What are therapists treating when they treat clients for “Gender Identity Disorder”?
Both insurance companies and standards of care demand that therapists carefully diagnose patients who present ourselves as having gender identities at odds with our bodies and social roles, ruling out other possible diagnoses before accepting our claims of transgender identity. But while some clients experience transgender identity – that is, a gender identity that doesn’t fit the conventional categories of male or female – as a “disorder,” many do not, and transgender critics have long argued against the “pathologization” of transgender identity implied by the diagnosis of “gender identity disorder.” These critics see therapists as “gate-keepers,” whose role should be limited to authorizing medical services and insurance coverage, rather than assessing clients’ claims to know themselves.
If therapists are merely gate-keepers for transgender clients, and “gender identity disorder” is merely a set of magic words required by doctors and insurance companies, therapy sessions should be few, brief, and pro forma. If “gender identity disorder” refers to a psychological condition that can benefit from therapeutic intervention, therapists should engage in diagnosis and offer therapy as well as statements of authorization. However, if claims of transgender identity indicate a psychological disorder, why would therapists support medical treatment to modify these clients’ bodies to match their “disordered” gender identities? And if transgender identity is not itself a disorder, what does “gender identity disorder” mean?
My then-wife, during arguments she hoped would save our marriage by dissuading me from gender transition, crystallized the epistemological challenges presented by claims of transgender identity: “If you tell me you’ve always felt like a chicken,” she asked, “should I start treating you like a chicken?” To her, when I declared that I had always felt female, I was demonstrating not that I had a female gender identity, but that I – a bearded, middle-aged father of three – was delusional. To my wife, my therapist’s diagnosis of “gender identity disorder” seemed no different from a diagnosis of “chicken identity disorder.” Clients who insist they can only live authentic lives by living as chickens are clearly suffering from some kind of psychological disorder. A therapist who affirms such clients’ claims, who encourages them to dress like chickens, to alter their bodies to resemble those of chickens and begin to come out to others as chickens, shouldn’t be a therapist.
That’s how my wife felt about my therapist. By accepting my claims of female gender identity and supporting my transition from living as a man to living as a woman, my therapist was exacerbating the very disorder with which she had diagnosed me, and encouraging me to destroy my life and family. To my wife, my therapist’s job was to help me understand the root causes of my gender identity disorder, and either guide me to a healthy embrace of male identity or to help me accept that however I felt, I was and would always be a man. Indeed, my wife saw a number of possible causes for what, to her, was my rejection of male identity. My father had been always been emotionally withdrawn, and abruptly stopped talking to me when I was 21. Since my father was my model of masculinity, of course I wouldn’t want to be a man. Or perhaps I was tired of the responsibilities that accompanied masculinity – supporting my family, dealing with yard-work and automobile malfunctions, pretending to be rational. Besides, my wife argued, if I thought being a woman was easier or better than being a man, then I obviously knew nothing about being a woman. My desire to live as a woman proved I was really a man.
My wife’s skepticism about transgender identity can also be found among therapists. Though I’ve been blessed with excellent therapists in the past decade, I encountered kinder, gentler variations of her theories in earlier journeys through the therapeutic world. Even therapists who listened empathetically to my inarticulate, shame-hobbled efforts to explain what I meant by “feeling like a woman” weren’t eager to explore those feelings. Consciously or unconsciously, they steered me toward more familiar ground: my father, my co-dependent marriage, my chronic, intermittently suicidal depression. They seemed happy to talk about anything other than my gender, and they didn’t seem to notice that despite any insights I achieved about my father, my marriage, and my misery, I remained just as depressed.
Of course, those therapists had little in the way of resources to draw upon. In the 1970’s and 1980’s, there was no Internet, and few clinical source books like Arlene Ishtar Lev’s invaluable Transgender Emergence. But even when I went to a gender identity clinic (I was living in San Francisco), the therapist I encountered wasn’t comfortable exploring gender identity issues. The moment I introduced myself as transsexual, I was offered hormone replacement therapy and other practical support for making the transition from living as a man to living as a woman. My therapist was baffled when I said that I had come there not for hormones but to better understand my lifelong sense of being female. If I was really transsexual, my therapist indicated, I should transition immediately; if I wasn’t ready to do so, maybe I wasn’t really transsexual.
There are many more books and educational resources on the subject now, but it is still hard for therapists to respond to clients’ claims of transgender identity without implicitly or explicitly questioning our sense of who we are. Insurance companies, endocrinologists, surgeons, and agencies issuing government IDs all require transgender people to present letters from therapists declaring that our claims to transgender identity are neither fraudulent, tentative, nor delusional – and to confirm that we are being “treated” for gender identity disorder. Therapists who take these letters seriously are required to engage in diagnostic processes that demand, if not skepticism toward transgender clients’ claims to know who we are, at least a suspension of belief until our soundness of mind and consistency of sense of identity has been established. But since transgender people live in a world that constantly and sometimes violently questions our identities, diagnostic skepticism can be alienating and wounding.
Even apart from the vulnerabilities of transgender clients, it is always complicated to respond to gender identity issues. Gender is built into our language, our mores, our intimate relationships, our very modes of understanding ourselves, which means that all gender identities, including those which fit normative definitions of male and female, are bound up with socialization, childhood experience, fantasy, fear, shame, and often trauma. Non-transgender people grow up without having to worry about whether their internal sense of gender identity is shared by those around them. For them, the gender binary that identifies everyone as either male or female represents a powerful, though sometimes oppressive, system for understanding and expressing themselves.
