Psychotherapy, which historically has been viewed as an adjunct treatment for gender disorder patients (especially surgery candidates) and only more recently as a primary treatment, has been successful in informing and educating patients, thus rendering relief to gender-dysphoric individuals pre- and postoperatively.

Although, surprisingly, psychotherapy is no longer required (although it is highly recommended) in the Standards of Care (Levine et al. 1998) for treatment of gender-dysphoric patients, it may take such forms as individual therapy (Kirkpatrick and Friedman 1976; Pfafflin 1993), group therapy (Keiler et al. 1982; Wilchesky 1993), behavior therapy (Barlow et al. 1977, 1979; Shtasel 1979), family therapy (Wrate and Gulens 1986), or an eclectic combination of these therapeutic strategies (Zucker and Green 1989, 1991). Conjoint or family therapy involving parents (Pleak and Anderson 1993) and significant others (DiCeglie 1993) may also be helpful. Comorbid psychopathology (Levine 1980; Levine and Lothstein 1981; Lothstein 1977; Lothstein and Levine 1981) and other aspects of the patient’s total psychosociosexual adjustment should be considered in a multimodal approach to treatment (Bockting and Coleman 1992).

Gender-dysphoric patients often reject psychotherapy - and understandably so - because 1) they have had poor experiences with unknowledgeable, judgmental, or ineffective therapists; 2) they feel driven by the “transsexual imperative” (Morgan 1978) to seek sex reassignment surgery and do not want to “waste” time and money on therapy; 3) they feel helpless to find appropriate or affordable services (although it is well known that all forms of surgery and illegally acquired hormones can be obtained); or 4) they are uninformed about the goals of psychotherapy in gender dysphoria conditions and perceive such therapy as an interference. Furthermore, therapists themselves may be reluctant to work with patients who are resistant to psychotherapeutic examination or change or who act hostilely (e.g., “lie about their social histories, miss appointments, or refuse to talk about anything besides hormones, electrolysis, or surgery” [Lothstein and Levine 1981, p. 925]). The major goals of psychotherapy with a gender-dysphoric person have been comprehensively addressed in the HBIGDA Standards of Care (Levine et al. 1998), and these guidelines should be consulted before undertaking this specialized treatment.

Hormonal treatments and sex reassignment surgery (SRS) require written referrals from a qualified psychotherapist (one letter for hormones, two for SRS [Levine et al. 1998; Lothstein and Brown 1992]). Many patients will attempt to minimize or avoid contact with the mental health professional or become only superficially involved. Some patients even offer to pay off therapists to speed up the process or bring in paid surrogates as “family” to provide the history they believe the therapist wants to hear (Brown 1990a; Schaefer and Wheeler 1995). Yet it behooves the therapist in such a situation to be understanding and sympathetic of this negative behavior and to attempt to overcome the patient’s resistance, as well as his or her own, to gain the benefits of the psychotherapy. Of primary importance is that the therapist share with the patient how he or she can profoundly benefit from the therapy by learning valuable ways of making life choices.

In early psychotherapy sessions, after the initial evaluation has been made, the therapist should inform the patient of the two major goals of the therapeutic process: 1) to educate the patient as thoroughly as possible about what is scientifically known regarding gender identity disorders and their treatment and 2) to apprise patients of all available options currently open to them for learning how to live in the world comfortably with their gender condition.

Psychoeducation
Inherent in treatment of GID patients is the principle that valid psychoeducation will counteract the negative myths and ignorance that permeate social thinking regarding transgendered persons (Francoeur 1991; Hirschfeld 1910; Spengler 1933; Talmay 1914). An important benefit of therapy reported by some patients is the realization that scientists worldwide are taking their condition seriously enough to investigate it with intelligence and respect. This realization, in and of itself, does much to raise the patient’s self-esteem.

Rational and educational psychotherapy informs patients that there are two major existing and somewhat opposing theories on the etiology of gender identity conditions. One theory is that the disorder is a conditioned entity, or “a conditioned condition,” to which a patient has to adjust, thus holding him- or herself responsible for having the condition. The other theory holds that the condition is a birth phenomenon or prenatal error that lasts throughout a lifetime (Schaefer and Wheeler 1987; Wheeler and Schaefer 1988), implying to the patient that he or she has come into the world with this condition and will leave the world with it (Schaefer and Wheeler 1983) and that psychotherapy, medications, and surgical treatments will not “cure” the patient of the condition. Spontaneous, durable resolution of established GID in adults has not been convincingly reported.

Among the concepts that therapists may teach patients in the process of gender transition are two basic lessons in learning how to live one’s life in the opposite-gender role: how to make a living and how to have and nurture a relationship. These two concepts parallel what Freud (1920) described as being the two most important issues in life - love and work. Since gender-dysphoric patients learned these lessons in their conflicted gender role as they matured, the therapist must now help patients adjust to living and loving in the context of the opposite-gender role consistent with the gender identity they have kept hidden all their lives.

