Current Policies, Practices and Recommendations Regarding Treatment of Gender Minorities

Current Controversies

The previous chapter described the use of behavioral treatment strategies (Rekers, 1992; Rekers & Lovass, 1974; Zucker & Bradley, 1995) which have been used with children who are gender nonconforming. The objective of these rehabilitative treatments is to put children “on track” in terms of their gender role behaviors and to ultimately help defend against the social ostracism that such children typically experience (Raj, 2002). Critics of these treatment approaches argue that they make the mistake of conflating gender identity and sexual orientation and raise a number of ethical and treatment-related questions.

The 1990s also saw many changes in the treatment of other segments of the transgender community. The idea that had been promulgated by John Money and his colleagues at the Johns Hopkins School of Medicine in the fifties—that newborns are “neutral” when it comes to gender identity and that the assignment of sex at birth and rearing are the major determinants of gender identity—was strongly contested in the early 1990s (Zucker, 2005). The standard policies for the treatment of intersex newborns were also criticized on ethical grounds. In 1993, what was started by Cheryl Chase as a peer support group for intersexed adults became the Intersex Society of North America (ISNA). The ISNA’s goals are to stop the practice of genital surgery in infancy and provide parents and intersex children with professional mental health care. The controversy over this protocol continues even today. In 1997, intersex activists visited Congress to request the Law to Ban Female Genital Mutilation be enforced to protect intersex children as well. The recent APA policy statement and report of the Task Force on Gender Identity and Gender Variance purposefully exclude intersex persons because of the growing division between persons who are born with medical conditions many of whom prefer the label Disorders of Sex Development over intersex and those who alter their bodies through hormones and/or surgery (APA, 2008).

Beginning in the late 1980s and throughout the 1990s, changes in the medical and psychological treatment approaches across all segments of the transgender population have emerged in large measure through the political activism of coalitions formed across the transgender community (e.g., the International Foundation for Gender Education, American Educational Gender Information Service, Renaissance Transgender Association) (Denny, 2006). For example, Tri-Ess, the national organization introduced earlier, for cross-dressers and their spouses, joined other organizations in ratifying the Gender Bill of Rights and developing outreach educational programs for counseling-related organizations such as the American Association of Sex Educators, Counselors, and Teachers (AASECT) and the NASW (Fairfax, 2006).

A number of clinicians (e.g., Rosario, 2004; Seil, 2004) reported that many of those who requested sex reassignment during the 1970s fabricated descriptions of their experiences, often copying the same terminology (e.g., “trapped in the wrong body”) over and over again, in order to assure that they qualified under the medical evaluation standards that were used for gender reassignment treatments. Some believe that this practice continues and serves to alienate gender minorities from helping professionals. For example, Spade (2006), a transgender activist, described this experience quite vividly:

After attending only three discussion group meetings with other trans people, I am struck by the naiveté with which I approached the search for counseling to get my surgery authorizing letters. No one at these groups seems to see therapy as the place where they voice their doubts about their transitions, where they wrestle with the political implications of their changes, where they speak about fears of losing membership in various communities or in their families. No one trusts the doctors as the place to work things out. When I mention the places I’ve gone for help, places that are supposed to support queer and trans people, everyone nods knowingly, having heard countless stories like mine about these very places before. Some suggest therapists who are better, but none cost less than $50/hr. Most people simply offer different ways to get around the requirements. I get names of surgeons who do not always ask for letters. Someone suggests that since I won’t be on hormones, I can go in and pretend I’m a woman with a history of breast cancer in my family and that I want a double mastectomy to prevent it. I have these great, sad conversations with these people who know all about what it means to lie and cheat their way through the medical roadblocks to get the opportunity to occupy their bodies in the way they want. (p. 327)