Notes on Gender Role Transition --T NOTE #3
Originally posted on Jan 1, 2009 -- Revised: August 6, 2011 and April 12, 2013
As you might expect, the first couple of meetings
in any therapeutic relationship are extremely critical. This is
especially true if the presenting problem is a gender identity issue.
People come in at varying stages of dealing with their gender issues
and the work always starts from there.
--A growing number of people have come into see me already self medicating using hormones bought over the internet. Although self medicating may not necessarily be a non-starter, it does raise serious safety issues which we will need to address immediately. Please be prepared to be open and honest about any online hormones you are currently taking or have taken in the past.
A minority of people enter the
work expressing a clear desire to transition to the opposite gender role and want me to
monitor their transition. I am, of course, open to doing exactly that
if all of the criteria have been met. Others are far less anxious to
think that far ahead. Female to male directed individuals seem to be far more sure of what they want while crossdressing is usually the most some male to female directed individuals
will openly discuss. However, in this Note, I want to concentrate on
those people who present at the outset declaring to be clear and
ready to enter transition.
The first level of transition is psychological
evaluation for hormone therapy. In version 6 of the WPATH Standards of care, there used to be a 12 week evaluation period. Version 7 did away with that and allowed the therapist to make a hormone recommendation based on readiness of the client.
The first two or three hours are used to establish
a therapeutic alliance. I realize that what is transpiring for my
client is life changing therapy. It is extremely important for them
to have as much confidence in me as I can possibly endow. This is
done by clearly defining the ground rules under which we will be
working. I also assure the client that nothing drastic is going to
happen immediately. The two of us will take all the time necessary to
work out what is right and take appropriate and controlled action as
the therapy evolves. I find it useful to slowly reveal my in-depth
knowledge and expertise in the field of gender transition while being
very attentive and authentic in my listening. This is also a good
time to take careful notes that can be reviewed and annotated between
When a safe, secure environment has been
established and as we move on in the series of interviews, the depth
of the gender dysphoria and its ramifications begin to emerge.
Family, friends, and workplace issues are examined. Often a joint
session with the client's parents or a significant other will be
called for now. Questions about what the client might expect if he or
she was to decide to transition are encouraged and answered as
honestly as possible.
I also make certain to keep the client aware of
the pacing of our interviews. Even though we start with my being more questioning and direct, I slowly shift the burden of responsibility for the
work we do directly onto the client. I make it very
clear that although I am there to help, it is he or she who will
decide to enter, and if he or she chooses, complete transition. The
pacing, of course, is dependent on the individual's ability to handle
his or her particular social/familial/economic situation. If additional time is necessary for any reason whatsoever, then we simply schedule in more
I've said it before and I will undoubtedly say it
again: Transition is hard. Very hard! The pre-hormone therapy sessions should be the time when fantasies and misconceptions are
tempered by reality. The range of transition that can be expected
from the hormones and potential plans for surgery should be clear in
the individual's mind before hormone therapy starts.
Meeting others who have already started or gone through transition is
usually the best way for the client to gain these insights. In that regard I make an effort to
arrange for the individual to meet, by mutual consent, others who are
dealing with common special problems.
At some point, both the client and I have a good idea where we are going
and at what pace to proceed. If we are still dealing with fundamental
fears and uncertainty, then there is naturally no talk of moving on
in transition. If on the other hand all appears to be in order, I
make a concerted effort to be very specific about what the client can
expect physically and psychologically. To aid in empowering the
client, I have him or her start thinking about what internist or
endocrinologist they will want to work with. Here in the San
Francisco Bay Area, we are lucky to have several physicians who
specialize in administering cross-sex hormone therapy. Each has a specific style and idea as to how fast transition should occur. Eventually the time comes when
we both feel the time is right to try hormone replacement therapy. It
may have taken a few weeks or twelve weeks or it may have taken twelve months.
Either way the time must be right.
In essence then, the pre-hormone sessions are
used to authenticate the transition, establish a bond between the
therapist and the client, set the pace for the rest of transition,
and importantly, empower the client by giving him or her control over
an element of his or her life that, until now, may have appeared
nearly impossible to attain.
(A substantial portion of this Note originally
appeared in issue Number 76 of Cross Talk)