OBSERVATIONS ABOUT TRANSGENDER PEOPLE Author: LIN FRASER, M.A./MFCC
OBSERVATIONS ABOUT TRANSGENDER PEOPLE PRESENTED TO ETVC SAN FRANCISCO, AUGUST 11, 1990 LIN FRASER, M.A./MFCC Edited by Ronda Schneider COPYRIGHT (c) 1990 by Lin Fraser. Reproduced by ETVC with permission from the author.
They told me to talk for about an hour, so I asked some of my clients when they came in for sessions what kinds of things they would be interested in my talking about. I wrote down a list of questions they were interested in, and that is what I am going to cover in this talk. I would like to be relatively casual, but I also have a lot of material, so if you have questions, I feel comfortable with your interrupting me and interacting with me, but if it looks like were going to get too interactive and I can't get through the material, then we'll stop; is everybody comfortable with that? How did I get involved in this work, my history? What do I get out of helping people with gender problems? What is my approach in helping people with gender issues; what classifications do I put people in and why; why do we classify? What are the people like in these classifications, how did they get that way, what is their history, what types of people are these people, and are they the same all over the world? What is the treatment or the therapy within these classifications? What does a transsexual have to do to meet the minimum criteria in the standards of care and why do they exist at all? What issues come up in therapy and what doesn't in this population? What changes have I seen in the gender community in the last 18 years? What is the future for transgender people, what is happening elsewhere, and what are gender researchers working on? The best way to divide transgender people to facilitate understanding them is as crossdressers and transsexuals. With transsexuals, their "dressed" role agrees with their primary gender identity. With crossdressers, or transvestites, it is opposite to their primary gender identity, which is how they are "crossed". In terms of this group, are you interested more in crossdressing issues, or gender dysphoria/transsexual, or is it about a mix here? Are you interested in both? Response: Yes. Response: It's predominantly transvestite. In this room? Response: In this room. I'm not sure, as I look around. Response: You can talk about both, though. I see both in practice and I see a lot of people who don't know. PERSONAL HISTORY Many people want to know how I got involved, and why I am working with you. I came from a family background where my mother was the more assertive person, and my father was very nurturing and receptive. That made me sensitive to the possibility of role reversal as a relatively natural thing. As the older daughter, I was raised with the belief that as a woman I could do anything I wanted to do. I was born a feminist, in a sense. Then I graduated from college with a degree in psychology and religion and became a flight attendant, and that's when my consciousness was really raised. As a flight attendant, everyone projected onto me hyperfemininity, and I wasn't. I liked my job, and I liked traveling, but I didn't fit the stereotype of a flight attendant. So I went back to school, and put myself through graduate school as a flight attendant. My first job, or internship, as a graduate student was at a place called Fort Help, and my very first assignment was DeeDee. I will never forget DeeDee. I did an intake on her. I was terrified; I had never seen a client in my life. A very attractive woman came in and I took her up to one of the counselling rooms and she said "I want to work on my anger", and I thought 'Whew, I'm so glad it's something I can relate to.' I wanted my first client to be someone I could identify with, and half-way through the intake, she said, "Oh, by the way, I am a preoperative transsexual. I have my surgery in two months, and I like you and I want you to work with me." I didn't know exactly what she was talking about, but I had heard of Christine Jorgensen. I told her I liked her too - you know how sometimes you just like someone and we just sort of connected - but I felt very inadequate to work with the issues that I projected onto her, because I assumed she was working on gender issues. She said, "I am not working on my gender. I'm having surgery in two months, but I came here because I would like to work on my anger, and I will teach you anything you want to know about gender issues." Meeting her was timely for me because as a flight attendant, I was particularly sensitive to stereotyped based on gender. I was fascinated. DeeDee took me in hand. She was my client, but she taught me. Back then I was working at Fort Help with alternative mental health, and dual relationships were OK. In other words, it was fine for us to socialize with our clients, to go outside of the psychotherapy space and interact. My subsequent training does not allow that, but back then as a beginning therapist in that environment, it was fine, which I am grateful for, because without that I would not know what I know today. DeeDee became my friend, and she took me to all of the places that existed back in 1972 for the transsexual community. She also introduced me to her surgeon, who was with the Stanford program, and they were kind enough to allow me to be present in the surgery. DeeDee felt she had a better chance of getting a good outcome if I was watching, even though I didn't have a clue as to what was going on. It was an incredibly informative experience for me. She told all her friends about me, and her friends started coming to Fort Help. At the time, there were no other providers in San Francisco who knew much about gender, to my knowledge anyway. Paul Walker was in Texas at the time. Millie Brown and most of the others you're aware of now had'nt got started. So I saw a lot of people who taught me, and that's how I learned. DeeDee showed me the literature and showed me Harry Benjamin's book, "The Transsexual Phenomenon", which is really very interesting. I learned a lot there, and then I started reading other literature, and as you may be aware, the literature is a mess. It's hard to find yourself when you're looking in the literature. "This doesn't describe me; it has nothing to do with who I am." And that's where most people start. They go to their local library, or they go to their local therapist, and they can't find anything. The literature is getting better, but back then... At that time, the Harry Benjamin International Gender Dysphoria Association was just forming and I joined. They didn't have standards of care. One surgeon in San Francisco, whom I had better not name, was accepting anyone and everyone, and people were killing themselves after surgery. It was a horror show. This surgeon was getting concerned because standards were starting to be formulated and surgeons were developing criteria about whom they would accept for surgery. He called me and asked me if I would help him screen people, so I went over to his facility. It was a garage on Lombard St. I saw one of his surgeries, which was done in the garage. It was horrible. Fortunately, soon thereafter the Standards of Care were set up and this particular surgeon lost his medical license, and is now either in jail or practising in Mexico, and no one I know ever refers to him. So that's my early history. I went into private practice, and was getting a number of referrals from the Stanford program. Then transvestites started coming to see me, and I didn't know anything about that, either, so I did the same thing. Always go back to the paraculture; that's where you get the information. That's