Issues of Countertransference in Therapy with Transgender Clients (2000)
Christine Milrod, Ph.D.
Therapist countertransference in the treatment of individuals presenting with Gender Dysphoria has until now been largely unexamined in the clinical literature, although the therapist’s conception of gender identity etiology, sexual orientation, gender role models and investment in gender presentation are highly influential in the therapeutic inquiry. This article considers therapist countertransference in conjunction with transgender intrapsychic issues, transitioning, genital surgery, transgender theory and how these issues affect the conceptualization and subsequent treatment of a client.
Although psychotherapists may encounter transgender or gender dysphoric clients in their practice, there is a lack of clinical literature specifically addressing the countertransference a therapist might experience when treating individuals who present with issues of gender identity. Available scientific publications and journals are often written from a quantitative perspective and few articles attempt to incorporate the subjective feelings and inner experiences of mental health providers as they interact with their transgender clients in a therapeutic context. By employing references from popular literature and autobiographical accounts of transitioning initially directed at the lay community, this paper will consider therapist countertransference in conjunction with transgender intrapsychic issues, transitioning, gender confirming surgery (GCS) and transgender theory. Client conceptualizations will primarily revolve around transfeminine individuals although countertransference issues may frequently be similar when engaging in treatment with transmasculine persons.
According to the DSM-IV (American Psychiatric Association, 1994), Gender Identity Disorder (GID) takes on two different courses in adult males. One, as explicated by the manual, is “a continuation of Gender Identity Disorder that had an onset in childhood or early adolescence” (p. 536). The other course is reported as appearing later in the individual’s life, and is associated with fetishistic aspects of wearing women’s clothing as well as less satisfaction with sex-reassignment surgery. It is also stated that “if Gender Identity Disorder is present in adulthood, it tends to have a chronic course, but spontaneous remission has been reported” (p. 536). Although these categorizations may somewhat educate and assist the therapist in the conceptualization of a client, the very interpretation and application of clinical interventions related to these statements may become problematic. If the therapist harbors and communicates an unconscious wish for the client’s gender dysphoria to “spontaneously remit,” the client could end up perceiving the clinician as an enemy. Many transgender individuals have a well-grounded and realistic fear of therapists, based on experiences of therapist-client miscommunication and perceived humiliation of the client.
Transgender individuals frequently report a lack of trust in clinicians, which is not surprising if mental health professionals have not themselves searched their countertransferential inventories regarding gender. In their autobiographies, Morris (1974), Richards (1983) and Munroe (1993) documented their shaming experiences with uncomprehending therapists and psychiatrists who despite their impeccable credentials failed to engage in empathic dialogue with their suffering clients. In addition, the involuntary isolation that many gender dysphoric individuals have been subjected to since childhood may contribute to the reluctance to open up to a stranger, even if the person is in the helping profession. Symptoms of paranoia may in many cases be justified and the therapist would do well to consider the perspective of a persecuted minority when dealing with those who have survived a lifetime of gender ostracism and perhaps also outright violence done by family members and others.
Many trans women seek out and gravitate toward female therapists. This may simply be a function of the preponderance of women in the therapeutic profession or therapist availability in the area or as Bolin (1988) suggested, because transfeminine individuals feel that cisgender females serve as optimal role models of experience. Whatever the reason, the relationship betwen a transfeminine client and a female therapist does, however, carry with it certain clinical implications. The twinship needs and desire of the client to develop a female gender identity may tap into the clinician’s own unresolved issues of dependency, narcissism and internalized gender constructs. While it may be flattering to the female therapist to provide advice on gender presentation, it would behoove such a professional to examine her underlying values and conception of the meaning of femininity. It is imperative that the therapist not impose her personal translation of female gender attributes onto the client by being directive when the client experiments with hairstyles, cosmetics or clothing. Instead, the client’s seeking of approval from the therapist could be clarified and related to the client’s own conception of external female cues. Such a discussion could become the focus of therapeutic inquiry and would possibly help the client solidify an internal identity not solely based on stereotypical attributes of femininity. Focusing on the internal identity would also free the client to explore parts of the repressed self, which in turn could lead to deeper issues such as recapitulation of crucial developmental tasks: differentiation, individuation and the expression and fulfillment of sexual needs which for many gender-dysphoric individuals were truncated at adolescence.
