenderist (TG) is also dual gendered but more likely to cross-live as the opposite sex, perhaps full time. The transsexual (TS) identifies as the gender opposite of birth sex. Gender dysphoria can affect both males (M to F) and females (F to M).


Within the transgender community is an almost infinitely diverse group, who define themselves in many ways. Establishing a gender identity often results in conflict. Many resist being "pigeon holed" and others want the comfort of a label, not having had a sense of self. It is important to remember that gender identity is only one of a host of fluid categories that make up self-awareness (Moorhead, 1999).

"Self-identification and the discussion of gender issues is clouded by the fact that language and (Western) cultural assumptions commonly applied to erotic or partnered relationships do not allow for couples for whom the psychological dynamics are incongruent with the ‘genital’ sexes. Therefore, individuals must search for understandable ways of communicating about themselves and their relationships" (Eyler & Wright, 1997). Coming out is a life long process not a specific event. There may well be rights of passage in that process. These can include finding an identity, self acceptance, and sharing with others your "real self" (Rogers, 1961).

One cause of misunderstanding stems from identifying the intentions of the transgendered person. "Only a certain percentage of individuals who disclose gender dysphoric feelings express a desire or intention to live full time in the preferred gender"(Ettner, 1999). Many are part time and do not wish to go further. Clinicians can help clients to determine where they fit in the gender continuum. It is essential to understand the difference between sex and gender.

Many professionals have little understanding of those who identify as crossdressers, and assume that crossdressing is always fetishistic in nature. Those, however, are the minority. In general, CD’s are motivated to wear and appear in the clothing of the opposite sex to create the image of who they perceive them selves to be. They also report a tension that builds between periods of dressing (Ettner, 1999).

Gender identification and sexual orientation among genetic females can become quite complicated. They are often not aware that they are transgendered or gender blended. Research has primarily focused on those that present themselves for treatment. Many genetic girls (GG) can live comfortably in a male or androgynous state with little or no cultural discontinuity.


There is an increasing realization that the concepts of self and gender are of major importance in the field of gender dysphoria (Hartman, et al., 1997), and in the treatment of gender variant individuals. One of the serious problems in counseling transgendered individuals is helping them deal with their sense of self: the lack or confusion about who they really are.

One of the theories in sociology is called the looking-glass self. You tend to become what those whom you value most (i.e. parents, spouse, boss), value. This is the definite imagination of how oneself is perceived by another (Cooly, 1901).

This is not a new notion. In his first Epistle to the Corinthians, the Apostle Paul says:

For now we see through a glass, darkly; but then face to face: now I know in part; but then shall I know even as also I am known.1 Cor. 13:12 KJV

The Greek word for darkly is ainigma root for enigma. One of the words in Old Testament Hebrew which can not be translated fully into English is Nepesh, soul, and one of the concepts is how you see yourself as well as how others see you.

Growing up as a transgendered child, it is learned very quickly that what you are is not acceptable (Ettner, 1999). Our society and culture has conditions of worth (Rogers, 1961) reinforced by parents, peers, and the media. We are given rewards when we accomplish, love when we behave, punishment when we transgress. Rogers (1961) calls this "conditional positive regard," i.e. getting positive regard "on condition." Since we need positive regard, the affect is huge. It is not based on our organismic value but on society and culture. These forces can be subtle and pervasive.

Conditional positive self-regard is the result of this conditioning. We like ourselves only if we have met the conditions and standards expected of us by others, rather than if we are realizing our own potential. Since the "standards" are created with out regard to the needs of the individual, it is impossible to meet them and therefore have a positive sense of self. This happens early in childhood before the child understands cognitively that gender problems are social problems. The child learns very early that the real self must be hidden and a wall or mask is built. The public persona of a transgendered individual is an artificial construct that is built to fit in, to be like every one else (Ettner, 1999; Rogers, 1961).

There is now an incongruity between the real self and the psudoself or as Rogers (1961) states it, the "ideal self" and the not real self. The gap between the I am and the should be is incongruity. "The greater the gap, the more the misery" (Rogers, 1961).

