| Katherine Rachlin, "Transgender Individuals' Experiences of Psychotherapy", American Psychological Association, 25 August 2001 |
| | Psychological evaluation is recommended to assess 'eligibility' and 'readiness' for surgery as defined by the Standards of Care for Gender Disorders (SOC) (Meyer et al. 2001). If factors are present which have been associated with negative outcomes, then psychotherapy may provide an opportunity for the individual to address these issues prior to surgery. |
| | Psychotherapy has a multifaceted role in the gender exploration and transition process. Psychotherapy can provide support for coping with external stressors, treat comorbid conditions, provide increased insight into personal history and motivations, facilitate exploration of the options for living with one's gender identity and enhance decision-making regarding gender transition options. Mental health professionals may see Transgender individuals in formalized gender programs, therapy clinics, or private practice. In every case the therapist will be challenged to provide treatment that is sensitive to the client's unique gender identity and individual circumstances. |
| Gianna Israel, Diane Shaffer, Donald Tarver, "Transgender Care: Recommended Guidelines, Practical Information, and Personal Accounts", Temple Univ Press, 1 January 1998 23 |
| 23: | Goals for the individual are jointly developed by the therapist and the client, and are modified as treatment progresses. Therapeutic change may take considerable time, though brief psychotherapy may change some responses to stress within a few as ten to twelve sessions. |
| 24: | Because the field of psychotherapy is so varied, clients are encouraged to ask potential therapists what type of therapy they practice and how its theoretical dynamics are applied in supporting a transgender client's needs. |
| 23: | In the course of psychotherapy, clients experience changes in behaviour, attitudes, mood, relationships with others, insight, energy level, expectations of oneself, and many other aspects of functioning. |
| John Cesnik, Eli Coleman, "Skoptic Syndrome: Treatment of an Obsessional Gender Dysphoria with Li Carbonate and Psychotherapy", American Journal of Psychotherapy, XLIV:2 April 1990, p. 204 |
| | This paper discusses the successful use of lithium carbonate combined with psychotherapy in two cases of skoptic syndrome, an unusual form of intense obsession and annoyance with body image, especially with primary and secondary sex characteristics. These cases broaden our understanding of sexually obsessive and compulsive drives and demonstrate an efficacious treatment approach. |
| E Fahrner, G Kockott, "Transsexuals Who Have Not Undergone Surgery: A Follow-Up Study", Archives of Sexual Behavior, 16:6 1987, p. 511 |
| | Hesitating patients have a particular need for psychotherapy. |
| L. Lothstein, Howard Roback, "Black Female Transsexuals and Schizophrenia: A Seredipitous Finding?", Archives of Sexual Behavior, 13:4 1984, p. 371 |
| | more attention should be placed on investigating the family and cultural dynamics related to transsexualism. |
| Laura Roberto, "Issues in Diagnosis and Treatment of Transsexualism", Archives of Sexual Behavior, 12:5 1983, p. 445 |
| | The expense, pain and psychological trauma clearly suggest that less intrusive techniques, such as Behavioral interventions or trials of intensive psychotherapy for sever personality disorder, are indicated as an initial effort. |
| | Many of these individuals show extreme resistance to psychological intervention, so that effective psychotherapy aimed at gender identity reversal is not considered likely. However, this fact has often precluded even consideration of nonsurgical interventions. Under these conditions, clinicians may view patients as "untreatable" rather than "resistant" persons with long-term patterns of disorder. |
| | Some investigators report that an empathetic approach, presenting psychotherapy as an opportunity for exploration prior to considering irreversible surgery, often increases motivation. |
| | The goal of (Supportive Psychotherapy ) is to help the transsexual cope with alienation, social rejection and other feelings concomitant with cross-gender identity, with the assumption that psychotherapy usually cannot reverse the condition. |
| | The purpose of exploratory psychotherapy is to confirm the diagnosis of primary transsexualism, to observe the patient's stress tolerance and reality testing, and to convey that surgery is not a gender reassignment but rather a modification of sexual functioning. |
| | Major therapeutic approaches include intensive psychoanalytic psychotherapy, supportive psychotherapy, group psychotherapy, behaviourally oriented psychotherapy, and gender reorientation with surgical sex reassignment. |
| | The goal of (intensive psychoanalytic psychotherapy) treatment is to stabilize the transsexual in a nonoperated state which will allow him/her to adapt to social and vocational living without surgery, or to reverse the cross-gender identity if it is unstable. |
| George Rekers, Alexander Rosen, "Gender Stereotypy in gender-dysphoric young boys", Psychological Reports, 51 1982, pp. 371-374 |
