VISTAS 2006 Online

Introduction

Collectively, transgenders represent a wide variety of expressions and identifications (Carroll, Gilroy, and Ryan, 2002) that exist within continua between male and female (Whalley, 2005), and that significantly differ from individual birth assigned or natal genders. The Harry Benjamin International Gender Dysphoria Association (HBIGDA) (Meyer, Bockting, Cohen-Kettenis, Coleman, Diceglie, Devor; 2001) provides Standards of Care (SOC) that establish medical and mental health protocols for transgenders who seek hormonal and surgical sexual reassignment. These protocols, while useful in developing overarching treatment strategies for these individuals, are not specific in guiding counselors through conceptualization and response to experiences of transgender identity development across the lifespan…experiences that may or may not include an individual's identified need or desire for sexual reassignment.

The relativity of gender identity makes absolute statements about identity development quite impossible. Whalley’s Continua (2005) present Gender Identity as 1 of 4 converging spectra that form a core matrix of each person as a gendered, sexed, and sexual being.

Sex

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Male                                                                                                              Female 

Sex refers to a person’s genitalia and secondary sex characteristics. Each individual is born with either male or female genitalia, or a combination of both.

Gender Identity

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Male                                                                                                              Female 

Gender Identity represents a person’s core sense of being male, female, or within a continuum that exists between male and female.

Gender Expression

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Male                                                                                                              Female 

Gender Expression reflects external characteristics and behaviors that are socially constructed as masculine or feminine. These include clothing, appearance, speech patterns, demeanor, etc.

Sexual Orientation

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Male Attracted                                                                                                    Female Attracted

Sexual orientation refers to the sex or sexes to whom a person is sexually and otherwise intimately attracted. Transgenders can be female-attracted, male-attracted, or attracted to both sexes in some combination.

Utilizing the continua as a conceptual framework of gender and sexuality, this article will feature the main presenter’s Transgender Age-Stage Development Model in describing the lived experiences of transgender identity development, ages 3 through advanced adulthood. Standards of Care will be expounded upon to emphasize the role of the counselor in work with transgender clients across the lifespan.

This model has been developed through the historical recollection of transgenders in self-describing their childhood identity formations (Reicherzer, 2005). Its primary focus is in work with emerging transgender identity issues as they may be appearing at any age. Developmental experiences are unique…the ages provided are intended as a general guideline that is based in biological, cognitive, relational, and emotional development that would be anticipated within each age group. Within this article, pronouns are identity-based. Natal females who identify as male are called “he” and natal males who identify as female are called “she”. Additionally, the model uses the third-gender pronouns “sie” (pronounced like “see”) and “hir” (pronounced like “here”) that were developed by Leslie Feinberg (1998) to describe identified gender experiences that are neither entirely male nor entirely female.

Reicherzer’s Transgender Age Stage Model

Pre-school (Ages 3-6)

During this period, children may begin to demonstrate degrees of behavior that are considered atypical for their natal genders, although they do not typically realize that that their behaviors are outside socio-culturally constructed gender roles. A significant problem of this period relates to parental shaming of the child for cross-gendered behaviors. This tends to occur more often with effeminate natal boys than for masculine natal girls, who are often identified as tomboys (Redmond and Flauto, 2001). A notable exception occurs when masculine behavior in girls is seen as extreme (using a male name, insisting that a penis will grow, etc.) (Halberstam, 1998; Brown & Rounsley, 1996). 

The ethical counselor works with families to understand the relative malleability of gender expression during this age period (generally, the younger the child, the more malleable the gender expression). It is important to help the family explore possible developmental trajectories that could include transgender identity development. In exploring this possibility, it is essential that counselors help the family develop coping strategies and supportive roles that may be needed as the child ages. These may include planning how the child should present at school.

School Age (Ages 6-11)

School is often a challenge for transgender youth. As school children age, a playground hierarchical structure begins to develop. Effeminate natal boys become increasingly ostracized and mistreated. This experience continues to vary for natal girls who may simply be accepted as tomboys and only experience mistreatment related to greater degrees of masculine gender expression. When experiences of parental and peer shaming have occurred, transgender children may begin hiding cross-gender behaviors (Egan & Perry, 2001).