There is a need for intimacy that begins in preadolescence between roughly ages 8 ˝ and 10 years. During this period any negative influences of family life may be attenuated or corrected. Because one draws so close to another, and because one is newly capable of seeing oneself through another’s eyes, the preadolescent phase of personality development is particularly important in correcting ideas about oneself or others. The progress of this phase of personality is of extreme importance. It is during this time that close friendships need to be formed. The intensity of the relationship needs to be powerful enough for each to get to know virtually everything about the other. Such familiarity remedies a good deal of the "often illusory, usually morbid, feeling of being different, which is such a striking part of insecurity in later life" (Sullivan, 1953).

For the young gender variant individual this level of intimacy is not possible as the real self can not be disclosed. It is during this time that the experience of aloneness begins or increases (Ettner, 1999). The force field around the self is strengthened. {"More power to the shields Scotty!" " I’m givin’ her all she’s got, sir." (any number of Star Trek episodes).}

Adolescence is a time of tremendous cognitive, biological, and social change. Formation and exploration of the self occurs. Homophobia silences LGBT youth. Attitudes and norms of introjected societies can lead to silence, self hate, and suicide. Drugs and alcohol are used to numb and cope. LGBT students are 1.6 times more likely to experience substance abuse (Little, 2001). Some transgendered teens will become involved with the Gay community out of ignorance, not realizing that what they are is transgendered not homosexual (Brown, et al., 1996).

AIDS Vancouver distributed a pamphlet stating: "It takes a lot of energy to deny your feelings, and it can be costly. You may have tried using drugs and alcohol to numb yourself against these thoughts. There are alternatives to denying these valuable feelings."(from the Campaign to End Homophobia). (Little, 2001).

Asked what would have been helpful to them in school, transgendered adults indicated several things that they felt might have been useful. These included role models (some one who is out), an advocate or representative to speak for them, awareness curriculum to educate other students, counselors open to questions, and to put a stop to all the jokes (Little, 2001).

                Christian Issues

For those that are Christian and transgendered, there is often a double whammy. Not only are there the societal norms that are being transgressed but Biblical decrees that seem to censure transgender activity. (cf: http://www.gendertree.com/Bible%20Verses.htm ) These have influenced Christians to condemn those that are gender variant. The perception that what you are is sinful is exceedingly powerful. Compound that with those that have entered the ministry in part to escape their transgender nature you have a recipe for suicide.

                Therapy models

Many times when a male-to-female transgendered individual enters counseling to address his gender identity issues, a personal history reveals a pattern of choices that may have been consciously or unconsciously made to in an effort to deny his transgendered nature. There may have been the feeling that it would disappear with time. Commonly, there are a number of ways this is attempted. Often careers that are very macho are entered. These include police, construction and military. One therapist reported over half of her TS clients had had a military career (Brown, et al., 1996). Many adopted a hypermasculine persona, for example active in motorcycle racing and hot cars. Choices in marriage partners and involvement in religious denominations that are not tolerant gender or sexual variance, (including as pastors) are also prevalent. Such choices help define an existence with support for the efforts to keep the transgender nature safely locked in the closet (Samons, 2001).


The Royal College of Psychiatrists (1998) made several recommendations for dealing with transgendered individuals. These include:

A full assessment, including emotional, behavioral, environmental, and family.

Therapy, assist development, gender identity. Reduce stress caused by gender identity.

Acknowledgment and acceptance of the gender incongruity and that removing secrecy can bring relief.

Decisions concerning what expressions of gender (clothing, name) are complex and not easily answered recommended is consultation with other professionals and that it be done as early as possible.

The therapeutic model espoused by most of those experienced in gender therapy is client-centered, existential, Rogarian, and rather eclectic. Person centered is the keystone of any effective means of therapeutic change (Duncan, et al., 1992; Ettner, 1999; Hubble, et al., 1999). A holistic health care approach which genuinely strives to address the individual's physical, emotional-mental, sexual, 'social' and 'spiritual' health is recommended (Raj, 2002). Becoming your true self is the stage when that little child trapped inside an artificial persona in order to fit in, breaks free, starts to grow up, and has their own life.