| | There is no substantial support for the position that claims that Behavioral treatment of boys with gender dysphoria of necessity yields macho stereotypically male behaviors or self-descriptions. There is no indication that Behavioral treatment masculinizes little boys nor does it punish or extinguish feminine behavior in those boys. |
| Stephen Levine, L. Lothstein, "Expressive Psychotherapy With Gender Dysphoric Patients", Archives of General Psychiatry, August 1981, p. 924 |
| | Psychological integration of gender role and identity cannot be achieved through surgery. |
| | The importance of setting realistic therapy goals for GD patients is crucial to their treatment. If one attempts to totally reconstruct all the SRS applicants personalities and have them entirely abandon their cross-gender identity and roles, cease cross-dressing, and achieve a complete heterosexual life-style, psychotherapy is bound to fail. When more realistic goals are set, according to the needs of each patient, then psychotherapy indeed can be beneficial. |
| | The GD patients profound disturbances in object relations, heightened separation conflicts, and defects in symbol formation cannot be resolved through surgery. |
| | Gender dysphoric patients often lie about their social histories, miss appointments, or refuse to discuss anything besides hormones, electrolysis, or surgery. The unusual intersection of their primitive psychological defences and dramatic pathologic character disturbance makes them like the borderline patient, difficult to treat. |
| | For those patients who do accept a trial psychotherapy, the problems of establishing an alliance may seem insurmountable. |
| | In the course of our studies we discovered that if careful diagnostic assessments are made and realistic treatment goals are set, expressive psychotherapy (using modified forms of traditional psychotherapeutic techniques) can be successful with most GD patients. |
| | Although many patients will submit to a psychiatric consultation to determine suitability for surgery, they refuse to undergo psychotherapy since the equate psychotherapy with a refusal for SRS. |
| L. Lothstein, "Psychodynamics and Sociodynamics of Gender Dysphoric States", American Journal of Psychotherapy, 33:2 April 1979 |
| | Many therapists who tried to change the gender identifications of the transsexual patient back to the original biological sex (hoping for a complete cure) failed to realize that there might be nothing to go back to; that is, no primary gender structures were established. Tampering with these defensive identifications without a recognition of their adaptive significance could be therapeutically dangerous. |
| James Morgan, "Psychotherapy for Transsexual Candidates Screened out of Surgery", Archives of Sexual Behavior, 7:4 1978, p. 273 |
| | Another large group (about 20 to 25% of presenting transsexual candidates) are sexually ambiguous but share the diagnosis of "inadequate personality". They correctly perceive the need for a major change in their lives if they are to get any pleasure and satisfaction out of human interaction but incorrectly identify their need as being the external genitalia of the opposite sex. This is a most difficult group with which to work psychotherapeutically under ideal circumstances, and far more difficult yet when they express the "transsexual imperative". At times the transsexual wishes can be ignored for a considerable period while the patient is urged to find a job, or return to school, or move out of the parental home, or whatever else seems likely to bring some structure. |
| | About 30% of the candidates who present themselves can be classified under the general term "homophobic". They are extremely reluctant to view their sexual desires for men as being homosexual because they either view homosexuality as "disgusting" , "perverse" or "abnormal" or they have had bad homosexual experiences or else view some portion of the gay subculture as "sick". In most of these cases the patients can be helped through psychotherapy to make a satisfactory homosexual or bisexual adjustment. |
| Charles Davenport, Saul Harrison, "Gender Identity Change in a Female Adolescent Transsexual", Archives of Sexual Behavior, 6:4 1977, p. 327 |
| | The patient's naiveté about the "sex-change operation" and her surprise that it could not make her a real potent male were focal points in treatment. This disappointment motivated her for psychotherapy and to consider changing her psychological identity to match her physical sexuality. Therefore, she could now participate in the therapy for her dread of femininity, which she had needed but could not previously acknowledge. |
| | We have described the successful psychotherapy of an adolescent female transsexual. The signs of this patients transsexual identity appear to have been present from early life, but her transsexual wish became overt and critical with the onset of puberty. |
| George Rekers, "Atypical Gender Development and Psychosocial adjustment", Journal of Applied Behavior Analysis, 10 1977, pp. 559-571 |
