The Tempest Over Sex Identity*

(revised 9/03)

By Lisa M. Hartley, ACSW-DCSW

( Lisa M. Hartley, ACSW-DCSW is a Master’s level Clinical Social Worker with over thirty years post Masters experience that includes clinical, supervisory, administrative and educational arenas. She began active transitioning from male to female in 1994, and completed her real life test in 1996-97. She underwent her confirmation surgery by Dr. Yvonne Menard in Montreal, Quebec, Canada on August 18, 1997. Several of her articles on the transgender experience have been published in books, magazines, newsletters, and the Internet. She has lectured to thousands of people about the transgender experience, including the sharing of her own story.)


Thomas N. Wise, MD., Professor of Psychiatry and Behavior Science, The Johns Hopkins School of Medicine wrote the following to The Dartmouth, the newspaper of Dartmouth College. It appeared as a letter to the editor in the online version, October 12, 2001 with the title “Transgender Truths.”

“I am concerned that there is ongoing confusion regarding sexual minorities. It is clear that homosexuality is not a psychiatric disorder. The official diagnostic stigmatization of homosexuality was abandoned after lack of data that could establish any pathology associated with being either gay or lesbian. Gender dysphoria, unhappiness with one’s biological sexual designation, is very different from same sex attraction and is a psychiatric disorder. Individuals who designate themselves as transgender, which is not a formal medical or psychiatric term, often are not homosexual but have significant problems of self identity. As director of research at the Sexual Behaviors Unit at Johns Hopkins, we have spent the past 25 years studying such conditions. Transgender individuals are not bad people but often have serious conflicts and issues that are not a result of society but due to internal psychological conflicts. They need treatment as well as acceptance. I recognize that this is not a popular stance but in the long run will save much suffering by these individuals.”

Well, I have serious concerns about Dr. Wise’s comments, which, at most could very well result in an injection of considerable suffering for transgender people and, at least, continues the tired mythological and stigmatizing belief that transgender is just another way to say “we’re crazy.” Those who read his comments, made by a man of obvious standing and influence, may seize upon his “diagnostic” opinion about “gender dysphoria” and use it as another reason to fear transgender people as potentially or completely unstable. This could worsen the already serious issues encountered by transgender people in areas such as employment and housing, in receiving adequate medical care and health insurance coverage, or in numerous other areas that mainstream society enjoys.

Although Dr. Wise has worked for years studying individuals who have significant problems with “self identity,” the idea that transgender is a psychiatric disorder that exclusively involves “internal psychological conflicts” seems quite interesting to me. Dr Wise states that there is “lack of data” establishing homosexuality as a psychiatric disorder. Does this mean that there is data that transgender is a psychiatric disorder? After 25 years of study, there must be a vast body of information to support his assertion. If so, where is it?

There also seems to be little scientific curiosity or motivation to discover any physiological components associated with transgender. Yet studies that have been conducted over the years have often shown a physical component to emotional disorders, whether they are neurotic or psychotic in nature. As a result, most, if not all emotional disorders, are remediable to forms of medicine that are designed to relieve the symptoms presented, thus allowing the person to regain control and proceed with insight that leads to resolution of the problem(s). For example, if a patient is suffering from an anxiety disorder, a medicine can be administered, such as Valium, to relieve the physical symptoms while talk therapy continues.

Having no apparent motivation to understand the physiological components of transgender means that there are no medicines identified that would impact the specific “symptoms” of transgender. Anti-anxiety medicine will not work. Anti-depression medicines will not work. Anti-psychotic medicines will not work. Even electro-shock therapy will not work. In fact, there is no medicine to help a person relinquish the symptoms of a perceived “psychiatric disorder” defined by an unhappiness with a culturally designated sex identity, that is often accompanied by a “delusion” of wanting to be the other sex and gender.

However, counseling can be an important adjunct to help support the transgender person in navigating the stormy seas of cultural ignorance. What seems interesting is that the counselor will, at the request of the “patient,” write a letter to the person’s physician approving the administration of opposite sex hormones. Upon receipt of the letter, the physician will do so. Later in time, another letter might be written to a qualified surgeon to confirm that the person is appropriate for “reassignment surgery.” Upon receipt of the letter, the surgeon will do the surgery. This would appear to be antithetical to the idea stated by Dr.Wise, that “gender dysphoria” is specifically an internal psychiatric disorder. Indeed, these actions might appear to be symptomatic of the counselor and the medical professionals being drawn into the “delusion” of the patient!

But, of course, that is not the case. It is a widely accepted belief among most in the professions that although there are physical elements in transgender, there is not, as yet, a precise understanding of the impact of these elements at this time. It is agreed, however, that it is absolutely crucial to provide transgender people with competent assistance in issues of adjustment in the transitioning process, including supportive counseling, advocacy, resource referrals, and so on. Counseling almost always focuses on issues associated with being transgender, not about the physical reality of transgender per se, which appears to be in-born and immutable.

There have been recent developments in research that provide important new and challenging insights concerning everyone, including transgender individuals. Ground breaking research studies reported in journals and the popular press within the past decade include work done with the BSTc in the hypothalamus at the Institute for Brain Research in Amsterdam, Netherlands by Dr. Zhou et al, and also by Dr. Wilson Chung et al in the USA. Another study, involving intersexed persons, reported by Dr Reiner et al of Johns Hopkins Hospital, has added significantly to our understanding of the origin of sex identity. These studies have substantially challenged the traditional thinking about sex identity designation, and present the thesis that sex identity is an inborn physical reality that originates in the brain. The genitals, which have been the focus of “biological” sex identity designation for millennia, appear to be only incidental to sex identity, whether functional or not.

The genitals appear to have three important functions. First is the elimination of waste from the body. Second is the production of sex hormones that promote the physical characteristics of that particular hormone. And third, the genitals facilitate procreation. The sex identity designation, so often done by looking at the genitals, is a socially ascribed action, a mythical power given to the genitals that, as we now know, is a catastrophic error, especially in the instances of transgender or intersex infants.

