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The CLIENT/THERAPIST CONFLICT: How it started and some thoughts on how to resolve it.

How it started and some thoughts on how to resolve it.

By Anne Vitale PhD
Upadated November 28, 2011
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Keywords: Gatekeeper,Transsexualism, Gender Identity Disorder, WPATH Standards of Care, hormone and surgery letters

Abstract: This essay outlines the history of the ongoing conflict between clients who present for gender reassignment and the clinicians who treat them. Each side of the conflict is stated, followed by suggestions on how the problem might be resolved.

A contentious relationship between the people dealing with gender issues and the therapists they work with has existed almost from the beginning of formal treatment of Gender Identity Disorder. To this day, far too many therapists are justifiably accused by gender clients of being autocratic, under- or ill-informed about the issues involved, and financially exploitative. As a result, many individuals who could profit from a therapeutic relationship avoid establishing one. Fortunately, there are new signs that contention between the two sides is easing. But how did we get into this mess in the first place and more importantly, how do we fix it? In this essay, I will attempt to answer the first question and present some suggestions on how we may continue to improve matters.

The role of the therapist in working with individuals regarding their gender identity is somewhat unique in the profession of psychotherapy. This is due to the elusive nature of gender identity, the psychological profile of the individuals presenting, and what is often construed by the clients as the "gatekeeper role" of the therapist. (The "gatekeeper role" refers to the client's need for referral letters from the therapist for hormone therapy and genital reassignment surgery.) Even the very notion of calling a gender issue a "psychological disorder" is subject to question. This is based on the broadly held belief among some clients and some therapists that one's gender is not ordinarily subject to psychotherapeutical review, let alone approval.

Although gender identity disorder appears to occur at random in all cultures and populations, for financial and access-to-information reasons, the person presenting with a gender identity issue in the United States is likely to be an extraordinarily high-functioning and accomplished individual. It is not unusual for the presenting client to be strong willed, independent, and well read on the medical aspects of gender related issues. In addition, with access to web pages such as these and through Internet chat and bulletin boards, potential clients can even get a sense of the profile and quality of care one might expect of some of the therapists that are available to treat them. Far from being paranoid, these individuals are cautious with good reason. It is a sobering experience indeed to face the possibility of having to change one's gender role in society.

The contentious relationship between the therapist and the gender patient was initiated by the medical profession. With the noted exception of the writings of Harry Benjamin, M.D. and Christian Hamburger, M.D., most of the early medical literature on gender-identity issues seemed more intent on showing just how sick gender-dysphoric people were than on expanding upon or critically evaluating each other's treatment techniques. The era I am speaking about began around 1960 and ran through the mid 1980's.

The tenor of those times can be summed up in a statement made by Howard J. Baker, M.D. in the American Journal of Psychiatry chastising the treatment of transsexuals.

"We also find in the literature such terms and phrases as 'psychotic,' 'delusional confection,' 'psychopath,' 'delusional quest,' 'masters of the art of self-deception and of deceiving others,' 'psychopathic personality,' 'paranoid,' 'neurotic,' 'schizophrenic,' 'borderline psychoasthenics,' 'intricate suicidal dynamics,' and 'so-called transsexuals,' all of which amounts to little more than psychiatric name calling and contributes little to our understanding of the disorder." Dr. Baker goes on to say: "My experience leads me to believe that the literature is actually quite constrained in its expression of disdain for these persons. Visits to medical, surgical, and psychiatric wards on which these individuals have been evaluated and treated have demonstrated clearly to me how physicians and nurses alike hold them up to ridicule. Is one paranoid in a delusional sense when he is in fact treated with ridicule, contempt, disdain and sometimes overt hatred by those from whom he seeks assistance, as well as being harassed by society in general?"(Baker, 1969, p. 1415-1416)

Fortunately, the way gender disorder is discussed in the clinical literature has improved immensely. The current literature, as well as papers presented at the biennial conferences of the World Professional Association for Transgender Health (WPATH), now routinely contain studies that disprove negative stereotypes and show overdue professional respect for the individuals who are their clients. Instead of considering gender dysphoria as a way to avoid dealing with more standard mental disorders such as depression or a dissociative disorder, studies are showing the opposite to be true. Treating the dysphoria as the core disorder helps individuals to return to productive and healthy lives. In addition there are an increasing number of studies of transsexuals who transitioned over the last 10 to 15 years showing that gender transition, when it is called for, significantly helps more individuals than it harms. Lawyers around the world have also taken on their respective legal systems in the defense of transsexuals. At least three papers by lawyers were presented at the 1995 WPATH conference held in Kloster Irsee, Bavaria, Germany.

The other major factor in the evolving relationship between the clinicians and the people who come to them for help is the developement of a Gender Community. This "community" is an advocacy group in favor of gender choice and intent on demedicalizing gender issues and removing the historically negative stigma many cultures place on cross-dressing and cross-gender behaviors.

Ironically, the gender community may have had its start in the minds of the medical clinicians. In 1971, while working at Johns Hopkins University, psychologist John Money warned his colleagues that transsexuals were avid readers of that portion of the medical literature relevant to transsexualism and to be wary of "textbook" presentations from individuals requesting sex reassignment. Although Dr. Money can now be called wrong in labeling transsexuals manipulative because they voiced common symptoms, I believe he inadvertently pulled the community together by confirming the common symptoms in the all important medical literature.