Psychotherapy and Gender Guilt
Schaefer and Wheeler (1995, in press) emphasize the importance of the damaging effects of gender-dysphoric patients’ guilt over their condition (Madow 1988), as well as the critical role therapists can play in helping patients work through this immobilizing emotion to achieve success. This overwhelming experience of internal conflict permeating the lives of gender-dysphoric individuals becomes familiar to them as soon as they become aware that they are not like other children (i.e., between ages 3 and 9 years). Children in general fear being different (with its implications of separation, rejection, and abandonment by others), but, because of the isolating nature of gender dysphoria, gender-confused children experience this fear of difference more intensely. Concluding that something must be inherently wrong with them - something for which they alone feel responsible - they develop a sense of secretiveness and shame. By its nature, guilt necessitates recompense. Restitution is expressed by GID patients in patterns of self-deprecating behavior, resulting in feelings of low self-esteem.

Because GID patients have internalized gender guilt at such an early age, they may be unable to recognize the degree and extent to which it has contaminated every level of their lives. For example, they often make unrealistic and damaging life decisions; cling to their feelings of worthlessness and internal misery; chronically apologize for themselves; feel victimized; display an intense discomfort with intimacy; sabotage employment opportunities; deny themselves a family environment; often choose hostile, unaccepting, unsuitable partners in life; and compulsively seek approval from others. One defense mechanism used by some patients as a substitute for inner self-acceptance is to become obsessive overachievers. Other patients do not allow themselves even the smallest feelings of the satisfaction of success. However, the seeking of self-acceptance from others to fill the void in one’s self-esteem is never sufficient.

Clearly, psychotherapy must focus on reducing or eliminating the crippling effect of gender guilt and on helping patients to ultimately find self-forgiveness. In this regard, therapists are challenged to work with adult patients who literally believe that they have no self to forgive - or that whatever self they do have is not worthy of forgiveness. In the treatment process, the therapist must emphasize that no one is to blame for the presence of gender transposition in their lives.

Discussion of Patients’ Options
The psychoeducational and therapeutic process necessarily involves exploration of a patient’s options once GID is diagnosed. Some patients have never considered any other options but cross-sex hormones and SRS, although many other choices exist which may be appropriate for them to consider (

Table 70-9). The Standards of Care also list numerous options other than somatic therapies that should be discussed in treatment (Levine et al. 1998). Patients learn that they have the right to make choices in terms of 1) acknowledging and respecting their cross-gendered feelings and 2) living in their preferred gender role. Further, within these options, patients may make certain choices that, although perhaps not opportune at one period in their lifetime, may be quite viable later on. Because GID will span a lifetime, certain decisions may be postponed until later in life when such choices might be more appropriate, acceptable, and feasible.

But the therapist must also stress the danger of choosing to do nothing about their gender condition, because such an approach generally has disastrous consequences. Suppression and repression often lead to depression and substance abuse, sometimes accompanied by suicidality. Although many patients retain, or commence, a sexual life after surgery (Lief and Hubschman 1993), anyone who chooses to have SRS must realize that disruptions in sexual functioning, in particular orgasmic capability, may be compromised. This issue needs to be addressed in an open way (Green 1998).

Finally, patients and therapists must become familiar with the often changing and highly discriminatory legal situations that may pertain to those contemplating transition (Gooren and van der Reijt 1994).

To be effective, psychotherapy must be tailored to the needs of each individual patient, with realistic goals being crucial to its success (Wheeler and Schaefer 1981, 1984a, 1984b). Therapists need to examine their own biases and countertransference regarding cross-gender feelings and behaviors (Benjamin 1964a, 1967; Pomeroy 1975; Schaefer and Wheeler 1983; Wheeler and Schaefer 1984a). Negative countertransference reactions that are not addressed can be damaging to patients. For example, Lothstein (1977) described the inadvertent near-suffocation of a transsexual patient undergoing anesthesia for SRS. This problem was thought to be related to negative feelings on the part of the anesthesiologist. As another example is an MTF transsexual patient referred to the author from a family physician with copies of her medical records replete with a written account of how the referring physician tried to “cure” the patient by administering an intramuscular injection of testosterone (against the patient’s will) and exhorting the patient to “join the Army and learn how to run over trees with a tank.” A competent referral for treatment is clearly preferable to treatment that is provided in the context of unresolved countertransference issues that cloud judgment.

Therapists who take on the responsibility for treating patients with GID also need to be knowledgeable about key issues and requirements - both legal and social - concerning patients’ gender transition. These include: how to write effective letters on patients’ behalf for changes of identity in regard to their legal name, birth certificate, motor vehicle license, social security number, immigration documents and passport, academic transcripts and degrees or professional licenses or certifications; how to write referrals regarding patients’ readiness for hormone treatment and/or genital reassignment surgery; and how to communicate effectively with insurance companies for patient reimbursement for treatment and medical expenses to the greatest extent possible.

Finally, involvement of spouses and family members can be critical to the success of transition for transgendered persons. Although many spouses are accepting of their mate’s undergoing transition, a majority have important issues that can be addressed in the psychotherapeutic process (Brown 1994). Frequently patients have suffered the loss of their spouse and children in the course of their gender exploration, often through expensive and emotionally devastating legal proceedings, and they are left with little support from those they care most about. Lack of social support is often associated with poor treatment outcomes. Patients may need to “start over” with respect to developing intimate relationships or learn how to approach reticent family members in their preferred gender role.