We must challenge the current perception that the genitals define sex identity. We must also challenge the view that the transgender person is psychiatrically disturbed. We must begin to understand and integrate the physical data from research. We must understand that transgender is an inborn physical incongruity where the origination of sex identity, located in the brain, is not matched by the genitals. This shifting of the paradigm is required of those in the counseling and medical professions, the insurance and allied industries, the systems of government and law, and everyone in the culture as well.

The dysphoria that Dr. Wise describes is, in all probability, not the result of “internal psychological conflicts” at all. It is most probably a product of an incongruity in physical structure that has been missed in the past due to a lack of understanding about the true origination of sex identity, which is located in the brain, and not the genitals. The mistake in sex identity designation at birth, followed by an intensive socialization in the wrong gender role, results in serious stress for the transgender person—an external stress induced by the culture that will challenge the very core of the transgender person, as will be explained later in this paper.

Background Context

It is important to distinguish the terms we use. Transgender is not a sexual minority. It describes issues with sex identity. Sex identity is also distinguished from the sexual minorities in that identity describes, “Who am I?”(girl, boy, or whatever) and sexual minorities describe a sexual orientation toward another person, as in “who do I want to have a relationship with?” All too often, sex identity issues, as seen in transgender, have been included with the orientation groups, i.e. gay, lesbian, bisexual, and heterosexual. This is not only confusing but it is entirely incorrect.
Other terms that are often confused are “sex” and “gender.” Sex is the biological presentation of male, female, or other. The biological includes the brain, genetics, and hormones, along with the genitals. Gender is a culturally developed term that defines norms for the behavior of males and of females—a set of rules I call “cultural clothes.”
I do agree with Dr. Wise that transgender people are not bad people. Actually, we are very good people. We are, in the main, above average in intelligence. We are mentally strong, creative, sensitive, reality based, and competent people. It is also important to understand that, like any other group of people, the transgender community includes a very diverse, broad continuum of personalities, lifestyles, sexual orientations, and gender expressions.

Schools of Thinking about Transgender

Much of the transgender journey is a private internal struggle. Thus, each transgender person has his or her own unique way of explaining the ‘why’ of his or her situation. When they connect with other transgender persons and share their explanations about “the journey,” there are often similarities and differences in their understanding of the process. Much is subjective and, for those who have researched, there are “factual” positions on the topic. Often there are heated discussions over who is more correct. Over time transgender people gravitate to others who, like themselves, believe in the same transgender process, resulting in the development of several “schools” of thinking. Those professionals and allies who desire to assist the transgender people have also developed their own views adding other “schools” of thought. All the “schools” have made contributions to our understanding of transgender, and all “schools” have their passionate devotees.

First, there is the school of thought that says a person has the right to express whatever gender, or claim whatever sex identity she or he desires, including androgyny. This is what I call the “naturalist school.” The generally held view expressed by this school is that there is no need to prove anything or to explain the “why” of transgender. It just is and that is sufficient, period. transgender persons have endured a multitude of negative experiences with the whole range of professionals and the systems in which they work. As a result, proponents of the “naturalist” school are suspicious of professionals in general. There is, then, a tendency to suspect professional people, often including transgender professionals, and to dismiss professional views as arrogant, assumptive, trite, and unnecessary.

The “naturalist school” encompasses a significant number of transgender people, including those who were our early “pioneers.” They are the true “sheroes” and “heroes” that continue to exert a powerful influence in the transgender community. There are also many advocates for social and legal justice who embrace this school of thought, as it espouses the human right of self-determination.

Secondly, there is an “anthropological-historical” school. This school, which is very supportive of the naturalist school, outlines the presence of transgender throughout history. The fact of historical presence further legitimizes the transgender community by revealing its roots.

Also in this school are those who document current trends and events that occur in the present time. Sobering is the website “Remembering Our Dead,” by Gwen Smith, who documents those of the transgender community who have been killed simply because they were transgender.

Then, there is a “psychiatric school.” Proponents of this school believe that “gender dysphoria” is present in the so-called ‘transgender’ persons. The “patient” reportedly suffers from an inner psychological unhappiness involving their biological sex identity designation, which, for some curious psychological reason, is unacceptable to that “patient.” The “dysphoric patient” is viewed as seriously neurotic, or perhaps even more seriously impaired, reflective of major diagnoses like, schizophrenia, dissociative personality disorder, bi-polar disorder, and so on. Also in this school are those who feel that the male to female “dysphoric patient” suffers from a condition described as “autogynephlia.” To me, that designation seems evidence of, “when psychoanalysis goes bad!” Others see transgender as a format of homosexuality, which is, of course, an obvious misunderstanding of the difference between identity issues and sexual orientation.

The psychiatric school sees the transgender person as a patient, i.e. one who is disturbed (ill). Therefore, an appropriate “professional distance” from the “patient” must be maintained. This attitude, of course, inhibits meaningful collaboration between the naturalist and psychiatric “schools,” and provokes the flow of negative transference and counter-transference phenomena, so evident in the “naturalist” school toward the professional community and vice-versa.

Another “school” embraces the “hard science” of medicine. In medicine, the transgender person is often viewed as a congenital anomaly, which occurs during the gestation process. After the proper clearance from the “patient’s” counselor, the physician develops baseline data collection, followed by careful administration of hormones, if the “patient” is desirous of taking them.