also what I tell people to do if they come to see me and haven't been exposed to the paraculture. Get involved; you will find out more about yourself there than, at this point in time, anywhere in the literature. I learned nothing about this in graduate school, by the way. And I have completed a doctoral program, with the exception of dissertation, so I have as much training in graduate school as any provider you will ever find, and I was never told anything about gender. So make sure, if you do see a therapist, that the therapist has experience in gender questions. MOTIVE Why I like working in this community is that people work really hard. There are a lot of personal rewards. People really want to understand themselves, and that is very rewarding for a therapist. I've seen a lot of change in people. People come in and don't know who they are or if they even have a right to exist. There's a lot of guilt and shame, and by psychotherapy and their own efforts outside of psychotherapy and by interacting with the paraculture. I see tremendous growth in terms of peace of mind, self knowledge, and knowledge about what they want. On an intellectual level, it's a very big challenge to work in this field. It's pioneering. We don't know much. So as a therapist, I'm in a situation where I don't have a lot of teachers above me. I have a lot of people whom I work with who teach me, and I am a student in the most wonderful sense. So much is unknown. We don't know much about etiology in terms of gender identity, gender roles, and sexual orientation, so it's very challenging. There's a lot of creativity involved and a lot of opportunity for travel, research, and meeting other providers around the world. So it's exciting. The only thing I don't like about working in the field is that as a provider I have to wear two hats. It's very uncomfortable. Everyone in this room can identify with having two sets of beings: you have a male side and a female side. When I am working with transsexuals, I have to be both a therapist and a gatekeeper, and that's schizophrenogenic. That is the one part I don't like about it, having to wear two hats. Once that's taken care of, with most people, then I can just be a therapist, which I much prefer. Question: What do you mean a gatekeeper? For people who are transsexuals, they need referrals for hormones and surgery, 50 some people who come in to see me may feel that they know their diagnosis and deserve their letter now, and they are angry at me if I don't provide it immediately. CLINICAL ORIENTATION As to clinical orientation, I am trained heavily in Jungian theory and in behavioral theory. My supervisor for my doctoral dissertation is a behaviourist. I have an MFCC license, which means I have a lot of training in systems theory and family relationships. I am in Supervision currently with two Jungian analysts, one of whom you may be familiar with, Jean Shinoda Bolen, because she's written two gender-related books: "Goddesses in Every woman" and "Gods in Every man". So I'm heavily oriented toward dream interpretation, archetypal patterns, and anima issues, but a lot of people I work with are not Jungian oriented and not interested in delving in that direction and that's OK. What's my approach? First order of business when you come in to see me is what do you want; what is your agenda? I don't have an agenda; it's what direction you want to go. Each person is different. Therapy is individualized, based on what direction you need to go. A lot of people who come into therapy to see me really don't have gender issues; the gender issue has been dealt with. They want to see me because I'm free to put the gender issue in proper perspective and to deal instead with work and relationships and whatever else they want to work on. Second order of business, though, assuming you do want to work on gender, is assessment. What direction do you want to go? I see so many people who just don't know. The most common person who comes to see me is someone who says, "I don't know if I'm a TV or a TS. I thought I was a TV and now I'm wondering." That's very typical. There are a lot of other people who come to see me too, but for this audience I am gearing it toward gender issues. Crossdressers who are not uncomfortable with crossdressing generally don't come to see me. I think a lot of people like that are members of ETVC. I'm talking primarily about people who do come to therapy. What we do is we assess together. In other words, I'm not sitting there telling you who you are; we work on it together. With some people it takes a long time. Many people who are seeing me feel confused. One day they think they're one way and one day another, and it's shifting and fluid and there are a lot of variables and a lot of things happening in your life that can change what direction you want to go. That's why it is usually a developing diagnosis. That's not always the case I do see people who know for sure they're crossdressers who are not leaning toward transsexualism and people who know they're transsexuals and have never had any crossdressing associated with sexual arousal, or any crossdressing that is a response to any kind of trigger, the way TV's do. In terms of complexity, the most complicated situation is when you don't know, and that usually takes the longest, and is very common. Why is this so complicated? Sexual identity is broken down into biologic sex, sexual orientation, gender identity, and gender or sex roles. We know almost nothing about any of those four. We know very little about etiology, about how they develop, and in this community we see fluidity and change in all these areas. So you can see how, in each person sometimes, you can have one gender identity or two gender identities, one gender role or two gender roles. Sexual orientation can be towards men, it can be towards women, and it can be towards your image of yourself as a woman. And it can be changing. So it's complicated. How do you got static, so you can settle down, so you know who you are and what you want? There's a lot of controversy, too, as to how crossgender identity develops. Is it nature; is it nurture? Again, nobody knows. So we just have to start with you, and what you want and what direction you want to go, because I don't have the answers. Nobody does. TRANSSEXUALISM What classifications do we have within transsexualism? There are in my practice over the years essentially three types, and if you look in the literature, they are going to be called primary and secondary by one author, and primary and secondary by another author, but they are talking about two different phenomena, so you still get confused. So I am going to describe the three types and see if anything rings a bell. Some of you may exhibit characteristics of more than one type, so if you're confused about yourself, that's also common. One type is early onset crossgender identity. The person is pretty much asexual, always. There is almost no sexual arousal associated with crossdressing. The person is usually a loner as a child, somewhat inhibited, may have tried marriage and family. Their presentation in the male gender role is not particularly effeminate. They are quiet people, and their sexual orientation seems to be changing, but really they are pretty much asexual. A lot of their psyche is taken up by crossgender identity. So these people have one gender identity, and that is female. Two gender roles, though, with the male presentation seeming like a guy, and the female presentation seeming the same, like the same person, but also seeming like a woman too, someone who is sort of androgynous, but not in the Michael Jackson