Dr. Money was right, however, when he described transsexuals as being avid readers of the medical literature. People with gender issues continue to have an insatiable need for more information. Information helps define who they are as individuals and how others are coping with or celebrating their cross gender proclivities. When you combine this need with the new ease of publishing and electronic communications, you have the basis for the creation of hundreds of organizations relating to cross-dressing and cross-gender issues world wide.

These organizations have grown not only in size, but in their visibility in petitioning the larger culture for recognition and equal rights. Some organizations exist to provide a social outlet and to foster a sense of pride in cross-dressing. Others are more militant and aggressive. For this latter group, in addition to civil laws and the WPATH Standards of Care, therapists in particular are a major target.

An additional factor in the evolution of the relationship struggle is that an increasing number of people who have personally dealt with gender issues in their own lives are getting involved in its treatment. This includes transsexual mental health professionals, transsexual physicians, and transsexual lawyers. Many of these professionals are members of their respective professional organizations and are prominent at international conferences.

To encourage further resolution of the therapist/client tensions regarding treatment, I suggest we clearly define what constitutes a qualified gender therapist. This may sound simplistic, but there are therapists and there are gender therapists. Training in the nature and treatment of gender issues is either non-existent or only now beginning to be taught in schools. Even then most therapists will never see a gender client in their practice, let alone be able to handle the situation with confidence.

I believe, therefore, that a Gender Specialist should be a licensed psychotherapy professional with sufficient post-graduate training and supervision to handle gender issues. Because there is no counterindicating evidence, the therapist should be willing to accept the possibility of cross-dressing and true sex/gender incongruity as not being an illness to be cured but instead as a developmental imprint that needs to be incorporated into the individual's life in a productive way. As long as the client is not showing signs of a thought disorder such as schizophrenia or multi-gendered personalities of a multiple personality disorder, the therapist should have nothing invested in what direction the client's search takes to find their gendered self.

I believe that every individual has the right to openly express the gender they believe themselves to be. As in all long-term, life-changing therapy the gender therapist's primary duty is to see that the client searches diligently and thoroughly and that the client is capable and accepting of full responsibility for their actions. The therapist should give the client all the time necessary to come to their own resolution. That resolution might be a low-impact one such as coming to feel comfortable about crossdressing, with perhaps some mild hormonally induced feminization or masculinization. Or, if a higher-impact change is deemed necessary, that resolution might include a complete alteration of secondary sex characteristics, with or without sex reassignment surgery.

Further, a good gender specialist should be free to individualize care. The better therapists I know take a case-management approach. As needs arise, a good therapist should not only be able to ease the anxiety inherent in gender role transition but must also be able to educate, support, and provide a wide spectrum of professional referrals. A good gender therapist personally knows other good gender therapists to back up his or her work or to consult with on hard cases. The therapist should also be familiar with the professional record, medical orientation, and demeanor of several endocrinologists, psychiatrists, and surgeons. A good gender therapist can help a client express him or herself socially. This can range from providing passing letters, to consultations with relatives and employers, to referrals to legal assistance. And yes, there are many times when straightforward psychotherapy is required. Issues of loss, guilt, and anxiety over the future impact of gender role transition are common. Who knows, eventually even the negative appellation of "gatekeeper" may be changed to something closer to "transition guide."

General References

Baker, H. J. Transsexualism: Problems in Treatment. American J. Psychiatry, 1969, 125, 118-12.

Exner, K., Schernitzky, B. Female-to-Male Transsexualism-Psychological and Social Follow-up of Reassignment Surgery in 67 Patients. Unpublished paper read at XIV Harry Benjamin International Gender Dysphoria Association. Kloster Irsee, Bavaria, Germany. 1995.

Green, R. Formerly the Orphans of Medicine, Transsexuals Are Currently the Orphans of the Law. Unpublished paper read at XIV Harry Benjamin International Gender Dysphoria Association. Kloster Irsee, Bavaria, Germany. 1995.

Hirschauer, S., The Medicalization of Gender-Migration. Unpublished paper read at XIV Harry Benjamin International Gender Dysphoria Association. Kloster Irsee, Bavaria, Germany. 1995.

Kuiper A., Cohen-Kettenis P., Factors Influencing Post-Operative ëRegretí in Transsexuals. Unpublished paper read at XIV Harry Benjamin International Gender Dysphoria Association. Kloster Irsee, Bavaria, Germany. 1995.

Money, J., Prefatory remarks on outcome of sex reassignment in 24 cases of transsexualism. Arch. Sex. Behav. 1971, 1, 163-165.

Seil, D., Dissociation and Gender Dysphoria. Unpublished paper read at XIV Harry Benjamin International Gender Dysphoria Association. Kloster Irsee, Bavaria, Germany. 1995.

Walling, D., Goodwin, J., Cole, C., Dissociation and Gender Dysphoria: Exploring the Relationship. Unpublished paper read at XIV Harry Benjamin International Gender Dysphoria Association. Kloster Irsee, Bavaria, Germany. 1995.

Weitze, C., Osburg, S., Empirical Data on Application of the German Transsexualsí Act During Its First Ten Years. Unpublished paper read at XIV Harry Benjamin International Gender Dysphoria Association. Kloster Irsee, Bavaria, Germany. 1995.

Whittle, S., Employment Protection For the Transsexual and Sex Discrimination Law. Unpublished paper read at XIV Harry Benjamin International Gender Dysphoria Association. Kloster Irsee, Bavaria, Germany. 1995.

Will, M., Marriage, Parental Rights, Adoption, and Employment. Unpublished paper read at XIV Harry Benjamin International Gender Dysphoria Association. Kloster Irsee, Bavaria, Germany. 1995.

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