Unfortunately, there is nothing to compel a physician to spend much time understanding transgender. Information and training in “transgender medicine,” if there is such a thing, is not readily available, unless provided by the “patient.” To many physicians, treatment given to a transgender person seems like sailing in uncharted waters. Many physicians refuse to provide care to transgender people because of perceived risks. Others feel compassion and try to be helpful. Still others accept transgender persons into their practice, yet seem unconcerned about the quality of care provided to them. Perhaps care is referred to the doctor’s Nurse or Physician’s Assistant, or ARNP, without much in the way of preparation. Some of these people turn out to be helpful, but the majority seems to view the transgender patient as an ‘organism from outer space.’

When a physician does accept a transgender person for treatment, there seems little, if any, sensitivity training provided to the office staff and nurses. All too often, the attitudes and behaviors of office staff and nurses destroy the “patient’s” motivation to trust the health care professionals or the process.

Another curious phenomenon that is evident, especially in the medical world, is an attitude of sophistication that is reflected in a calm exterior when a transgender person appears for care. There seems an aura of, ‘we treat everyone the same and are completely objective.’ The use of an “objective professionalism” most likely will be perceived by the transgender person as a defensive cover for a good deal of anxiety that lies within. All this foolishness is exposed when one looks at the quality of treatment, which all too often reveals a betrayal. It might be refreshing for the doctor to be open and honest when treating a transgender patient. The doctor might see the transgender patient as part of the care team—a valuable member indeed!

But with the increased volume of information, and the presence of transgender people in the world today, many professionals feel less fearful and more interested in helping. I thankfully acknowledge the array of professionals from many different disciplines who are crucial to the emotional, legal, and physical health and welfare of transgender people. As more and more transgender persons identify themselves, the diverse bio-psycho-social needs of the transgender community will require more and more supportive professional resources to assist them.

Next, there is the important arena of the “Research School.” There are two different parts to this school. The first part is focused upon understanding the “why” of transgender through physical research. The prevalence of physical research on transgender is very limited at present, perhaps because there is little financial or cultural support for such work. Still, I believe that the physical research findings about the BSTc in the hypothalamus have been ground breaking and crucial to our development of a clearer understanding of the physical/biological etiology of sex identity.

The second part, social research, looks at the physical health, emotional well-being, and social issues that impact the transgender community. Most of the work has been done by activists in specific cities and states, who use the data to show the need to protect transgender persons by including ‘gender identity or expression’ in anti-discrimination laws.

As yet, there continues to be no definitive understanding of the incidence or prevalence of transgender. There are many guesses, but no one knows the numbers. In most census data collections, transgender is not mentioned, as if we do not exist. If we knew more about the incidence and prevalence of transgender, we could develop a clearer understanding of the issues, needs, and the many positive contributions made by the transgender community.

Finally, at least finally at this time, there is the “Legal/Political School.” Proponents of this “school” borrow heavily from the psychiatric and hard sciences schools in their work as legal advocates or policy makers. However, this school is vulnerable to the strong influences of social customs and deeply held values and ideals that often reflect entrenched mythical beliefs of culture. As we know, cultural traditions change very slowly, especially in the integration of new knowledge gained from research. This vulnerability can result in maintaining the status quo, which, for the transgender population means serious delays in obtaining social justice. Another issue, which often influences decisions, is the practice of citing past court decisions, reflective of old myths and outdated “facts.” This only perpetuates the myths and misunderstandings about transgender.

Yet the “legal and political school” holds great promise. As lawyers and policy makers become educated about transgender, they are recognizing the urgent need to protect and defend transgender persons’ civil rights, as well as to advocate for their acceptance in the mainstream of culture.

Even though the field of transgender study is relatively new, the “schools” have somehow maintained an independent status from one another that creates a sense of “turf” separateness. As they are not compelled to work together, any attempt to identify an “eclectic school”(my preference) or develop communication strategies that link the “schools,” would probably encounter significant barriers.

As a “resolved dysphoric” and a surgically “confirmed” female Master’s level clinical social worker with over thirty years experience, I learned long ago that each of us is a bio-psycho-social entity. I have become acquainted with the various “schools” of thought on transgender, and reviewed much of the vast amount of wonderful material associated with each school.

There are good things in each of the “schools.” I agree with the “naturalists,” who feel that there is an implicit human right to be oneself. After looking at the findings from physical research, and from understanding my own experience and the experiences of many in the transgender community, I do not agree with the “psychiatric school” position that transgender is a psychiatric problem. I do not believe that there is a “gender dysphoria” evident in transgender. I do believe that there are strong cultural components that complicate and exacerbate the transgender person’s struggle to define their true sex identity as reflected in the brain. I believe that the response to transgender by so many in our culture reveals a cultural dysphoria. Culture is unhappy with, and cannot accept the reality of transgender. I agree with the “hard sciences school,” in that there must be a significant biological component that strongly contributes to the human motivation to express another gender role or sex identity, either on a part time or on a full time basis. Although I may be making premature assumptions from the studies done in Amsterdam and elsewhere, I believe that the ongoing work in the BSTc of the brain will eventually prove to be an important factor that defines the origin of everyone’s sex identity.

As I mentioned earlier, there are many good people doing a lot of good things to serve the transgender community. I do not believe that there is an evil plot against transgender people. I do believe that we are wrongly perceived by many in our culture as a foolish, unwholesome, unstable, and worthless minority. These negative descriptors get further associated with all sorts of other negative images. In time, myths develop that pose a significant barrier to any legitimate effort at educating the public about the true etiology of transgender, or in obtaining social justice and equality for transgender people.

Fortunately, tireless efforts by many including transgender individuals, professionals from many disciplines, as well as advocates from human rights organizations, have made a significant impact in the education of everyone about the truth of transgender. Little by little facts are beginning to replace the fear and the many false and destructive myths about us. Yet I still continue to wonder why the archaic and mythological thinking about transgender is so amazingly persistent in professional circles, as well as in the general population, despite important research developments that have been reported. Perhaps it is very difficult to let go of long held belief systems, despite strong physical evidence to the contrary.