sense - someone who is undifferentiated. Their sexual orientation can change as they shift roles, as they start living in the female gender role. Another type is someone who appears in the male gender as an extremely effeminate homosexual. They are the sissy boys, who have always had a crossgender identity at the extreme end of effeminate homosexuality. They seem like girls, and they are very talkative and uninhibited and talk about sex all the time. They have always been interested in men; there is never a change in their sexual orientation. The third type is a person who starts out as a transvestite. The crossgender identity is a late onset one. The person for many, many years has assumed he was a garden variety crossdresser, whose crossdressing was associated with sexuality, sometimes tranquility, but there were triggers to it. Maybe he didn't know what the pattern was, but when he undergoes therapy he realizes there were triggers to the crossdressing. What happens as he gets older is that the female gender identity, which used to be a subordinate part, starts taking over, and he becomes she. There were two gender identities that were quite split, with sexual orientation usually toward women. As the female identity takes over, whereas he originally thought he would be a lesbian, she goes into the female gender role, and often, with time, she becomes interested in men, but never has been before. This is the late onset. A lot of these people are at ETVC. In terms of outcome with these three, I can't tell any difference. All three types do just as well following sex reassignment surgery. At least that is what I've seen in my clinical practice, but many researchers disagree. Many refuse to authorize surgery for secondary transsexuals because they fear that the chances of making a mistake are too great. Then there's the person who comes in and says they're transsexual and they're not, or I don't think they are, and what I have to do with that group is set up a therapeutic alliance with them, otherwise they will just leave therapy. In other words, help them to realize that I am on their side, and that my job is to help them even though they might not be transsexual. What is sometimes going on in this case is a multiple personality disorder, which I see infrequently but I do see. There are usually several personalities, with at least one a male and one a female, so the experience is that "I might be transsexual." Another possibility is a psychotic experience. More common though is the crossdresser who is under extreme stress, has a big loss in his life, and then escapes into the female temporarily. That's where he is used to going for comfort, safety, and security, and he believes then that he is transsexual, and what happens over time with psychotherapy, and just time really, but the push is an internal push, is that he eventually realizes he is still fundamentally a crossdresser. So if you are a crossdresser one thing to be careful with if you find yourself moving in the direction of the feminine is to see how much stress you are under; see if you've had any experiences that could be causing you to want to escape into this other identity. Treatment for transsexualism is supportive psychotherapy and help with referrals for hormones and sex reassignment surgery - if that is what you want. A lot of people don't; a lot of people just crosslive and feel comfortable without changing their anatomy. Such people are often termed transgenderists, although the term is a relatively new one. One of the things I can do for clients is being a female role model for them. I was raised as a woman and I can refer you to image consultants, electrologists, endocrinologists, surgeons, speech therapists, and other providers to help you with your socialization into the female gender role. The Standards of Care are essentially that you be in therapy for three months before getting a referral for hormones and for six months with the same therapist prior to surgery, and that you cross live for at least a year, preferably two, so you can go through a transition similar to adolescence, the way that I did, to find out what it is like to be a woman full time. Question: When I first came to you, I couldn't have called myself a transsexual because I wasn't contemplating surgery. I think categories are harmful. For me it wasn't a question of defining myself in a category, but of finding a way of living that brought a sense of wholeness. My experience is that one becomes a transsexual when one starts experiencing life as a woman. I agree with you 100% in that regard. Trying to simplify, it helps to look at three types because the therapeutic issues are different, but what actually happens, as you know, when you come in, is you are not spending time in categories, but trying to decide how you want to live and what is/best for you. It is highly individualized. Still, treatment tends to run according to type, and categories are still useful, especially academically. And for insurance purposes, to get psychotherapy paid for, I have to label you, and everyone else who walks through my office. Question: When I began, I had no sense of options of how I want to live; I felt I was stuck with a diagnosis. I never hear people say, "I am living as a transsexual because for me it is the best way to resolve my life issues." Instead, they define themselves as being born into a category without choice. The only solution I have is in therapy. I am just working with whomever is sitting in front of me, in an individualized way. Question: I would like to hear people talk about these being resolutions to life situations rather than this is what you are, because one of the things I have noticed in the years I have done therapy is when you label somebody, frequently they become it. That is true. I have felt that, not just about gender, but the whole DSM- III-R. I personally am a recovering alcoholic, and for a long time, wherever I went, my whole sense of who I was that, and I don't want to be just that, so your point is well taken. Question:You were saying some people think they are transsexuals but they're really not and are merely using that to escape, but on the other hand, there are people who have been forced into the male role and primarily want to escape from that and they really should escape from that, so the whole thing gets very confusing. Might it not be more productive in each case simply to focus on where do you really want to go, rather than where you've been? We do both. This is giving you an overview, but what happens in therapy, with me anyway, and hopefully with other people, is we are dealing with what's going on with you. We really are. Question:I'm also a therapist with a similar orientation to yourself. For insurance purposes we have to put labels on people, but in the actual therapeutic process, we strive toward wholeness, although categories do help in certain ways to give you an idea of where you're going. It certainly helps. I've had so much frustration being confused by the literature and hearing something different on a daily basis from my clients, and hearing a complaint all the time from my clients that "providers don't know anything about me." When I went out and looked at what providers were saying, including myself, it didn't fit, so I'm trying to make sense of this. What I've presented to you is in terms of categories I'm familiar with, in an attempt to try to use some logic in a very complicated field, but it really isn't what happens in ongoing therapy. CROSSDRESSERS What do people who are crossdressers generally want? They usually want to integrate crossdressing into their lives in