For the majority of those who have documented their transgender journey (Conn, 1974; Morris, 1974; Munroe, 1993; Richards, 1983), sexual preference shifted as the individual transitioned into the opposite gender. As Richards (1983) pointed out:
“I’ve been asked why I didn’t simply live the life of a homosexual. This question is asked by those who do not understand that Dick was a heterosexual male and that Renée was a heterosexual female. Dick had no sexual interest in men and, when Renée fantasized, she fantasized the pleasures of sex as a woman with a vagina” (p. 57).
It is important to note the therapist’s own ideas of preference versus orientation, etiologies of essentialism versus social constructionism and how they affect the conceptualization and subsequent communication with the client. The confluence of genetics and cultural imprinting present an issue of ideology that often serves as the basis for the therapist’s understanding of the client’s sexuality. Despite the temptation to voice any political or scientific convictions in reference to sexual orientation, the therapist would most likely serve the client’s needs if this topic were conceptualized from an existential perspective. The therapist would in this case encourage the client to enjoy his or her amplified sexual response and the freedom of sexual expression that may come with the client’s emerging gender congruency, whether the object choice were male, female or transgender. In relation to this, the empathic clinician would be sensitive and affirmative toward the client seeking validation for any newfound enjoyment which could stem from mood and affect changes occurring after a hormonal regimen has been initiated. Paradoxically, the therapist could at this time also expect the client’s grief over wasted years and the regret of not starting the transitioning process sooner. During this phase, the therapist would serve as a container and provide the appropriate holding environment in which the client can mourn years of unfulfilled longing for a different life. Many fantasies related to the client’s younger years may emerge in the clinical material and it is necessary for the therapist to help the client explore and work through the meaning of such expressions. Frequently, clients will attempt to recapitulate adolescent developmental tasks and it may become challenging to the therapist to step back and observe what may seem as regressive behavior in an otherwise mature individual. Such regression, however, is necessary and vital to the transitioning process and should not be impeded unless the client is causing harm to others or the self.
In many autobiographical accounts of transgender issues (Morris, 1974; Richards, 1983; Stringer, 1992) transitions are reported to occur in tandem with midlife, when the individual has reached a developmental-existential crisis characteristic of normative adult development. Particularly for trans women, having delayed the transitioning process for several decades may be less related to their desire to wait and more tied to their lifelong attempts at fulfilling societal expectancies of gender-congruency. These individuals may have been married with children; in addition, they may have been involved in male-dominated pursuits such as the armed forces, engineering, computer science, etc. (Morris, 1974; Munroe, 1993; Richards, 1983; Stringer, 1992). Among many other factors, these issues become crucial for both client and therapist when dealing with the client’s family. It could be expected that the client (or, in some cases, the spouse) will attempt to triangulate the therapist into the relationship in order to manage his or her anxiety about the situation. This may pose some difficulty to the therapist who clearly needs to remain as untriangulated as possible while maintaining a therapeutic alliance with the client. Perhaps this paradox will become more clear if one imagines that many other unresolved issues in the marriage may surface during this process. The therapist should encourage both parties to accept responsibility but not blameworthiness for such issues and not conflate them with the client’s gender exploration. If there are children in the relationship, the family may become polarized. Again, the therapist needs to maintain a firm commitment to the client while allowing for expressions of grief from any family members. In addition, the therapist must be empathically attuned to the grieving of the client if his or her permanent partner leaves the relationship against the client’s wishes. Many partners may have valued the masculinity or femininity of the client and now feel betrayed (Denny, 1991). Conflict may ensue when the client becomes the focus of spousal hate, in that the transitioning individual is both the metaphorical executioner and the executed. In this instance, a therapist who is partnered and not gender-dysphoric may be at countertransferential risk for unconscious collusion with either partner and may thereby minimize the clients’ sense of loss.