The situation with transgender people is not so simple and easy to dismiss as Dr.Wise has stated, “not bad people who often have serious psychological issues.” With ongoing study, my own experience, and listening to many anecdotal accounts from those in the transgender community, I have developed an explanation that, I trust, reflects a more accurate picture of reality, and embraces elements of several of the schools of thought outlined above.

A Formulation Concerning Transgender

First of all, “transgender” is an inclusive, umbrella term under which a continuum of behavior is revealed. At one end of the continuum are the most secretive (“closeted”) transgender persons. As one moves toward the center of the continuum line, behaviors include progressively more and more open expressions of opposite gender or gender-neutral behavior. Moving along the continuum toward the other end are transgenderists, who live in the opposite gender role. And finally, at the other end of the continuum are the transsexuals, many of who obtain corrective genital surgical procedures to confirm their true sex identity. Most transgender persons fall near the center of the continuum line.

I think that what we see in transgender is related in some way to the intersex community. But in the instance of transgender, the person is born with completely formed genitals. Because the new and important research has not been incorporated by the medical community to date, an archaic protocol continues to be used, in which the designation of a “biological” sex identity is made by looking at the external genitals of the infant. Although the genitals should reflect the brain sex identity, in transgender there is no match. Thus, a catastrophic error in sex identity designation occurs in the case of a transgender baby. This error starts a chain of events that are outside the control of the child. Events like naming the child, completing legal papers that include the error in sex identity designation, primary socialization, and the continual reinforcement of wrong gender role expectations is carried out by a culture that is unaware of the primordial error.

Equally devastating is when the genitals are ambiguous, as is often seen in an intersexed infant. Surgery is all too often the solution to a perceived medical or social “emergency.” In these cases, a transgender person is all too often surgically created! Yet the practice of surgical assignment of sex identity upon intersex infants continues to be done by rigid, unsophisticated professionals. Surgery on helpless infants seems to me to be a serious violation of their rights. In my opinion, it constitutes a criminal surgical assault upon the helpless infant.

In addition to the work with the hypothalamus, which continues in Amsterdam and elsewhere, a study done at Johns Hopkins Hospital by Dr. Reiner et al on intersexed infants with incomplete external genitals, has demonstrated that the brain is the primary site in determining a person’s true sex identity. As Dr. Reiner stated:

“The sense of who one is (boy or girl) is a crucial existential aspect of humanity. It is powerful and inborn….. The most important sex organ is the brain.” (Johns Hopkins Hospital Magazine, September 2000).

This finding strongly reinforced the conclusions by many in the scientific community concerning the famous “twin study,” where one of the infants, David Reimer, was injured in a botched circumcision. Clearly, Dr Milton Diamond did science a great service by discovering that John Money, PhD was in error in his assumptions that genital manipulation could be done without the child ever knowing the difference. Despite all the surgical technology used to impose a female sex identity upon David Reimer’s genital region, all the hormones administered, and all the psychosocial strategy with the family designed to reinforce the surgical sex identity assignment, he refused live as a girl. His true sex identity as a male, originating in his brain, would not be denied.

Overview of Culturally Induced Stress (Internal and External)*

When the transgender community is viewed as a whole, a pattern of stages emerge that reflect an intense struggle which every transgender person must navigate in order to “be.” As the person moves from one developmental stage to another, the awareness of a need to express the “other” sex identity intensifies. While trying to “be” what culture assigned him/her to be, the transgender person must also privately address the relentless inner struggle to understand their true sex identity as reflected in their brain. This struggle often results in outward signs of a culturally induced stress that can take the form of mild to moderate depression, isolation, anxiety, low self-esteem, and other stress related behaviors.

The inner struggle to understand their brain sex identity, versus the culture’s designation of a sex identity via the genitals, will never cease until the transgender person resolves the struggle by getting information, finding and joining supportive groups, going into counseling, or by a courageous exploration on their own. Once the true sex identity is understood and accepted, a “coming out” process begins.

The external struggle to achieve acceptance by the culture is a scary one indeed. Ideally, the culture should recognize the error made in the sex identity designation, and then assist the transgender person in the transition process to confirm their true sex identity as expressed in the brain. But the rigidity of socialization is enforced by many persons of influence in the culture, such as those in positions of power and authority, like physicians, psychologists, law makers, the courts, law enforcement, the church, employers, and others, who continue to insist on forcing the transgender person to live with the sex identity designation mistake that was made at birth, regardless of the human suffering it induces.

Even the media participates in this rigidity, referring to transgender persons with the wrong pronoun or using the person’s former name. After speaking in Nyack, NY, a newspaper reported me as a “former man!” There are countless other examples, including the use of the birth given name in referring to transgender persons. For example, Eddie “Gwen”Araujo instead of just Gwen Araujo.

The stress phenomena experienced by the transgender person is what I call “Culturally Induced Stress”(CIS)*. There is an “internal CIS” component, and an “external CIS” component.

Internal CIS

The “ CIS” component involves the transgender person’s dealing with the struggle that exists between the constantly reinforced culturally designated, genitally based “sex identity,” versus the opposite and true biological sex identity that is physically present and expressed in the brain.

The inner struggle may be more clearly understood by referring to the process of homeostasis (physical balance) as described by Walter B. Cannon, MD, ScD, in his book entitled The Wisdom of the Body, (Second Edition, WW Norton, New York, 1939).

Simply explained, homeostasis can be understood by the following example. If you had a headache, you would be experiencing an imbalance, a lack of homeostasis. The pain you feel would be a signal for you to do something to eliminate the discomfort. Perhaps you would take an aspirin or enjoy a brief rest, or do whatever you do to find relief. Soon the pain is gone and you feel like yourself again—you have achieved a physical balance called homeostasis.

Most people are born with genitals that match the brain sex identity. But in the instance of transgender, an incongruity is present. The genitals do not match the brain sex identity. But to be in physical balance, to achieve homeostasis, the incongruity must be resolved.