some comfortable way. They want to understand it and want to control it. Everybody's different, by the way; these are just representative types of things that people bring in. They may want to overcome shame and guilt associated with it. They may want to get rid of it, or make sure it doesn't develop into a crossgender identity full time. Those are basically the type of issues that come up when crossdressers come to see me. What is the therapy? First order of business for most people if they are not already connected with the paraculture is to refer them here (to ETVC), because the number one concern that I see with crossdressers who don't have any contact with the paraculture is the overwhelming shame and guilt, the secrets. "I have a secret and nobody knows about it and I'm the only one and I hate myself and what's wrong with me?" That kind of thing. They've been living with it their whole lives, and don't even know that this paraculture exists. What generally happens once they come to ETVC is they come back to me and say, "Those people are normal!" I hear that all the time. They start out terrified; there's a lot of fear about walking in this door. "Who am I going to see? Is anyone going to talk to me? What are these people like?" And they invariably come back and say, "Gee, I found somebody just like me." And that feels wonderful. The work that this organization is doing, and other organizations like it, I cannot commend enough, particularly now that there are a lot of outreachs going on. I have some contact with the hotline right now, and I am very impressed with that. The word is getting out. There are so many people who will no longer have to be so alone with this. The number one thing for a crossdresser is to get them in contact with others. One exception is when the person is absolutely sure that what they want is to get rid of the crossdressing behaviour, and then it's not necessarily the best thing to have an exposure to other crossdressers, but those people are a minority. For control, understanding, and integration, what happens in the psychotherapy itself? If the person is in a relationship and the secret is out, I always want to involve the spouse, if possible. That is very helpful. Crossdressing can become a symbol for a lot of other issues that are going on in the relationship, that have to do with power, control, autonomy, and trust. It can become much more than it actually is, and it is a good idea to bring this up and include the spouse, and what the limits to the crossdressing are with the spouse, what the issues are with children, and so forth. The most important thing to the crossdresser is usually how does this affect my relationship, or if I don't have a relationship, how will it affect a relationship. Because the crossdresser does this part time, there's not the issue around work. Were not dealing with the same kind of issues as the transperson who is living the female gender role full time. So we do a lot of couples counselling. Then if you want to get into really understanding the crossdressing, to understand yourself in the context of it, I have a number of questions that we deal with over time, and this depends on how deep you want to go. What I just mentioned up to now is what a lot of people do; they just want to work with their relationship and don't have a real need to go further. What we do with the crossdressing behaviour itself is assess when, why, and under what circumstances do you crossdress? We look at intensity, frequency, and duration of crossdressing patterns. Do you feel you have a choice? Is this a part of who you are, or is it not? Is it more a compulsive type of thing that seems to overwhelm you, or is it an expression of who you are? What is going on here, let's take a look at that. What is the function of it in your life? How did it start? How does it develop and change over time? Is it just sexualized, or is it a part of your gender identity? What happens to your crossdressing when you fall in love? If it goes away, which it does with a lot of people, then you can develop an understanding of what we call in Jungian theory the 'anima'. The anima, in the biologic male, is the image of the feminine, or the woman within the man. Every man has that, and Jung writes a lot about this, but never with respect to crossdressers. When the non-crossdressing heterosexual male falls in love, he projects his own anima out. With the crossdresser, when he falls in love, sometimes he projects his own anima out and stops crossdressing, but other times what he is doing is having a relationship with his own anima. So he has a blissful, sometimes an almost in love relationship with an internal image of the feminine, that he needs to concertize, he needs to put into the world and have a relationship with. We want to know what is the crossdressing related to in terms of when the overwhelming need comes. What a lot of people talk about in therapy is that it is related to assertion and reward. Sometimes crossdressing is a reward for something, and sometimes it's an avoidance response, a fear of assertion of the male side. That isn't always the case, but it is something I have commonly found when working with such people. We have to assess, for instance with dream interpretation, whether the unconscious is pushing the psyche in a female or a male direction. Often the conscious self is unaware of what the unconscious is doing. Who is the whole person? Who is the second self? In the crossdresser, first is the male and second is the female. What is the male identity like, the female identity like? Can the male have access to the female? It's very important for you as a crossdresser in the masculine to be able to tap into some of that stuff that you can get in the feminine. The question I always ask people is, do you want to keep these two separate, or do you want to integrate? If you want to keep the male and female selves separate, then it is important to get them working together, cooperating rather than competing. If the crossdresser has no conscious awareness of this, the female side will often try to gain control, and that is the origin of many problems I see in therapy. We want to find out in which direction is the female identity going, and what is happening to the male identity. As a Jungian, I assess the archetypal patterns in each gender identity. What I find with the crossdresser is a sort of Apollonian identity in the male and a sort of Aphrodite in the females and I'll explain what that is in a minute. A lot of people in the paraculture talk about feeling like two different people. The guy is usually rational and concrete; you might say he's kind of boring. The female is spontaneous and blissful and in the moment. That frequently is what people report to me, typical crossdressers. This is what the male side usually looks like: He's the thinking type. He might have a little obsessive- compulsive behaviour going on. He's introverted and quiet. He may have been shy and inhibited growing up. He's rational. He's future oriented, which Jungians describe as living in Kronos time. He's serious and responsible. He's a professional and somewhat conservative. Logos is what he's involved in, that's thinking. Things are concrete to him. He could be clinically prone to depression. He's independent; it's difficult for him to ask for help. And he's a heterosexual. What is his female side like? That's the anima. That's the soul, by the way, in every man; the anima is the soul. Here we have the Aphrodite archetype, a lot of bliss; it's a highly aroused state. The world is now in colors rather than black and white. Here's where the feeling is, and