A fundamental concern in providing therapy to transitioning individuals involves the therapist’s conception of gender, including fantasies of his or her own possible gender change as well as the change of the client. During the cross-living period in the transitioning process, the therapist’s internalized gender values will most likely be found to subtly influence the client. The therapist has to ensure that his or her value system does not interfere with the client’s choice of gender expression, particularly if the client has chosen to explore a gender role model which may seem inappropriate to the therapist. Instead, the therapist should help the client clarify the meaning of appropriating certain gender role aspects. It is important to communicate to the client that trying out different gender expressions is part of a healthy developmental trajectory and that this process may take several years. In this sense, the therapist also helps the client recognize and deal with the frustration of not being able to rush through the transitioning period in order to attain the goal of desired completion and possibly gender confirming surgery.
Gender Confirming Surgery (GCS) issues
According to Stringer (1992), only about six percent of all diagnosed trans persons or only one person in four or five who starts the affirmative process (Stuart, 1991) will proceed with gender confirmation surgery. While many who begin the transitioning process initially feel that GCS is the only answer to their sense of becoming complete, the majority opt for hormones but keep their genitalia intact. Others in the trans community have also raised the issue of undue importance placed on GCS. Whatever the decision, it is one that must be reached by the client without any interference or influence from the therapist. Optimally, the clinician will walk a fine line of being accepting but not condoning, despite the client’s possible wish to obtain direction in the therapy room. It is not surprising that a majority of gender dysphoric individuals have second thoughts and that they may wish for the therapist to dissuade them from surgical interventions. Others, despite the risk of impaired sexual function, will insist on GCS as the only solution. The implications of this desire were stated by Richards (1983):
“If ever there was an opportunity for regret it came when I was quaking in the recovery room, yet that opportunity was not seized. At that moment I realized that I would rather have died in the attempt than live any longer in a nightmare of duality” (p. 282).
In view of the irreversible effects of GCS, both therapist and client should be encouraged to obtain as much information about the issue as possible. Particularly for trans women, an area of therapeutic inquiry should deal with the complete removal of the testes and the ensuing hormonal effects. While some post-operative individuals feel extreme happiness and a sense of well-being, others may experience some loss of libido due to the massive decline of testosterone production. Some come to the realization that despite the surgery, they will still not be considered members of the opposite sex or gender. In striving for post-surgical perfection, the individual may also develop hatred for body parts that cannot be changed, such as hands or feet (Bornstein, 1994; Denny, 1991; Stuart, 1991). In addition, the fear of being “read” by the public may reintensify post-operatively because the external appearance will still remain the same when the person is fully clothed. Depending on the client’s emotions and circumstances, androgyny may be an acceptable solution; to open up this area of inquiry to the client may mean a thorough examination of the therapist’s own biases regarding gender and sexuality.
Ideology and therapy
During the last the fifteen years, transgender ideology has been associated with a paradigmatic shift in gender theory which encompasses sociological, psychological and political constructs. Much of the prevailing gender discourse has centered around the social construction versus the essentialism of gender, which in turn has stimulated an ontological debate in the transgender community. Transphobic feminists such as Raymond (1979) in her classic diatribe against transgender women maintained that “all transsexuals rape women’s bodies by reducing the real female form to an artifact, appropriating this body for themselves” (p. 104). In the deconstruction of gender in general and of transsexualism in particular, Kate Bornstein (1994) stated:
“There are some transsexuals who agree with the way I look at the world, and quite a few who are really angry with me for writing this stuff. Every transsexual I know went through a gender transformation for different reasons, and there are as many truthful experiences of gender as there are people who think they have a gender I know I’m not a man–about that much I’m very clear, and I’ve come to the conclusion that I’m probably not a woman either, at least not according to a lot of people’s rules on this sort of thing. The trouble is, we’re living in a world that insists we be one or the other—a world that doesn’t bother to tell us exactly what one or the other is” (p. 8).
It is highly unlikely that Bornstein would have found a receptive audience for these ideas in decades past. In examining the biographies of Jorgensen (1967), Morris (1974) or Richards (1983), it becomes clear that there are cultural cohort aspects to gender presentations and socially constructed gender roles that have little to do with essentialism or ontology. The pioneering Jorgensen who completed her final genital surgery in 1954 apparently never questioned her post-operative status as anything else but that of a woman:
“At that point, I felt at last that I’d completed the transition to womanhood, and except for the ability to bear children, was as complete a person as I’d dreamed of being, both emotionally and physiologically” (p. 228).