The process of homeostasis, then, includes the person’s internal struggle to understand and accept that the culture’s designated sex identity that was imposed upon him or her at birth was an error, and then recognize and accept that the true biological sex identity located in the brain is what defines his or her true sex identity. This process, in the final analysis, is truly “mind over culture.”

The process of working through the internal component of CIS to achieve homeostasis, is exceedingly difficult. After all, there are observable, “normal” genitalia. Everyone says she is a girl, or, he is a boy. Yet, there is the continuous feeling that something is wrong-- that things are slightly out of focus. For most transgender persons, the awareness of the incongruity of their sex identity begins in early childhood as a preconscious awareness, which is usually not fully understood or articulated by the child.

The ever-present internal struggle to understand their true sex identity is continuously frustrated by the relentless external efforts to reinforce the primary cultural socialization. There is a strong prohibition (“taboo”) on any conversation that questions the sex identity designation made by the doctor, let alone the “preposterous” idea of “changing” one’s sex. These rigid external pressures constitute a culturally induced stress that inhibits the transgender person’s freedom to outwardly explore and understand his or her true sex identity. transgender persons, like everyone else, have learned that there is retribution for openly embracing and expressing their true sex identity, which is at odds with the initial designation made by the culture.

It should not be surprising that the transgender person will most often choose to struggle with their sex identity incongruity alone. It is much safer, and avoids the likelihood of punishments from others who would not understand. Like the ‘skeleton in the closet,’ the struggle is almost always regarded as a private and carefully guarded “secret”—a “secret” that carries with it much suppressed fear, guilt, shame, loneliness, and feelings of futility--that there is no way to resolve the problem.

Most transgender people make an attempt at conforming to the culturally designated sex identity as a way to survive. But this approach is rarely satisfactory or successful, even with culture’s positive reinforcement. As the years go by, the transgender person becomes more and more aware of the need to resolve his or her sex identity incongruity. In Wilson Chung’s study reported in 2002, we learned that the BSTc matures in adulthood. Thus, like turning up the volume on a radio, the need to understand and achieve homeostasis increasingly intensifies through the years, forcing the person to pay more and more attention to the issue of their sex identity incongruity. Indeed, the internal CIS struggle will never end until homeostasis, is somehow achieved.

The details of the internal struggle are individualized for each person, their environment, experiences, perceptions, and so on. But there are many common guideposts in the journey. These common points are presented in the “The Process of Becoming—A General Overview of the Transgender Journey” section at the end of this paper. The range of coping strategies can go from emotional ups and downs, to acting out, to substance abuse, to just about anything else, including an outwardly “normal” adjustment.

The relentless internal struggle will eventually lead the person to information, counseling, support groups, private or public cross-dressing or cross-living, or a combination of these resources and activities. Tragically, many transgender persons fall into lives of despair in the margins of culture, often experiencing physical abuse, emotional abuse, and exploitation. For some who can no longer go on--- there is suicide.

For the survivors who overcame their fears of retribution, the achievement of homeostasis in such a basic, cornerstone reality of sex identity is very empowering. The relief in resolving the intensive and painful internal struggle brings an emotionally moving fulfillment that is described in many ways, such as: ‘for the first time in my life I felt a peaceful feeling inside,’ or ‘I felt a reduction of tension,’ or ‘at last I felt a comfortable feeling inside myself,’ or ‘at last I am me,’ and so on. There is a sense of euphoria, as occurs whenever anyone achieves an incredibly difficult goal. Indeed, the transgender person has achieved an incredibly difficult goal in rising above culture’s error in sex identity designation and courageously proclaiming his or her own true sex identity!

In the study by Dr. Reiner et al with intersexed infants described earlier, a discussion of Kayla, age seven, who had been born without a penis and was subsequently surgically made into a female, is a powerful example:

[After thorough evaluation, Dr. Reiner met with the parents. When he met with Kayla to tell him that “she” was in reality a boy], “his eyes opened as wide as eyes could open,” recalls Dr. Reiner. “He climbed into my lap and wrapped his arms around me and stayed like that.” As Dr. Reiner cradled the child in his arms, he felt as though an enormous weight had been lifted, and he himself was overcome with emotion. The child remained in his arms without moving for half an hour.” (Johns Hopkins Hospital Magazine, September 2000).

Those who were born with a congruent sex identity, where the brain sex identity and genitals match, have a difficult time understanding what it is like to realize, at last, what one’s true sex identity really is. To them, all this activity seems foolish and absurd. After all, they have always known their sex identity without having to put forth any effort whatsoever. Yet it is important to understand that for the transgender person, there is an incredibly complex struggle to overcome strong cultural forces to reach “square one.”

External CIS

Once homeostasis is achieved and the internal CIS is overcome, the outward expression of that resolution takes a multitude of formats, as seen in a continuum of gender manifestations and behaviors that can include cross-dressing, cross-living, a plethora of other creative expressions, or complete transitioning that surgically confirms the person’s true sex identity. It is incorrect to view genital surgery as a “sex change,” or “sex reassignment,” or “gender reassignment.” These terms reflect the dysphoria of culture. In truth, the genital surgery confirms the true sex identity of the person. It is confirmation surgery (CS).

Unfortunately, the transgender person’s joy-filled proclamation in resolving his or her true sex identity struggle, is all to often met by a world that most likely will doubt it, and will probably label the transgender person as psychiatrically disturbed. This is as catastrophic as the wrong sex identity designated at birth, and initiates what I call the “external” component of Culturally Induced Stress”(external CIS).

Initially, there are various and seemingly relentless activities carried out by family, friends, and the culture in general, which seem to be a “warning” designed to force the transgender person to conform to the genitally based sex identity designation. Implicit in these “warnings” is the threat of retribution-- that the culture will use punishment, including emotional and physical abuse, neglect, exploitation, or the outright rejection of family and friends. Should the behavior reflective of one’s true sex identity continue, more serious punishments may be undertaken. Cultural marginalization, and economic impoverishment are extreme forms of rejection experienced by many transgender persons.