sensation. In the moment - there is no future and no past, what is called Kairos time. It feels good; it's highly pleasurable. He can focus on the details of the moment. He has a desire, or maybe I should say she, has a desire to connect with others, a desire for relationship out in the world. She wants to go out to connect. And there is a recognition of dependency needs in this state, and a feeling of safety, security, and tranquility, as well as excitement and risk and a sense of spontaneity. This is Eros instead of Logos. The sexuality is towards the female image of self. That's why mirrors are important. Dick Doctor did some studies on this. His book is fabulous. He has been testing sexuality in the crossdressed state, and one of the things he is finding is an attraction to men with many crossdressers, which is surprising, because there is so much obvious heterosexuality; we almost talk about heterosexual crossdresser as one word. For some crossdressers, the female archetype is more Persephone, who is childlike and spontaneous and fun, and also in the moment. When you're crossdressed, I want to find out, do you feel different to me. Often you don't, by the way. You feel very different to yourself, but you don't feel different to me. You look different, but you seem the same. Crossdressers are very narcissistic when they are crossdressed. "How do I look! Tell me about what I'm wearing. Look at my nails. " Once you get beyond that, there can be more recognition of who you really are. It's easy to understand, I think, just looking at those two sides of the psyche, why the feminine is so appealing. A lot of the fun is there; a lot of the pleasure is there. Once again, if you feel like you're moving toward a crossgender identity, take a look and see if you're under a lot of stress, because that tends to shift people into the feminine even if they are not really transsexual. What a lot of people say to me is their heart wants it even though their head doesn't; then later they can't believe they ever said that. What do we do in terms of control? A lot of people say, "I just want to control this. I don't want to give it up, but I don't want it to take over." Again, the bottom line, the therapeutic issue, is what do you want? And a lot of people don't know. Once the female starts taking over, it's very difficult to stop it, because that's where the psyche wants to go. What do you do to stop it? You need to work on the masculine side. This is very hard to get people interested in. I have so many of these people coming in looking like such slobs as men. And then they get their courage up to come to see me crossdressed, and I have this elegant thing coming in with the nails they spent four hours on. They need to spend time on the masculine. "What a nice sweater you've got on today," and that kind of thing, to reinforce the masculine image. You need to seek other ways for bliss, for the risk taking and spontaneity that's associated with the feminine. Being in the moment - how else can you get that, besides dressing? Find out what your triggers are for crossdressing. Often it's stress control. Take a look at other ways you can deal with stress. I do a lot of dream interpretation. One of the things I'm interested in is what your unconscious is saying. Lots of times you may feel one way and your unconscious may be saying something else. Where is the ego in the dream state? Crossdressers and transsexuals dream a lot about themselves in the female gender, but it's very different in terms of how they dream about themselves and where the ego is and what direction is it going. So I do a lot of dream interpretation. Another way to find out what direction you are going, as a last resort, if you feel like you're moving toward a female gender, is to try crossliving for a short period of time. What tends to happen is that a lot of people get tired of it. Work out some way that you can take a vacation and crosslive, to be a woman on a daily basis. Fantasia Fair isn't good enough. Fantasia Fair is a fantasy. It's great for what it is, and I encourage people to go, but I'm talking now in terms of what it's like in your daily life every day. A lot of people do get tired of that, and they realize they are not really moving in that direction. Another thing that you can do, although I don't recommend it, is to marry a transsexual, or take a lot of pictures of crossdressers, because there is something called projective identification, a psychodynamic term. You can project and then bring it back on to yourself in an intimate relationship, or with an object, and often that will take away the need for you to do it yourself. Another thing in the male gender is to have a lot of sex, as a man, and to also work on masturbatory fantasies, to shift them away from the image of self as a woman and toward intercourse with women. There are specific techniques for doing this. We do this with people in practice who do not want to proceed in a transgender direction, but want to go backwards. CAUSES How did you get this way? What kinds of things happened in your childhood that may have been a contributing factor. What I say is based on listening to lots of life stories of lots of different people. There are basically two paths; well, there are three, but two that are very different. Sissy boys One is the gender dysphoria secondary to homosexuality. That's the sissy boy. There's a lot of work being done by Susan Coates in New York now and Ken Zucker in Canada and Pichard Green at UCLA working with crossgender identified boys. That's not most of you, in terms of what I see in practice when we talk about your history, and when I interact with you here. There's usually been a very close family system, very close to the mother. If you ever read some of the psychodynamic literature by Robert Stoller, he talks a lot about this group. He calls this 'primary transsexualism'. This child never really has any conflict, and the theory is that he never separates from Mom in the separation/individuation stages of development, which is between ages 2 and 4. This also may be the person who has a biologic basis to the crossgender behaviour. We don't know. The biologic studies are inconclusive, but we do have some. Louis Gooren is doing some really good work in the Netherlands, and Eicher and Goerner are in Germany. With these extremely effeminate boys, there may have been some 'in utero' effect on development of the brain. Joe Gonzalez over here (in the audience) hopefully is going to find out with his PET scans and other biologic research, and perhaps some day working on the biologic end of gender disorders we will know more. These boys are always very effeminate. They are like a girl from the word go. They are only attracted to men, and have always been. They are apparently at a very early age trying to repair some kind of damage to the Mom by becoming the Mom; Susan Coates' work on this if absolutely fascinating. They often come from homophobic backgrounds, a lot of Catholicism or other religious backgrounds. This is also the phenomenon that we see when we look at crossgender identity in non-Western preliterate and cross cultural studies. Many cultures have a place for this population, a third gender if you will. There's the berdache in Native American studies, the acault in Burma, the Kahunain the South Pacific, the hijras in India. What you tend to find there is people who are somewhere in between the spirit and the flesh. They are often priest-like people, or shamans. They will often live in the female gender and marry men. The majority of people in our culture who start out that way develop a homosexual orientation as