               Trans-Culture and the influence on sense of self

When looking at a culture, it is often beneficial to look from the outside as an anthropologist and to compare other cultures. It neutralizes Maslow’s hammer to some extent (when you have a hammer, everything looks like a nail). Or expressed another way, we do not see our culture, we see through it. The current heterosexist society has the presumption of binary sex and gender (and that they match). Those living outside these paradigms often find themselves isolated and fragmented.

Trans-cultural paradigms are influenced by, and in some cases erroneous and certainly ethnocentric, views of gender (Towle, 2002). Popular books such as Transgender Warrior influence views of transgenderism on the part of therapists, supporters, and transgendered individuals themselves.

               Developing Self

A universal for those that are transgendered is a sense of isolation. Many first become aware of what and who they are as a result of the internet; it will be the first step in coming out. It is a mirror and tool. Much of what people do on the internet is a search for self, exploration and presentation, e-mail, home page (Turkel, 1995).

The Internet feels safe because it provides anonymity and freedom from the judgments of others. Internet surfers embark on an unfettered, self trip. Web searching provides a history of their interests, hobbies and fixations. Creating a home page is a way of presenting an ideal self to the world. They are disinhibited; the on-line world lacks the constraints they live under every day (Suler, 2003).

Much hinges on the personal approach. If people use the Internet to compartmentalize selves—if online and offline selves are forever separate and split—problems can ensue. An example would be a transgendered individual who has no expression of the transgendered self other than on line. Conflict is probable. "People ‘stick’ in online alter-egos and can't reconcile them with offline life. People can work through their situation and it can bring a sense of not alone" (Suler, 2003).

Sometimes the need is to hide a bit or stay put a while before moving forward. "But as long as they're using the net in the spirit of self-reflection, they're making the most of life on the screen" (Turkle, 1995).

"The Web is a safe place to try out different roles, voices and identities. It's sort of like training wheels for the self you want to bring out in real life" (Suler, 2003). The rise of a sense of community is part of what helps transgendered folks not feel so alone. That community is often found first through the internet.

So…what is it all about? It is about being your self, or, as a Japanese transgendered person put it, "Living like my self" (newhalfnet IJT, 2002). The result of a survey at the "Create Our Own Destiny" conference stated "To be fully and wholly themselves and to belong with dignity" (Moorhead, 1999).


When considering the counseling of those who identify as transgendered, one aspect stands out: the general lack of information. This is a relatively new area of research and accepted practices are evolving. Traditionally, transgenderism has been considered to be pathological behavior. The object of treatment was generally elimination of symptoms rather than management and understanding. There was little distinction made between transsexuals and cross-dressers. It was often assumed that a transgendered individual either wished the behavior to disappear or they wished to physically transition. The Harry Benjamin Standards of Care (2001) was the guideline for counseling. Now in its sixth edition, the SOC was developed as a road map for transsexuals who desired reconstructive surgery. It does not address the needs of those who do not intend to transition or who have no interest in transitioning.

Recently, the emphasis has shifted in counseling the transgendered population. Rather than eradication of feelings, the focus is toward awareness and coping with being transgendered. It is acknowledged that "the concepts of self and gender are of major importance" (Hartman, et al, 1997), but there is little information available on therapeutic treatment techniques. The research being conducted appears to be primarily on possible physical causes. Hopefully, further research will provide directions for counseling.

Through the internet, the transgendered community is actively helping in creating and enhancing the sense of self. In some ways, this has out-paced the counseling community. As therapists, there is much that needs to be done.




bulletBlanchard, R., & Steiner, B.W. (Eds.). (1990). Clinical management of gender identity disorders in children and adults. Washington, D.C.: American Psychiatric Association. bulletBrown M.I., & Rounsley, C. A. (1996). True selves: Understanding transsexualism for families, friends, coworkers and helping professionals. San Francisco, CA: Josey-Bass, Inc. bulletCooley, C.H. (1902). Human Nature and the Social Order. New York: Scribner's. bulletDuncan, B.L., Solovey, A.D., & Rusk, G.S. (1992). Changing the rules: A

client-directed approach to therapy. New York: Guilford Press.