Counseling Interventions include identifying school problems as early as possible and helping families develop plans to counter mistreatment, encouraging families to develop their homes as safe places that are free of ridicule and shaming, and the counselor’s normalization of a child’s experiences of transgender expression. The counselor’s role as a school advocate emerges during this period, as a family may require assistance in intervening in school for a transgender child’s safety. Given the complex overlay of experiencing transgender identity development within a potentially hostile social setting, counselors may also address issues of depression, anxiety, suicidal ideation and other life problems that the child may be encountering.

Early Adolescence  (Ages 12-15)

This period may be marked by a transgender adolescent’s experience of body betrayal. For natal females, both menarche and breast development may be sources of great embarrassment and personal discomfort. This discomfort is often exacerbated if it results in a change in male peers’ treatments toward him. For natal males, the experiences of body hair growth, shaving, and deepening of vocal range may exacerbate an experience of gender incongruence.

This period may be marked by additional concerns related to sexual orientation. Both transgender identified natal males and natal females may be attracted to males, females, both sexes, or no sexes. Very often the development of sexuality is confusing for transgenders when it is experienced through feelings of bodily incongruence.

The ethical counselor explores the adolescent’s feelings of loss and body betrayal with her, hir, or his body; and helps each family support and work with their adolescent’s experiences. Continued school advocacy is critical. Egan & Perry (2001) call for more detail to be placed on the “multidimensionality of gender identity,” (p. 461) in work with adjustment that is specific to this age. This can be enhanced by use of Whalley’s Continua (2005) as an educational tool.

Late Adolescence (Ages 15-18)

This period is often marked by extreme social opprobrium for very effeminate natal males and very masculine natal females. Feelings of isolation are often severe, and may lead to dropping out of school, depression, substance abuse, or suicide. Additionally, a transgender adolescent may feel resentment toward non-transgender peers because of difficulty in understanding why sie, she, or he feels different or unable to develop a sense of congruent self-expression.

Many learn to mask their genders by late adolescence and often express this by hyper-gendered behaviors of their natal genders. People in these instances often experience alternated periods of congruent gender expression (cross-dressing, etc.), that are then followed by personal shame and a return to hyper-natal gendering. This behavior is observed more often in natal males than natal females.

Ethical counselors provide safe environments that allow individuals to identify and articulate their personal gender experiences. Additionally, counselors identify problematic areas in the adolescent’s life: suicidal ideation, drug use, etc. and help identify options with family and support systems to reduce harm. This includes continued advocacy in school as well as possible vocational and athletic settings. An additional emphasis is the continued exploration of sexual orientation issues, and helping the adolescent understand differences of sexuality and gender.

HBIGDA SOC identify intervention protocols for transgender adolescents and adults who articulate a need for sexual transition (the more common self-description is “transsexual” for people who are changing their bodies hormonally and surgically to match gender identity). Interventions include 1) Fully Reversible Interventions- Testosterone or estrogen agonists that may be started at puberty; 2) Partially Reversible Interventions- Masculinizing or feminizing hormones that may be started at age 16; 3) Irreversible Interventions- Surgical procedures that may commence at age 18.

Early Adulthood (Ages 18-35)

After leaving high school, new challenges often present for transgenders who begin actualizing transgender identity developments. Role exploration occurs within the contexts of societal, professional, and intimate relationships through a process that Devor (2005) calls Witnessing and Mirroring.

Many transsexual-transgenders begin to seek hormone therapy. Danger exists in that often mail-order or hormones purchased on the street (Chen-Hayes, 2001) are utilized as an inexpensive alternative to seeking hormones through the medical community. Additionally, bodily augmentation through use of black market liquid silicone is a dangerous procedure that many males to females utilize at relatively low cost and without the need of mental health evaluations and formal medical interventions.

Ethical counselors are aware of the severe marginalization that transgenders experience at societal levels, and respond with education and advocacy in interfacing with law enforcement, employers, and social service organizations. Additionally, knowledge of the dangers of black market hormonal and surgical procedures is necessary; as is knowledge of safe and legal hormonal and surgical treatments. As clients shift gender roles and concomitant bodily experiences, counselors help clients explore changing relationships and emerging patterns of intimacy.