adults, and seldom take the extreme path of transsexuality. Those with More Variable Initial Gender Identity Everyone else that I work with comes from a background where they are not particularly effeminate as children. Transsexuals in this group usually, but not always, experience an earlier onset of crossgender identity than crossdressers. The early onset transsexuals seldom fetishize. They have very little sexuality associated with crossdressing, and very little sexuality at all. Their relationship to their penis is neutral or negative. Except for those things, everything else is similar in terms of history for both the crossdressers and transsexuals in this group. Both seem to come from a background where there is very little touching. This may not apply to you, but I have found it commonly among most clients. They didn't get a lot of touching and they didn't have much discussion growing up in their family system about sex, or sexuality. So when the child is developing, he develops his sexuality in private, and then he may reinforce his crossdressing with masturbation. He doesn't tell anybody about his crossdressing. He never learned anything about it, or that anyone might ever condone such a thing. Often they come from a working class background. Lots of people I work with are not themselves working class, but are professionals who have come from such a background, where male identity and female identity was polarized. There was a big difference between who men were and who women were. Usually mother was not available all the time. She was there, but it was not the close kind of thing I was taking about with the sissy boys. She's not there all the time, and she's often withholding, particularly when it comes to touching. The father is either inconsequential, absent, or he is disliked. He is a negative, or at best a neutral. Even so, the father is sometimes perceived as more nurturing than the mother. Women have the power in this kind of family, or that is what it looks like to the child. It is often an extended family and there are a lot of women around, so the child is often in the company of women, and he likes that. These are mother's sons rather than father's sons. Possibly in this family a girl was wanted; this happens sometimes. Somewhere along the line the child decided it was better to be a girl. Occasionally you run into sexual child abuse, and in the cases where that happens, often the crossgender identity is developed as a response to that. That's when you get into dissociative states and multiple personalities. Once in a while I will talk to someone who was forced to be crossdressed, but that is rare. You see that in the literature, but in my practice most people remember that they crossdressed themselves. It was something internal. Some people recognize it was a transitional object for Mom. Mom was gone and they put the clothes on to be close to Mom. They felt with the clothing there was a safety and comfort and security, kind of like holding, the feeling of being held. As adolescents, most of my clients were introverted and shy, and their social and sexual skills were not well developed. There wasn't a lot of dating or a history of many different women - very little contact with real girls. So there was a lot of opportunity to develop the image of the feminine in private. From a Jungian perspective, people I see are usually introverted, thinking, sensation types. What that means is that a lot of the psychological material is going on internally. It's a very rich internal world. That's one of the reasons I like working with this community. There's usually a tremendous amount of internal stuff going on. The thinking orientation comes out in the kinds of jobs that are picked - large numbers of engineers, and computer people, and people who are comfortable with things and manipulating the environment. They are interested in details, concreteness. Sensation types concertize experience. They concertize the image of the feminine to make it real. And it feels good, and gives them security. One of the things that I find very interesting is that I have only found this kind of phenomenon in the West, and Japan. I am only aware of it in the United States and Canada, Northern Europe, South Africa, Australia, New Zealand, and Japan. The other kind I was talking about earlier, the sissy boy and the effeminate homosexual, is what you see more often in less technological cultures, including Southern Europe. What I think might be going on is that as we become industrialized, we have a nuclear family where we don't have much contact with the father. The father is out in the world, and there is not much available role modelling there. Also, when we look at the cultures where the non-homosexual type is prevalent, and now I'm getting into Jungian theory, they are cold and untouching cultures and there is little connection with the goddess. The cultures are not warm and spontaneous and connected with the earth. I think what happens in our community is that a lot of you are in touch with that at a very deep level. You are introverted sensation types and you recognize that it is missing and you need to concertize it. The culture needs to do it. We need a lot more female images out there. In the Southern European cultures, at least, you do have the Madonna - I'm not saying that's great - and there are a lot of cultures in the East with a wide variety of goddess images, where the image of God is not patriarchal, not male identified. I think you're hooking into the lack of that in this culture at a very early age. This ability is typical of sensation types. That is getting off into Jungian theory, but I think that's what's going on. OTHER THERAPEUTIC ISSUES There are different issues for people who are going to live full time in the female gender role versus people who are balancing two gender images. With the transsexual, once the gender shift occurs, most of the work is done and you can get on and live your life. If you're a crossdresser, it's an ongoing issue. Your whole life you are dealing with balancing the two, and that's a big challenge. What a lot of people deal with in therapy is problems related to having a secret, so we have intimacy and trust issues. If your whole life is a secret, it affects who you are and your relationship with other people, particularly with people whom you love. Who do you tell, how do you tell, what is the effect of having a secret, of feeling not completely known, feeling if you really knew me you might reject me? Of course, there are issues of depression, isolation, loneliness, feeling different, issues of self-esteem, and a lot of guilt over who you are. One of the things we usually need to work on is overcoming feeling guilt about being who we are. Other people are overwhelmed by obsessive- compulsive issues around crossdressing. We have a relatively new treatment coming out of the University of Minnesota for obsessive- compulsive gender dysphoria and/or crossdressing which is Prozac and/or lithium. What that seems to do is take the edge off the feeling of overwhelming urgency. It allows you to be free from that and start to deal with your issues. Some people even give up the gender dysphoria, but not many. What doesn't come up with this group? I don't see much psychosis at all. I very rarely see paranoia, with the exception of legitimate paranoia, in other words people who say "I'm scared to go out in the world crossdressed, with people reading me and rejecting me." I see almost no clinical paranoia. I think because I'm in private practice, I don't see a lot of borderlines, or acting out, except for the people who are absolutely sure