Two decades after Jorgensen’s transition, Jan Morris (1974) appeared entrenched in a now-considered anachronistic conception of femininity:
“The more I was treated as a woman, the more woman I became. I adapted willy-nilly. If I was assumed to be incompetent at reversing cars, or opening bottles, oddly incompetent I found myself becoming. If a case was thought too heavy for me, inexplicably I found it so myself” (p.149).
Morris also stated that there were essential aspects of being female which she now experienced:
“These were essentially changes in attitude and response; but there were inner changes in me, too, more subtle, more important. Some were simply the psychological effects of fulfillment, but some sprang from the end of my maleness, and were more truly the symptoms of womanhood” (1974, pp. 151-152).
Even Richards (1983) whose conspicuous career as a tennis player and ophthalmologist defied traditional female stereotypes, never questioned her status as she was recuperating from painful GCS: “In spite of these incredible sensations, my mind did shift to the fact I was now a woman”(p. 281). Whether positioned in the direction of Bornstein’s deconstruction and questioning of gender or embracing the ideas of Jorgensen, Morris et al., the effect of the clinician’s convictions will reverberate throughout the intersubjective field of therapeutic inquiry. The concept of “passing” and the fear of being “read,” i.e., found out and possibly exposed by those who come in contact with the transitioning individual, may be topics that provoke anxiety in both therapist and client. If the therapist is personally vested in his or her own gender presentation, the unconscious impulse may be to subtly steer the client toward what the therapist considers appropriate for a particular gender. Instead of uncovering the significance and meaning of an internal gender experience, the therapist could possibly inhibit the process by directively focusing on external issues. Conversely, the client may trigger therapist countertransference when engaging in hyper-feminine, gender-stereotypical explorations. Cisgender male therapists who engage in treatment with transfeminine individuals may also face literal castration anxiety which in turn could become expressed countertransferentially. Although it is less likely that a male therapist who is wedded to a traditionally masculine gender role would engage in treatment with a trans woman, it would not be entirely unreasonable to assume that even less traditional male clinicians could become affected by patriarchal gender constructs. Such therapists could unconsciously use these constructs to influence the client, which in turn could affect the establishment of the client’s gender identity.
According to Bornstein (1994), the concept of passing is a cornerstone of the cultural definition of transgender issues, which results in its tacit acceptance by those whose open existence could seriously affect the current binary gender system. Historically, passing has affected all ethnic, religious and sexual minorities who seek participation in the dominant culture. In the case of transpeople, the desire to pass frequently taps into the fear of being “read,” all of which can become a stressful circular feedback loop. Bornstein’s position is highly analogous to that of the queer movement wherein the closet is regarded as a place of silence and disempowerment indirectly upholding the status quo. At the other end of the spectrum is Stringer (1992) who stated that she became the stepmother to three teenaged children who were not aware of her “past.” With these divergent views operating in the political and psychological climate of the gender universe, it is essential to become aware of internalized transphobia and its presence among both clinicians and clients. Several transgender autobiographers have indeed stated that after transitioning, they “avoid the transsexual ghetto” (Harlow and Rheims, 1994, p. 14), either because “misery loves company” (Richards, 1983, p. 152) or because “transsexuals keep away from each other because we threaten the hell out of one another” (Bornstein, 1994, p. 63). With these statements in mind, working through the client’s internalized transphobia and the well-established defenses and cognitive patterns the client brings to the new gender identity (Denny, 1991) will undoubtedly bring the clinician in contact with his or her own gender issues. A thorough internal exploration of such issues may ultimately serve to expand sociocultural norms for the clinician as well as for the client both in and out of the therapeutic context.
The conceptualization and treatment of a client who presents with gender dysphoria may become significantly affected by therapist countertransference in several areas subject to therapeutic inquiry. Subjective and interpretive issues of ideology may come to serve as the basis for the therapist’s conceptualization of the client’s emerging gender and sexuality. In addition, unconscious collusion with the client’s internalized transphobia may create a therapeutic atmosphere in which the freedom to explore various gender roles and presentations may become curtailed. If, however, the therapist is able to identify and to confront emerging issues of countertransference and the underpinnings of deeply held gender constructs, then the awareness gained will undoubtedly become beneficial to both parties involved in the intersubjective pursuit of transgender affirmative therapy.
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