Middle Adulthood (Ages 35-60)

Historically, many people have not begun identifying as transgender until middle adulthood. When the transgender identity begins to emerge, there is often an experience of “coming home” (Reicherzer, 2005). The individual’s history prior to claiming himself, herself, or hirself as transgender may include a marriage or long-term relationship, children, a career, or other areas that will need to be navigated carefully as the individual moves toward a congruent gender expression. Individuals who identify a need for sexual reassignment may experience great urgency to begin hormonal and surgical treatments.

Counselors help clients negotiate their personal and professional relationships in ways that create safety for the client and respect for effected individuals. It may be useful to discuss numerous possibilities and trajectories to help the client identify the most appropriate course of action. This period is often one of celebrating with the client her, hir, or his emerging transgender identity while anticipating and responding to possible losses that are subsequent to the client’s transgender emergence.  

Advanced Adulthood (Ages 60+)

Clients who begin to name themselves as transgender during later years often do so because they have waited for an event to pass before transgender emergence. This may include the death of a spouse, retirement, or other experiences that the client believes have necessitated delaying this. Additionally, some people do not identify as transgender until advanced adulthood.

An additional concern is in more frequent needs of interaction with the medical community. For transgenders who have lived comfortably with gender-blended bodies, anticipated doctor visits can be very traumatic. Many transgenders neglect their health in efforts to avoid potentially embarrassing interactions with the medical community.

Ethical counselors explore with clients the experiences of personal loss and grief. In cases in which clients have health care concerns, counselors help locate appropriate medical referrals. This may also include screening potential healthcare providers or educating potential providers about the sensitivity of the client’s issues.

Working with transgender clients throughout the lifespan requires a great deal of the counselor’s own introspection. Many transgenders have expressed concern and outrage over lack of counselor preparation in work with gender issues (Devor, 1997). Important considerations in working with this population include the client’s awareness of the therapeutic power differential; her, hir, or his perception of the counselor’s comfort and knowledge of transgender issues; and the client’s trust in the counselor’s ability and willingness to advocate and educate on the client’s behalf. It is paramount that transgender clients recognize counselors as personal resources for the purpose of identifying and navigating life in the gender continuum.

References

Brown, M.L. & Rounsley, C.A. (1996). True selves.  Understanding transsexualism for families, friends, coworkers, and helping professionals. San Francisco: Jossey-Bass.

Chen-Hayes, S. (2001). Counseling and advocacy with transgendered and gender-variant persons in schools and families. Journal of Humanistic Counseling, 40, 1, 34-48.

Carroll, L., Gilroy, P.J., & Ryan J. (2002). Counseling transgendered, transsexual, and gender-variant clients. Journal of Counseling & Development, 80, 131-139.

Devor, A. (2004). Witnessing and mirroring: a fourteen stage model of transsexual identity formation. Journal of Gay and Lesbian Psychotherapy 8, 1/2, 41-68.

Devor, H. (1999). FTM. Female to male transsexuals in society. Bloomington, IN: Indiana University Press.

Egan, S. & Perry, D. (2001). Gender identity: a multidimensional analysis with implications for psychosocial adjustment. Developmental Psychology 37, 4, 451-463.

Feinberg, L. (1998). Trans liberation. Beyond pink or blue. Boston: Beacon Press.

Halberstam, J. (1998). Female masculinity. Durham, NC: Duke University Press.

Meyer, W.; Cohen-Kettenis, P.; Coleman, E.; Diceglie, D.; Devor, H.; et al. (2001, January- March). Harry Benjamin International Gender Dysphoria Associations’ the standards of care for gender-identity disorders (6^th version). International Journal of Transgenderism, 5,1. Retrieved June 5, 2005, from http://www.symposion.com/ijt/soc_2001/index.htm.

Redmond, D. & Flauto, P. (2001). Gender identity  disorder in children (Report No. CG031-226). Kent State University. (ERIC Document Reproduction Service No. ED457456).

Reicherzer, S. (2005). Transgender relativities: a phenomenological perspective of the mental health diagnostic process. Manuscript in preparation.

Whalley, S. (2005). The continua. Unpublished manuscript.

VISTAS 2006 Online