The punishments that are designed to force conformity to cultural expectations, act as a self-fulfilling prophecy. Poverty, brought about by the removal of economic opportunities from the transgender person, all too often results in a lifestyle of high risk behaviors that place the transgender person in situations where many serious problems will develop, including stress related problems and health issues. These unfortunate outcomes are then weaved into false cultural myths that look at the status of transgender persons and judge them as unworthy, even though it was the dysphoric culture that trashed the transgender persons in the first place!

All too often, the punishments are so blatant and cruel that many transgender people cave in, succumb to depression, and commit suicide. Uncorroborated estimates are as high as 25% of the transgender population, who successfully kill themselves.

There also seems to be a shockingly perverse and implicit “approval” in the culture that a few mindless people interpret as a permission to do whatever they wish to do to the transgender person. Perhaps they believe that severe punishments will serve as an example of what would happen to others who would dare to cross the culture’s rigid binary, genitally focused, sex identity designation lines. Hate crimes are all too frequent. According to statistics compiled by National Transgender Advocacy Coalition and Gwen Smith, there has been a hate filled murder of a transgender person every single month since 1990.

Those that survive the social wounding inherent in external CIS must face continuous instances of discrimination, public humiliation, and attempts at cultural marginalization. This relentless level of culturally dysphoric behavior sends a message to the transgender person that he or she is not fit to be in the cultural mainstream. For many, the only alternative becomes a marginal lifestyle that is very different from the world that the transgender person knew before he or she “came out.”

The Role of Counseling

The internal stress experienced from having to deal with the sex identity incongruity is indeed monumental. That, combined with the constant external cultural pressures to conform to a sex identity and gender role expectations that are genitally focused, accompanied by the guilt and a fear of retribution by others, and there will ultimately be various stress related symptoms exhibited by the transgender person,
ranging from acting out, to withdrawal, and everything in between. These symptoms, along with various expressions of unhappiness, anxiety, or other stress related symptoms (CIS), will often be expressed at intake. Sex identity issues may be verbalized, but due to fears of retribution, the transgender person will need time to feel safe with the therapist in order to feel comfortable enough to “come out.”

It is crucial that the counselor understands the physical origins of transgender and be comfortable in working with a transgender person. It is not a psychiatric problem. It is a physical issue that has placed the transgender person at the mercy of a culture that not only refuses to understand, but one that ostracizes and punishes the transgender person relentlessly. Individual supportive approaches and later adding group sessions with other transgender persons, appear to be the state of the art in counseling, and generally work well.

Many counselors follow the Harry Benjamin International Gender Dysphoria Association’s Standards of Care. The standards are helpful but must never be used as a rigid procedure or used to prolong counseling to satisfy the counselor’s need for power as a gatekeeper, or to the benefit of the counselor’s income. The Standards of Care have always been accepted as guidelines for working with transgender persons. Rigid adherence to these standards usually reflects a counselor who is not competent in working with transgender persons.

In some instances there may be other diagnostic conditions concurrent with, but separate from, the presence of transgender related CIS, which can make the treatment process more complex.

But whatever the presenting problem(s) described, the appropriate tasks for the counselor in these cases include: 1. defining the problems, including the history of these problems; 2. taking a detailed history of the person; 3. the understanding and exploration of the current bio-psycho-social issues experienced by the person; 4. assisting in the management of stress related issues; and, if applicable, 5. the exploration and confirmation of the true sex identity as reflected in the brain. Basic counseling skills are necessary, as always. A good counselor knows that he or she must develop rapport that earns the right to respectfully discuss the information shared by the person.

Along with the ongoing assessment, diagnostic, and intervention work, there are a number of other important roles that the counselor will need to assume in working with transgender persons. These include, but are not limited to: family counselor, civil rights advocate, and resource mentor.

The fact of transgender is not an issue for employing so called “reparative therapy” strategies that attempt to force the person to accept the gender roles of the “culturally induced” sex identity designation made at birth. If attempted, “reparative strategies” will succeed only briefly, most likely as a way for the person to show compliance with the counselor. But over time, the relentless sex identity incongruity struggle will reassert itself. The person will then become aware that he or she has been seriously wounded by the process of “reparative therapy,” and will undoubtedly feel betrayed by the counselor. Confidence in the counselor, as well as the process of helping and support will be seriously compromised, if not destroyed. Tragically, this cruel abuse of trust by the counselor quite often results in the person stopping counseling altogether. Many conclude that the process is useless, thus rejecting a crucial support system that can assist them in the successful working through of the many issues related to the transgender journey.

The primacy of the brain in determining sex identity cannot be overridden or ignored. It must be respected as the true sex identity of the person.

In Conclusion:

It is a profound human tragedy that the transgender person is consistently viewed as the dysphoric one--the one with the problem. The research seems clear that transgender is a physical incongruity of sex identity where the brain, now seen as the origination of sex identity, is not matched by the genitals. This biological fact continues to be ignored, resulting in an the ongoing error of sex identity designation that is genitally based. The primordial error is then compounded by cultural socialization that relentlessly pressures the transgender person to conform to gender roles that are not congruent to the person’s true sex identity. The induction of stress, that I call CIS, needs to be identified as a predominant exacerbating factor in the internal and external suffering of transgender persons. The stark reality is that the culture itself commits a serious crime against the true and courageous spirit of the transgender person, who is only trying to correct a tragic mistake of a wrong birth sex identity designation, and a wrong gender socialization. In the final analysis, it is the culture that suffers from dysphoria, in that it refuses to understand and accept the transgender person. It seems to me, then, that the culture must stop the wounding of transgender persons, resolve their dysphoria, and reach out to assist them medically, legally, in housing and employment, and in the process of public policy making. Along with the cultural institutions, everyone in the culture needs to reach out with acceptance and compassion toward transgender people. Then, a tragic mistake would be corrected.