But the gender binary has no place for transgender people. We grow up in a world that offers us no way of understanding our gender identities, no way of expressing them that will be intelligible to others. There is of course one exception: the widely familiar idea that transgender people are women or men “trapped” in the bodies of the opposite sex. This concept of identity was developed for transsexuals, people like me who identify with a binary gender that is the opposite of the one we were assigned on the basis of the sex of our bodies. Transsexuals represent only one of the many forms of transgender identity. But even for transsexuals, the “I am an X trapped in a Y body” meme is an inadequate and confusing model of identity, as one well-meaning questioner demonstrated when he asked me, “Did you know you were a woman trapped in a man’s body even when you were a child?” Of course not, I told him: When I was a child I didn’t have a man’s body, and I had no idea what it meant to be a woman.
But since this meme is the only model our culture offers for transgender identity, I, like many transsexuals, spent most of my life trying to use it to understand my gender identity. I was delighted by the idea that my sense of female gender identity meant that there was an authentic, fully-developed girl or woman hidden within my male body. Unfortunately, though, I could never locate the girl or woman inside me. Since I wasn’t sure I fit the “X in a Y body” model, I obsessively, anxiously questioned my gender identity.
Those anxieties were exacerbated by my equally obsessive monitoring of my behavior to ensure that I wouldn’t do anything that might suggest that I wasn’t really the boy or man everyone thought I was. But the more successful I was at passing as a boy, the more anxious I was that I might not “really” be a girl. The terms of the decree that my gender identity should consist only of a fully-formed, unambiguously female self that existed independently of not only my body but of any of the complexities of human development or relationship. There was no way I could understand my fragmented, constantly self-questioning consciousness, my robustly maintained male persona and robustly repressed female gender identity in terms of the “I am an X trapped in a Y body” meme.
Did that mean I wasn’t transsexual after all? That my sense of female gender was a delusion, or a lie? How could I tell?
From childhood through adulthood, I tormented myself with these questions, interminably searching my feelings, desires, fantasies, and actions for a fully-formed female self that somehow had come into being without ever being expressed in my actions or relationships. Such a self, of course, is impossible. Becoming a woman requires more than a female gender identity, it requires living that gender identity. I could never fulfill the requirements of the “I am a girl or woman trapped in a boy’s or man’s body” model because I wasn’t a boy or a girl, or a man or a woman. I was an anxiously self-monitoring, chronically depressed, intermittently suicidal person with a male body, a male persona, and a female gender identity that I was too ashamed and afraid to express.
But miserable as I was, I knew my gender identity wasn’t a disorder, a symptom, or an illness; it was at the core of who I knew myself to be. My therapist’s diagnosis of “gender identity disorder” referred not to my female gender identity, but to the psychological, social, and developmental consequences of growing up in a culture that offered me no way to understand or express my true self. A diagnosis of gender identity disorder, then, is a diagnosis not just of an individual, but of a culture: The client diagnosed with gender identity disorder is manifesting the culture’s failure to support the articulation, understanding, expression, development, and integration of transgender selves.
Susan Loud, the therapist who helped me through gender transition, asked me in our first session whether anyone had ever taught me to be true to myself. No. No one had taught me to be true to myself, because no one could recognize or conceive the self to which I needed to be true. And though I wouldn’t learn words like “transphobia” until middle age, even as a young child I knew I was living in a culture in which being true to myself would have terrible consequences. Whenever a teacher addressed a class as “boys and girls,” whenever a sitcom got laughs premised on the utter incompatibility of men and women, whenever the image of man in a dress was presented as humiliating and ridiculous, my culture taught me that someone like me, someone with a male body and female gender identity, didn’t, couldn’t, and shouldn’t exist. No one taught me to be true to myself because my self was a contradiction in terms, an unimaginable short-circuiting of the categorical distinction between male and female on which personal relationships, social order, and the very notion of being human depended.
The beliefs that kept me constantly thinking about killing myself – the beliefs that my gender identity was not only shameful but harmful to those I loved, that to live as myself would be unconscionably selfish and violate values of family, community, and faith I held sacred – were major symptoms of my gender identity disorder, individual consequences of cultural failure to understand and affirm the validity of transgender identities.
Transgender people have become much more visible in the last decade. But the vast majority of Americans, even the most highly educated, spiritually enlightened, and socially progressive, still have little understanding of gender identities that don’t fit the binary categories of male and female. In much of the country, it is still legal to discriminate against transgender people; even where there are legal protections, visibly transgender people suffer abuse and harassment, shunning by family, unemployment, poverty and homelessness, and, once or twice a week, murder.
The high costs and ongoing risks of being openly transgender contribute to what might otherwise seem a puzzling problem: Even after we begin living as who we are, many transgender people remain at risk of suicide. Even when we stop hating ourselves, others may continue to hate us; even when we accept ourselves, others may reject us; when we finally show up as who we are, those who love us may turn away or attack us. Though we may heal our individual gender identity disorders, we cannot heal the social gender identity disorder, the lack of understanding of transgender identities that gave rise to our “symptoms.”
Therapists cannot give transgender clients a world that welcomes them, any more than our understanding and acceptance of ourselves can magically foster understanding and acceptance in others. But when therapists help transgender clients recover from the disordering effects of growing up in a culture that still offers us little means of making sense of and intelligibly expressing our gender identities, those therapists and clients spur our culture to grow beyond the limitations of the gender binary. One friendship, one family, one workplace at a time, they inspire new, more capacious ways of understanding ourselves and one another.