bulletEyler, A. E., & Wright, K. (1997). Gender identification and sexual orientation among genetic females with gender-blended self-perception in childhood and adolescence. International Journal of Transgenderism ,1 . Retrieved July, 2003, from http://www.symposion.com/ijt/ijtc0102.htm bulletEttner, R. (1996). Confessions of a gender defender: A psychologist’s reflections on life among the transgendered. Evanston, IL: Chicago Spectrum Press. bulletEttner, R. (1999). Gender loving care: A guide to counseling gender-variant clients. New York: Norton.
bulletFox, R. (1996). Bisexuality in perspective. In B. Firestein (Ed.), Bisexuality:

The psychology and politics of an invisible minority (pp. 3-50). Thousand Oaks, CA: Sage.

bulletHarry Benjamin International Gender Dysphoria Association. (2001). Standards of care for gender identity disorders, sixth version. Retrieved July, 2003 from http://www.hbigda.org/socv6.html bulletHubble, M.A., Duncan, B.L., & Miller, S. (1999). The heart and soul of change: What works in therapy. Washington, DC: American Psychological Association. bulletMcLelland, M.(2002). The newhalf net: Japans’s "intermediate sex" on-line. International Journal of Sexuality and Gender Studies, 7, 163-175. bulletMiller, N. (1996). Counseling in gender land: A guide for you and your transgendered client. Boston: Different Path Press. bulletMoorhead, C. (1999). Queering identities: The role of integrity and belonging in becoming ourselves. Journal of Gay, Lesbian, and Bisexual Identity, 4. 327-343.

Rogers, C. R. (1961). On becoming a person. Boston: Houghton Mifflin.

bulletSamons, S. L. (2001). Building your own prison: The use of external structure to reinforce suppression of transgender feelings and behaviors. Journal of Gender and Psychoanalysis, 6, bulletSuler, J. (2003) Rider University. Retrieved July 18, 2003 from http://www.apa.org/monitor/apr00/mirror.html
bulletSullivan, H.S. (1953). The interpersonal theory of psychiatry. New York: Norton.
bulletThe Royal College of Psychiatrists, Council Report CR63. (1998). Gender identity disorders in children and adolescents. International Journal of Transgenderism, 2, Retrieved July, 2003 from http://www.symposion.com/ijt/ijtc0402.htm
bulletTurkle, S., (1997). Life on the screen: Identity in the age of the internet. New York: Simon & Schuster Adult Publishing Group.Towards a transpositive therapeutic model: Developing clinical sensitivity and cultural competence in the effective support of transsexual and transgendered clients. Citation:  http://www.symposion.com/ijt/ijtvo06no02_04.htm
bulletTowle, E. B., & Morgan L. M. (2002). Romancing the transgender native.

Project Muse. Retrieved July 20, 2003, from http://muse.jhu.edu


Glossary of Terms

Cross-dresser: An individual who dresses in clothing that is culturally associated with members of the "other" sex. Most cross-dressers are heterosexual and conduct their cross-dressing on a part-time basis. Cross-dressers cross-dress for a variety of reasons, including pleasure, a relief from stress, and a desire to express "opposite" sex feelings to the larger society.

Drag King: A term usually reserved for individuals who identify themselves as lesbians and who cross-dress for entertainment purposes in lesbian and gay bars.

Drag Queen: A term usually reserved for individuals who identify themselves as gay men and who cross-dress for entertainment purposes in lesbian and gay bars.

Gender: A complicated set of sociocultural practices whereby human bodies are transformed into men" and "women." Gender refers to that which a society deems "masculine" or "feminine." Gender identity refers to an individual’s self-identification as a man, woman, transgendered, or other identity category.

Gender bender: An individual who brazenly and flamboyantly flaunts society’s gender conventions by mixing elements of "masculinity" and "femininity." The gender bender is often an enigma to the uninitiated viewer, who struggles to comprehend sartorial codes that challenge gender bipolarity. Boy George, a popular culture icon, was often referred to as a "gender bender" by the press.

Genderdysphoria: A term used by the psychiatric establishment to refer to a radical incongruence between an individual’s birth sex and their gender identity An individual who is "gender dysphoric" feels an irrevocable disconnect between their physical bodies and their mental sense of gender. Many in the transgender community find this term offensive or insulting because it often pathologizes the transgendered individuals due to its association with the DSM—IV.

Genderidentity: see Gender.