The Process of Becoming—A General Overview of the Transgender Journey

Stage One: In the Beginning, there was a Catastrophic Mistake

Infant given biological sex identity designation by observation of the external genitals. Stereotypical gender specific reactions by medical staff and parents occurs immediately.

Infant with ambiguous genitalia (intersexed) may be surgically assigned a sex identity.

Birth records are completed including the sex identity designation and the name of the child.

Stage Two: Primary Socialization

Parents and family celebrate the child’s arrival

Formal announcements are made in the newspaper and elsewhere.

Intense Socialization in gender role expectations begins immediately.

Stage Three: The “Awakening”*----the sex identity quandary is realized---

The child awakens to a feeling of being “different” or of not “feeling comfortable” with expectations. (*I thank Dr. Randi Ettner for this term)

Stage Four: The Internal Struggle to Understand (Internal CIS)

*This stage will take as long as the person needs in order to identify and resolve the sex identity incongruity. For some, it will take several years. For others, several decades. Common elements seen throughout the internal CIS struggle include:

Fascination with the opposite sex and gender roles.

Cross-dress openly or in secret discreet settings.

Continuous struggle with shame, guilt, fear and low self-esteem.

The purge/purchase phenomenon.

Some developmental issues that may occur include:

The child begins to struggle with the need to conform to outside expectations versus the need to explore and understand the internal true sex identity.

As the child interacts with others inside and outside the home, there are often experiences of being a victim of bullying and other types of social wounding by others that exacerbates an already low self-esteem.

Use of magical thinking and fantasy in daydreaming and play to “experience” the gender role that is congruent to the true sex identity.

The important process of homeostasis.

Awareness of the social consequences of the desire to “change” results in suppression of desire, fear, guilt, shame, diminished self-esteem, and feelings of futility.

Decision to:

Carry on as the world has assigned her/him to be, OR

Demand assistance in sex/gender “change,” OR

Act out the inner conflict by:

Anti-social behavior,
Exhibiting emotional disturbance,
Developing addictions to escape the stress,
Other (e.g. become withdrawn, chronically depressed, or compliant in a passive aggressive way).

Continued relentless internal struggle compels the person to seek:

Information, AND/OR
Connection with the “community,” AND/OR
Psychotherapy, OR
An escape from the pain through drug/alcohol abuse, a “drop out” marginal lifestyle, acting out behavior, which has social consequences, or, tragically through suicide.

Stage Five: The Victory---The conflict is resolved within and homeostasis (balance) is achieved!

Eventual resolution of the sex identity incongruity and acceptance of one’s true sex identity brings profound inner peace and euphoric happiness.

Stage Six: “Coming Out*”---The formal Courageous fear-filled Step and the experience of External CIS

*Extremely stressful because, like everyone else, the primary internalized socialization that transgender people have learned placed a strong prohibition on “sex change.” Yet, the fear of punishment is overruled by the power of the need for homeostasis, which relentlessly compels the transgender person to be their genuine self—to express their true sex identity.

Who must know:

Telling family.
Telling friends.
Telling the employer and employees.
Telling others that need to know.

Responses from others to our “coming out” include:


Attempts to stay “cool” to prevent sending the transgender person into a “psychotic episode”
Supportive statements like, “Are you happy? Well. That’s all that counts!”
Seek out others to spread the word and to find comfort


Fear about what others might say (guilty by association)
Fear for the transgender person’s safety
Fear of cultural pressures to “correct” the transgender person (enforce conformity to birth assignment of sex identity
The hope that this is only a phase that will go away


Why is this person putting us through this mess!!?
Attempts at forcing conformity
Expressions of caring laced with discontentment (e.g. using the wrong pronoun)
Development of “rumors” about the transgender person
Experiencing emotional distress (e.g. depression or anxiety)
Outright rejection
Emotional and/ or physical abuse
Discrimination and hate crimes against the transgender person

Estrangement and mourning

Feeling the loss of the “other” familiar person
Becoming detached from the transgender person
Avoidance of contacts or interaction
Intimate relationships are seriously strained
Moving toward a decision about the future relationship with the transgender person


Decision to terminate the relationship or to invest in saving the relationship with the transgender person
Sharing concerns and fears with the transgender person
Beginnings of thought about the phenomenon of transgender

Need for information and support

Start to read information provided by the transgender person
Seek information from other sources such as:

legal resources
media (TV, radio, print media)

Achieving and integrating a true understanding of transgender

Achieved from integrating outside information and personal reflections
Decision to re-connect with the transgender person despite the risks of cultural attitudes and responses
Transgender is no longer an “issue”

Re-acquaintance with the “new” person

Becoming accustomed to seeing the “other” person
Valuing the transgender person

Acceptance and love

Gradual process toward meaningful acceptance
Integration of the transgender person in everyday life

Advocate---Ally or a Supportive role

Join with the transgender community to achieve the goal of being fully integrated into all aspects of the broader cultural life.

In a formal way, one may make a name change and complete changes in legal documents, such as driver’s license, birth records, social security records, etc.

Stage Seven: Living with CIS---Making a Life

Adjusting to and rising above other people’s reactions,

Overcoming the stress of cultural isolation and marginalization,

Networking within the transgender community, OR

Finding a new life in as normal a way as possible apart from the “community,” OR

Becoming an advocate, an activist, or an educator/writer

Developing a normal competency and routine in the true sex identity and gender role, whether living full time (transsexual) or part time (cross-dresser/transgenderists),

Developing new traditions in celebrating holidays, etc.