they are transsexual and they want their hormones and I don't agree with them. I see very little sociopathy; most people in this community play by the rules, so I don't see people who are breaking laws. I don't see people who are not serious about psychotherapy. This population is extremely interested in self understanding, and that's one reason I like working with you. I tell providers who are thinking of entering this field that there is usually a great sense of responsibility in this population. People pay their bills, and they show up for appointments, and they work hard in therapy, which is very good for the providers. I don't see a lot of codependency. Occasionally I do, because it's such a common thing in this culture, but transgender people are not controllers; they are usually not controlling other people. They are focused on what's going on with them, and you can do your own thing. Live and let live. CHANGES IN THE COMMUNITY What changes have I seen in the gender community? What is the future for the T-person? I think that's the latest politically correct term. What is happening elsewhere and what are gender researchers working on? I've been around the paraculture for l8 years, and I've seen a lot of changes, all good. The people today are much more knowledgeable and sophisticated, and much more organized and political. There is a lot more pride of being who you are, a lot more self acceptance and self confidence. I think what is happening is these people are moving in the same direction the gay community was 20 or 30 years ago. ETVC is incredible. How many people are members now, 500? In how many years, 8? That's incredible. More and more people are coming out of the closet. I was at the gay parade at your booth and you kept running out of literature and people kept showing up asking questions. There was very little hostile judgment, and people were interested. And that's a shift. I know it's San Francisco, but I think it's happening elsewhere more slowly. There's even a radical contingent, which I found out the other night from Telzey, and I think that's good. The "Act-Up" of the transgender community. You meet all types, and we need to get to know each other. The Catch 22 this community has that others don't is that a lot of you just want to stay in the woodwork. When you're dressed, you want to be like any other woman. You can't go out and be political, because you want to fit in with everybody else. That will always be a problem, I think, but some people don't feel it as strongly as others. Another thing I see is that the image of the feminine in this community has changed, and this I like so much. It's much more realistic. Eighteen years ago, what I saw when I would come in these rooms was a real Madonna/whore split. Of course, that has been characteristic of our culture, too. As we as women get more choices, what we see in this community also reflects that, and everybody doesn't look alike, and most tend to look more realistic. Eighteen years ago, you didn't do as good a job. Also, you have a lot more options. Eighteen years ago, unless you were a DSM- III-R transsexual wanting to get rid of your penis, nobody knew what to do with you. Also, you had to be heterosexual in the gender you were moving into or you weren't considered a candidate for surgery, so people were lying to us as providers because there is so much variation among transgender people that wasn't being acknowledged then by the providers. People then were not comfortable with diversity. There's a lot more diversity and options now. There are a lot more people who are living as women, but not electing sex reassignment, or even hormones. The role is what's important to them; being related to as a female is what's important. That's not for everybody, but you now have that option. I think providers and consumers are closing the gap between them. I was at a meeting of HBIGDA in Cleveland recently and there is a consumer member on the board of directors of the Harry Benjamin Association. I really think this is good, that were interacting. I know for me, most of what I've learned has been from you, not only in my office, but from associations outside. And I see that is happening more; there is more exchange. Also I notice that providers are communicating more around the world. There are so few of us, that it is great that we know who each other are and can communicate with each other. In terms of research, there's a person now, Louis Gooren, who is Chair of Transsexuality, if you can believe this. At the Free University in Amsterdam, there is now a whole chairship for him; he was just installed. So this is exciting, in terms of doing research in this area. It is getting more acceptable. In Canada they're doing a lot of work in classification. In the United States, work on sissy boys, and in sexual addiction and compulsivity, and that's probably where the money is, unfortunately. The only area I'm aware of where funding is potentially available for research in the gender field is in obsessive-compulsive behaviour using Prozac or lithium. The drug companies will pay for that. Otherwise, it's hard to get funding. One negative that everyone's aware of is what's happening in the Supreme Court, what's happening with the First Amendment, and that concerns me in terms of what direction you will be able to go because of the direction that the country is going. This is an on-going concern. QUESTIONS Question: Is the TV syndrome for escaping stress a more healthy behaviour than self-destructive ones like alcohol or drugs? Oh, definitely. Yes. It's definitely a more healthy response to anxiety. Question: And as far as escapism, as long as you don't go into a multiple personality or something and use it as a tool to help cope with real life situations... You can. See, this is the thing: it varies from person to person. One of the things that you need to strive to do is to use it that way as opposed to using it in ways that can be destructive. Only you can decide how that works for you. Question: What criteria do you use to judge whether one is a transsexual? I am not sitting there diagnosing you. We are working together to figure out (a) would you be more comfortable living in the female gender role, and (b) if you would, are hormones or reassignment surgery appropriate. That's again something we do together, because there are a lot of options. I don't have criteria per se. I don't have a list because everybody's different, although I do follow the Standards of Care. It's not accurate to use DSM-III-R because DSM-III-R says that a transsexual is someone who hates their penis, and some people who are going to live in the female gender role, whom the paraculture terms transgenderists but the literature has no category for that, don't hate their penis; they use it. Question: In your experience, have you worked with people who have been taking hormones for extended periods who are not surgery candidates who are still living on both sides of the fence and have been talking hormones for more than a few years? Yes, I have. We don't have good data on that. All I can tell you is to the best of my knowledge, the hormones have not harmed them. There is a concern about someone taking high levels of hormones for an extended period of time, but we just don't know. There's a fellow in Amsterdam, H. Asscheman, who did some very good research on the negative effects of female hormones on the genetic male, but still it wasn't the long term kind of thing. Question: Obviously "high" is going to be relative to the individual. Yes, but someone who has surgery immediately goes down in the dosage, so if you're not going to have