Gender outlaw: A term popularized by trans activists such as Kate Bornstein and Leslie Feinberg, a gender outlaw refers to an individual who transgresses or violates the "law" of gender (i.e.., one who challenges the rigidly enforced gender roles) in a transphobic, heterosexist, and patriarchal society

Gender queer: A term that refers to individuals who "queer" the notions of gender in a given society. Gender queer may also refer to people who identify as both transgendered and queer (i.e., individuals who challenge both gender and sexuality regimes and see gender identity and sexual orientation as overlapping and interconnected).

Gender trash: A term that calls attention to the way that differently gendered individuals are often treated like "trash" in a transphobic culture.

Gender variant: A term that refers to individuals who stray from socially accepted gender roles in a given culture. This word may be used in tandem with other group labels, such as gender-variant gay men and lesbians.

Intersex: Formally termed hermaphrodites, individuals termed intersex are born with some combination of ambiguous genitalia. The Intersex movement seeks to halt pediatric surgery and hormone treatments that attempt to normalize infants into the dominant "male" and "female" roles.

Queer: Queer is a term that has been reclaimed by members of the gay, lesbian, bisexual and transgender communities to refer to people who transgress culturally imposed norms of heterosexuality and gender traditionalism. Although still often an abusive epithet when used by heterosexuals, many queer-identified people have taken back the word to use it as a symbol of pride and affirmation of difference and diversity.

Queer theorist: An individual, usually an academic, who uses feminism, psychoanalysis, poststructuralism and other theoretical schools to critically analyze the position of gay, lesbian, bisexual, and transgendered individuals in cultural texts.

Sex: Separate from gender, this term refers to the cluster of biological, chromosomal, and anatomical features associated with maleness and femaleness in the human body. Sexual dimorphism is often thought to be a concrete reality whereas in reality the existence of the intersex points to a multiplicity of sexes in the human population.

Sexuality: An imprecise word that is often used in tandem with other social categories, as in race, gender; and sexuality. Sexuality is a broad term that refers to a cluster of behaviors, practices, and identities in the social world.

Sexual orientation: This term refers to the gender(s) that a person is emotionally, physically, romantically, and erotically attracted to. Examples of sexual orientation include homosexual, bisexual, heterosexual, and asexual. Transgendered and gender-variant people may identify with any sexual orientation, and their sexual orientation may or may not change during or after gender transition.

Trans: An umbrella term that refers to cross-dressers, transgenderists, transsexuals and others who permanently or periodically dis-identify with the sex they were assigned at birth. Trans is preferable to "transgender" to some in the community because it does not minimize the experiential specificities of transsexuals.

Transgender: A range of behaviors, expressions, and identifications that challenge the pervasive bipolar gender system in a given culture. This, like trans, is an umbrella term that includes a vast array of differing identity categories such as transsexual, drag queen, drag king, cross-dresser, transgenderist, bi-gendered, and a myriad of other identities.

Transgendered lesbian :An individual, regardless of biological sex, who identifies as both transgendered and lesbian. This could include male-to-female transgenders who are sexually attracted to women, or to biological females who identify as lesbians and who often "pass" as men or who identify to some degree with masculinity or with "butch."

Transgenderist: Coined by Virginia Prince, this category refers to an individual who dis-identifies with their assigned birth sex and lives full time in congruence with their gender identity. This may include a regime of hormone therapy, but usually transgenderists do not seek or want sex reassignment surgery.

Transphobia: The irrational fear and hatred of all those individuals who transgress, violate, or blur the dominant gender categories in a given society. Transphobic attitudes lead to massive discrimination and oppression against the trans, drag, and intersex communities.

Transsexual: An individual who strongly dis-identifies with their birth sex and wishes to use hormones and sex reassignment surgery (or gender confirmation surgery) as a way to align their physical body with their internal gender identity.

Transvestite: An older term, synonymous with the more politically correct term cross-dresser, that refers to individuals who have an internal drive to wear clothing associated with a gender other than the one that they were assigned at birth. The term transvestite has fallen out of favor due to its psychiatric, clinical, and fetishistic connotations.

E-mail 4ane...@embarqmail.com  
Last modified: 02/09/09