Dating and mating (what is your orientation?),

Setting goals and making a contribution or legacy for others,

Adjusting to life developmental stages, including aging gracefully,

Dealing with illnesses,

Planning one’s end of life care and burial,…and

Other…(because no list involving human beings can be exhaustive!)

*Copyright 2001 (revised 9/03) by Lisa M. Hartley, ACSW-DCSW---all rights reserved

[reprinted here with kind permission of the author]


Zhou, J.-N., Hofman, M.A., Gooren, L.J., and Swaab, D.F., A Sex Difference in the Human Brain and it’s Relation to Transsexuality, Nature Magazine, #378: pp. 68-70, November 1995.

Kruijver, Frank P.M., Zhou, J.-N., Pool, Chris W., Hofman, Michel A., Gooren, Louis J.G., and Swaab, Dick, Male to Female Transsexuals Have Female Neuron Numbers in a Limbic Nucleus, The Journal of Clinical Endocrinology and Metabolism, Vol. 85, No 5, pp. 2034-2041, 2000.

Hendricks, Melissa, Into the Hands of Babes, Johns Hopkins Magazine, September 2000.

Chung, Wilson C.J, DeVries, Geert J., and Swaab, Dick F., Sexual Differentiation of the Bed Nucleus of the Stria Terminalis in Humans May Extend into Adulthood, The Journal of Neuroscience, February 1, 2002, 22,(3): 1027-1033.

Cannon, Walter B. The Wisdom of the Body, Second Edition, WW Norton, New York, 1939.

Wilchins, Riki Anne, et al, First National Survey of Transgender Violence, April 1997, GenderPac, 332 Bleecker Street, #K-86, New York, NY 10014-2980.

Ettner, Randi, Confessions of a Gender Defender: A Psychologists Reflections on Life Among the transgender, Chicago, Spectrum Press, 1996.


--Colapinto, John, As Nature Made Him: The Boy Who was Raised as a Girl, HarperCollins publishing, 2000.

--Kotula, Dean, “A Conversation with Dr. Milton Diamond,” an internet document found at, created April 26, 2003, Revised May 3, 2003, Copyright 1999-2003, prepared by Craig Andrews for FTM Australia, all rights reserved.

--The Harry Benjamin International Gender Dysphoria Association, Inc., Standards of Care for Gender Identity Disorders, Sixth Version, February 2001.

--Moir, Ann and Jessel, David, Brain Sex: The Real Difference Between Men and Women, New York, Dell Publishing, 1991.

--Ettner, Randi, Gender Loving Care: A Guide to Counseling Gender Variant Clients, New York, WW Norton & Company, 1999.

--Bockting, W. and Coleman, E. editors, Gender Dysphoria: Interdisciplinary Approaches in Clinical Management, New York, Haworth Press, 1993.

--Denny, D., Gender Dysphoria: A Guide to Research, New York, Garland Publishing, 1994.

--Walworth, Janice, Transsexual Workers: An Employer’s Guide, Center for Gender Sanity, P.O. Box 10616, Westchester, California, 97296-0616, 1998.

--Feinberg, Leslie, Transgender Warriors, Boston, Beacon Press, 1996. 20.

--Bornstein, Kate, Gender Outlaw: On Men, Women and the Rest of Us, New York, Vintage Books, 1994.

--Bornstein, Kate, My Gender Workbook, New York, Routledge Press, 1998.

--Boenke, Mary, Our Trans Children, Washington, DC, PFLAG, 1998 (Booklet).

--Boenke, Mary, Transforming Our Families: Real Stories About transgender Loved Ones, Imperial Beach, California, Walter Trook Publishing, 1999.

--Stuart, Kim Elizabeth The Uninvited Dilemma, Metamorphous Press, P.O. Box 10616, Portland, Oregon, 97296-0616, 1991.

--Benjamin, Harry, The Transsexual Phenomenon, New York, Julian Press, 1966. Last reprinted in 1989 by the Outreach Institute and Renaissance. Can also be reviewed on the internet in the International Journal of Transgenderism, electronic books published by Symposion.

--Sullivan, Louis, From Female to Male, The Life of Jack Bee Garland, Alyson Publications, Inc. 1990.

--Brown, Mildred and Rounsley, Chloe Ann, True Selves: Understanding Transsexualism, San Francisco, Jossey-Bass Publishers, 1996.

--Kirk, Sheila and Martine Aliana Rothblatt, Medical, Legal and Workplace Issues for the Transsexual, Together Lifeworks, P.O. Box 93, Watertown, MA, 02272-0093, 1995.

--Devor, Holly, FTM: Female to Male Transsexuals in Society, Indiana University Press, 1997.

--Evelyn, Just, “Mom I Need To Be A Girl”, Imperial Beach, California, Walter Trook Publishing, 1998.

--Bohjalian, Chris, Trans-Sister Radio, (A novel), New York, Harmony Books, 2000.

--Morris, Jan Conundrum, New York, Henry Holt and Company, 1987.

-- Cossey, Caroline, My Story, Boston, Faber and Faber, 1991.

Web Site Information (International Foundation for Gender Education) (National Transgender Advocacy Coalition) (International Journal of Transgenderism)

The above websites have been helpful for me. One of the best starting points in getting to Transgender websites, and there are hundreds of them, is to use a drive engine. I use ‘YAHOO’—at the home page click on ‘Society and Culture’—when that page opens, click on gender—when that page opens click on ‘transgender.’ This will get you to many good sites from which more can be accessed, especially if you are in the mood to surf the net. Chat rooms are generally not the best areas for information. They are wonderfully supportive to many struggling with the many issues of transgender. Most find others who have ‘been there--done that.’ There are the usual pitfalls, e.g. Porn, which, in my opinion, shouldn’t be accessed anyway. I have found that the IFGE (International Foundation of Gender Education) website has access to a number of excellent websites.
Another way to get surfing, is to type the key word ‘transgender’ in any drive engine search box, click search, and you will get into the swim!