| | Rekers and Lovas presented four related reasons for treating a boy with a cross-gender identity.(1) to relieve the boys current maladjustment, social isolation and personal suffering (2) to prevent the severe psychological and social maladjustment problems in adulthood that accompany the transsexualism for which the boy is at high risk (3) to prevent transsexualism, transvestism, or homosexuality per se as the most probably adulthood diagnostic outcome in the absence of treatment and (4) to respond to the parents legitimate request for professional intervention. |
| | A 5 yr old boy with pronounced sex-role inflexibility and stereotypic extremes in gender behavior was behaviourally treated by Rekers and Lovas. Winkler criticized Rekers and Lovas for selecting certain feminine sex-typed target behaviors for intervention, but he presented neither relevant empirical evidence nor a methodology for translating such evidence into a value judgement to select target responses. |
| R Winkler, "What types of sex-role behavior should behavior modifiers promote?", Journal of Applied Behavior Analysis, 10 1977, pp. 549-552 |
| | A number of authors have commented that sex-role socialization research appears to assume that traditional sex roles are natural, rather than questioning whether these sex roles will permit the maximal development of individual potential. |
| | It can be argued that Rekers and Lovaas, by using traditionally defined sex roles, may be preparing children for less than optimal adult roles. |
| Jon Meyer, "Training and Accreditaiton for the Treatment of Sexual Disorders", Am J Psychiatry, 133:4 April 1976 |
| | Behavioral modification techniques. These techniques have their theoretical foundation in learning theory. Disturbed function is viewed as dependent upon disordered learning, conditioning, or habit. Behavioural modification though systematic desentization and reciprocal inhibition is viewed as the therapeutic goal. The techniques developed by Masters and Johnson are classified here since they establish a hierarchy of sexual behaviors and use systematic desensitisation as well as reciprocal inhibition. Related techniques include adversive conditioning, biofeedback, etc. some forms of "masturbation therapy" would be included here. |
| | Dynamic psychotherapies. As a general class, these techniques are based on psychoanalytic theory and observation. Core concepts include an ontogenetic psychological-developmental sequence, psychic structure, psychic conflict, defence mechanisms, the active unconscious and transference development. Psychoanalysis, psychotherapy and many group and family techniques are based in this framework. |
| | Educational Techniques. This includes efforts at education as the primary focus. Lectures, audiovisual materials, the conjoint physical examination, and other methods are used in demonstrating sexual anatomy, physiology, or practice. |
| | The dynamic psychotherapies are indicated for the treatment of neurotic, characterological, borderline and psychotic disorders having sexual dysfunction as one component. This is not to say that Behavioral or educational techniques may not be useful in a supplementary way, so long as the transference is protected by having them implemented by another therapist. |
| Lawrence Newman, "Treatment for the Parents of Feminine Boys", Am J Psychiatry, 133:6 June 1976 |
| | With treatment, Behavioral change, and a new acceptance by his male peers, the child gains in self worth, which seems to influence the long-term outcome. |
| | Treatment is indicated for the very feminine boy. The preference for feminine behaviors seems to be based upon a deficit in learning masculine behaviors from an appropriate model. Once the therapist provides this model, identification occurs, new behaviors are learned, and the feminine behaviors are gradually given up. |
| | A happier childhood as well as primary prevention of an adult gender identity disorder are two related goals of treatment. |
| | Even if the boy does not then become completely masculine, the reduction in overtly feminine gesture and play preference makes him acceptable to boys who previously teased and avoided him. Experiences of being ostracized and ridiculed may play a more important role than has been recognized in the total abandonment of the male role at a later time. |
| | Because extreme boyhood femininity is often a precursor of adult transsexualism, transvestism, and homosexuality, the author recommends early intervention for boys who meet specific Behavioral criteria of gender disturbance. It is necessary to involve the parents in such treatment and to deal with the resistances they may have to recognizing and working on the problem as well as problems within the marital relationship that may affect the child's behavior. These boys are remarkably responsive to treatment given between the ages of 5 and 12, becoming more masculine in behavior and more comfortable with their identity as males. |
| Claude Friedmann, Martha Kirkpatrick, "Treatment of Requests for Sex-Change Surgery with Psychotherapy", Am J Psychiatry, 133:10 October 1976 |
| | Irreparable harm could have been done if either patient had had surgery. Bieber presented a case report of a man who did not fit the currently accepted diagnostic criteria for transsexualism but was given surgery. Two years later he committed suicide. |