surgery, you're going to be taking higher levels of hormones than the person who has surgery. Once a person has surgery, required hormone levels drop because that person's body is no longer producing as much testosterone. If you don't have surgery, we don't know what the long term effect is. Question: I'd like to gather information on the risk factors of taking hormones under a doctor's supervision. Were trying to get data, but this is something relatively new, so we don't have long term studies, and few people are even trying to collect it. The best advice I can give you is to continue interacting with your doctor on a regular basis and paying attention to the possible effects. There is potential for stroke, and some really horrible possibilities. Question: If you read the warnings on the bottle, they would scare you to death. Yes, they are horrible. But in terms of what I have experienced with people, they haven't suffered many medical side effects. What my clients much more commonly talk about is psychological side effects. Question: The other thing from my personal experience is that I was taking the high but commonly prescribed dose of 5 mg Premarin, 10 mg Provera, and 0.5 mg Estinyl, and I think that's dangerous. After a few years, I wound up with arrhythmic heart, cramps, all the things that were on the label. On lower doses, I didn't have those side effects. Thank you. I heard a really good lecture from an endocrinologist who works with female-to-males, and he was essentially saying that you have to self monitor the side effects, and you have to judge for yourself. Like Annie, who decreased her dosage and eliminated the side effects. Everybody's different. Question: Do you inform your clients of the drawbacks and limitations of surgery? To the best of my knowledge, I do. I've worked with a number of people who have had surgery over the years and they have reported to me what their experience has been, and what I do is relate that information, and tell all the horror stories that I am aware of. I also advise people to talk with an endocrinologist who has had experience with postoperative clients, because such a medical doctor can make observations more objective than mine, which are anecdotal. The problem you run into outside of therapy is that when transgender people get together in a group and talk about their surgeries and their vaginas, they tend to make it sound better than it really is. It tends to sound a lot better than what someone might say to me in individual therapy. But on the whole, the majority of people I have worked with who have gone ahead and had reassignment surgery do not regret it and feel that it is much better than their previous experience. Question: In your practice, do you find a psychic difference between transsexuals and transvestites; do they dream differently? Yes. In terms of themes. It's very helpful in terms of assessment to look at what the themes are in your dreams. A person who starts out as a crossdresser and becomes a transsexual develops changes in her dreams and begins to dream like a transsexual. Question: What is a typical transsexual dream? I can't say that there's a typical transsexual dream in terms of content. One difference is, transsexuals as a group tend to dream of themselves as women; crossdressers tend to dream of themselves crossdressed. There is a real difference in terms of who is the dreamer, what is the ego state of the dreamer. Often a transsexual will dream of herself going back in time, but in the past they are a little girl. For a transsexual, the dreamer is usually female. For the transvestite, there are a lot a dreams about risk taking and escaping with a strong sense of being crossdressed, and also dreams of themselves as hurt little boys. That's the main difference, but there are others. Question: What's the percentage of crossdressing that you find related to obsessive behaviour? It seems from what I see on TV that Prozac changes such behaviour in a broad way. I don't know yet. My friends in Minneapolis who are doing the research on that are going to be presenting their findings in November, and that is one of the questions I have too. The researchers are wonderful people and have worked extensively with this community, and they were saying that the last thing they wanted to do was take away any part of anyone's identity. They started with a small group of people who said they were obsessing all the time, and what they found was a tremendous sense of relief for most people. Because in the gender community people talk to each other, they began getting more and more people showing up wanting it, and many of them began completely letting go of crossdressing. Now this is brand new research. Joe over here is a psychiatrist to whom I have referred some people that he has put on Prozac. In some it doesn't affect the gender dysphoria at all, and in others it does. We only have 5, so I don't have a large statistical sample, and I am very interested in finding out the results of such studies myself. Question: You made an extreme distinction between a transsexual and a transvestite in that a transsexual feels herself a girl and transvestite just dresses up as an escape. No, no, no. If I gave the impression that transsexuals and transvestites are very different, I was not trying to do that. At each end of the continuum, and there's not exactly a continuum but ignoring the sissy boys for a moment, the people at the ends are very, very different, but most people are in the middle. There is a tremendous amount of crossing over, and of ambiguity in classification. Put if I'm asked specifically a question, about differences I see in dreams for instance, then I'll be thinking of the extremes at the ends. Question: What specifically is gender dysphoria? Gender dysphoria was a term that Norman Fisk came up with in the late 70's. I believe, trying to come up with a generic term which applied to everyone who had some kind of gender discomfort or confusion. At that time, he did not mean to include in it crossdressers who had no transsexual fantasies. However, the term is often used in this community for everybody, and when I use it, I am talking generically about some kind of gender identity concern. In the literature, though, you may find it only to refer to people who are either transsexuals or transgenderists. Question: How many crossdressers involved in relationships go further into transgenderism? That is an excellent question. I don't know. I am the wrong person to ask because I see a disproportionate share of those. I think a good way to find out would be to do a research project with this community. Question: Now that women's roles are greatly expanded, and most women today don't fit the old stereotype, has there been a comparable change in the way transsexuals see themselves, or do they still tend to perpetuate the old stereotypes? Another good question. There has indeed been a change in the population I see. In general, transsexuals seem to be changing in their perception of themselves at about the same rate as women in general in the society. People are no longer bound, as they used to be, by the same old stereotypes. There is much more diversity now, which I am very pleased to see.
Lin Fraser is a therapist practising in San Francisco, 415-922- 9240. ETVC is a social and educational organization open to all crossdressers and gender dysphoric people, P.O. Box 6486, San Francisco, CA 94101. ETVC has periodic social meetings, provides outreach to the gender community and to the public, and has periodic educational meetings for its own members. This is a transcript from one of those meetings. SOURCE: ETVC