| | The transsexual request should be evaluated not only in terms of the genuineness of the gender disorder but also as a cry for help. It may be the patient's way of manifesting a need for crisis consultation. The clinician can help the patient to identify the crisis and make use of psychotherapy in dealing with it. |
| | There seems to be general agreement that the true transsexual is rarely available to psychotherapeutic intervention. We are concerned that these statements may discourage the practitioner from approaching the initial interview with such patients in a way that could lead to recommending or continuing psychotherapy. This is a disservice to the patient. Many patients who request sex-change surgery, such as the two we will describe below, are not true transsexuals and can benefit from conscientious psychotherapy. |
| | While neither of our patients elected to pursue any in-depth investigation of their homosexual feelings, psychotherapy helped them with their crises. |
| | The authors describe two patients whose requests for sex-change surgery represented crises in sexual identity and anxiety-masking symptoms. Brief psychotherapy enabled these patients to relinquish their belief in a surgical "cure". In evaluating such requests, the psychiatrist should consider the patient's total personality rather than focusing on the genuineness of the perceived gender disorder. Whatever the final decision, the opportunity for continued psychotherapy should be provided. |
| | Benjamin emphasized that there is also a risk of suicide in patients who consider surgery their only answer but do not meet diagnostic criteria and are rejected without being offered alternative treatment. |
| John Bates, "Intervention with Families of Gender-Disturbed Boys", Amer. J. Orthopsychiat., 45(1) January 1975 |
| | A treatment program for gender-problem boys and their families is described. In addition to being highly effeminate in their interests, the boys were also markedly deficient in social skills, especially with peers. Intervention procedures ere based largely on behavior modification principles, and were eventually applied in group settings for both the boys and their parents. |
| Lionel Oversey, Ethel Person, "The Transsexual Syndrome in Males II. Secondary Transsexualism", American Journal of Psychotherapy, 1974 |
| | A second limitation is crated by the psychiatrists themselves. Nearly all our subjects had sought psychiatric opinion sometime in adolescence or early adulthood. Invariably, they described the encounter in negative terms. Their subjective experience ranged from useless to catastrophic. |
| | Even a therapy conducted by an experienced psychiatrist, who eschews a judgemental stance, will still be severely limited by the transsexual's personality, particularly his poor aptitude for psychologic insight and his affective shallowness. Nevertheless, because of the radical nature of sex conversion, we strongly recommend that psychotherapy be attempted, often with the aim of stabilizing the patient somewhere short of surgical intervention, rather than reversing the syndrome altogether. |
| | The major limitation of psychotherapy is the unwillingness of the patient to participate. This unwillingness, whatever its psychodynamic motivation, is intensified by the ready availability of sex reassignment. |
| Ira Pauly, "Female Transsexualism Part II", Archives of Sexual Behavior, 3:6 1974, p. 509 |
| | Female transsexuals respond favourably to psychotherapeutic efforts to help them adjust to their preffered role. |
| Ivar Lovaas, George Rekers, "Behavioral Treatment of Deviant Sex-Role Behaviors in a Male Child", Journal of Applied Behavior Analysis, 7 1974, pp. 173-190 |
| | This study demonstrated reinforcement control over pronounced feminine behaviors in a male child who had been psychologically evaluated as manifesting childhood cross gender identity. |
| David Barlow, "Gender Identity Change in a Transsexual", Archives of General Psychiatry, April 1973 p575 |
| p575: | A suggestion of the importance of fantasies in sex role behavior is also present in this case. Rejection of the female role did not occur until sex role fantasies were directly altered, despite the earlier changes in overt behavior from feminine to masculine. |
| p576: | Many transsexuals, particularly older and more sophisticated patients, refuse any treatment perceived as a threat to their mistaken gender identity. |
| P576: | Changes in sexual arousal patterns in transsexuals must be preceded by changes in sex role behavior, since positive conditioning of heterosexual arousal and elimination of homosexual arousal worked only after sex role behavior had been changed and not before. |
| p575: | Complex role behaviour such as masculinity or femininity can be defined, broken down into is components, and changed piece by piece producing clinically important changes. In this case gender-specific motor behavior, social behavior, vocal characteristics, sexual fantasies and attitudes, and patters of sexual arousal were changed one by one resulting in a total sex role change. |
| Richard Green, "Treatment of boyhood "transsexualism" An Interm Report of Four Years Experience", Archives of General Psychiatry, March 1972 213 |
| 213: | Results indicate the capacity for gender role preference in the preadolescent male to undergo considerable modification toward masculinity. |