The following article appeared on pages 14-16 of the February/March 1993 issue of _SIECUS Report_, the publication of the Sex Information and Education Council of the United States ** ** ** ** ** ** ** ** ** ** ** ** ** ** ** ** ** ** ** ** ** ** TRANSSEXUALITY, IDENTITY, AND EMPOWERMENT A View from the Front Lines Barbara E. Warren, Psy.D. Director of Mental Health and Social Services, Lesbian and Gay Community Services Center of New York It is a Thursday night support group. Luis* is talking about adjusting to being back in school. He is anxious about passing exams and making new friends. A survivor of foster homes, psychiatric institutions, and drug addiction, Luis -- at the age of nineteen -- is turning his life around. He's clean and sober, in a good relationship with his girlfriend, and getting his GED. The group gives him encouragement and support to stay in school. At thirty-six, Karen* is also back in school. In her Wednesday night support group she shares fears about succeeding in her new career while juggling school and family responsibilities. Here again, the group provides support and encouragement for her coping with stress and hanging on to her aspirations. In addition to dealing with life transitions and stresses -- the kind with which anyone might identify -- Luis and Karen share another, less-common experience. They are transexuals who participate in support groups at the Gender Identity Project (GIP) of New York City's Lesbian and Gay Community Services Center. Luis is a female-to-male transexual man and Karen is a male-to-female transexual woman. A ROSE BY ANY OTHER NAME Transexuality and gender dysphoria (discomfort with one's identity as male or female)) are not modern experiences. Instead they are modern terms for experiences that have existed and been recorded cross-culturally throughout history. For example, Native Americans of the Northern Plains described those with both male and female characteristics as "the people-in-between" and revered them as shamans[1]. In Ancient Rome, there was social acceptance for males who castrated themselves to adopt female identities. Despite its long history and place in other cultures, transexuality has received a great deal of publicity in recent years but very little real understanding. Transexuals are people who find their gender identity (the inner sense of self as male or female) in conflict with their sexual anatomy. Transexuality is part of a spectrum of experience related to gender dysphoria. Manifestations across this spectrum can range from occasional cross-dressing (wearing clothes that are socially designated as belonging to the opposite gender); to living part- or full-time in the gender "opposite" of one's sexual anatomy; to taking hormone therapy and ultimately undergoing sex reassignment surgery. Transexuality is differentiated from transvestitism (the Latinate word for cross-dressing) in that transvestites maintain an inner identity that is consistent with their sexual identity. For them, cross-dressing is related to fantasy fulfillment, erotic stimulation, and stress release. Technically, once sex reassignment surgery has been accomplished, and a person's sexual anatomy has been surgically corrected to match his or her gender identity, he or she is no longer transexual. However, many who have had the transexual experience, male and female, use the term on a continuing basis as a way to own and to describe their unique experience. Sometimes the abbreviation "TS" is used as a noun. Additionally, the dropping of one of the second "_s_" from the traditional spelling of the word "transsexual" was initiated by some members of the transexual community to articulate the concept of an ongoing identity beyond the transition phase. As a member of a transexual women's support group describes it: Many of us came into [the support group] with what we have come to view as a skewed vocabulary. We referred to non-transexual women as "real." If they were "real", what did that make us -- "unreal women?" So we tried "biological women." That didn't work much better. Again, what did it make us? "Unbiological women?" [And] "Genetic women" left us as "non-genetic women." We always seemed to be stuck as "non- somethings" when we wanted to affirm our identity and experience. So we tried to turn it around. Suppose we, being us, defined ourselves as us, and defined them as not-us. This yielded immediate and practical results. They simply became "non-Transexuals!"[2] LESBIAN, GAY, BISEXUAL, TRANSEXUAL Transexuality is often confused with homosexuality. Sexual orientation, a separate aspect of identity from transexuality, refers to one's sexual, romantic, and affectional attraction to others. Although gay men and lesbians may challenge traditional, socially-accepted gender roles by exhibiting dress and behaviors that are associated with their "opposite" gender, their gender identities remain congruent with their sexual anatomy. Contrary to the belief that all true male-to-female transexual women are sexually attracted to men,[3] approximately fifty percent of male-to-female transexual women who participate in the Center's GIP report an affectional, sexual attraction to women. These transexuals then describe themselves as lesbians. Male-to-female transexual women who are attracted to men see themselves as heterosexual in sexual orientation and describe themselves as heterosexual women. There are also female-to-male transexual men who in their sexual attraction to men, identify as gay men, as well as female-to-male transexuals who are attracted to women and identify as heterosexual men. Sexual orientation then is accurately described in relation to one's gender identity and not in relation to one's sexual anatomy. For many transexuals it is part of the evolution of understanding their transexuality to have attempted to resolve gender dysphoria by trying on a gay or lesbian identity. For example, many female-to-male transexuals attracted to women go through a period of identifying as lesbians, but the inner sense of themselves as men persists. Sandy*, a female-to-male transexual man, went into a lesbian support group at age fifteen. His counselors saw Sandy's gender dysphoria as an inability to accept being lesbian. Unfortunately, his experience in the group was probably similar to that of any adolescent heterosexual boy put into a group of homosexual adolescent girls. He could not and did not fit in. This increased his sense of isolation and despair. After leaving the lesbian youth program, his drug use escalated. In contrast, four years later, Sandy's initial experience in the GIP support group for transexual men was one of intense identification and feelings of relief and hope. Transexuals who identify as lesbian or gay often face a double stigma. They may find themselves being rejected by gay and lesbian society as illegitimate or unauthentic. At the same time they may be reviled by heterosexual society for being both transexual _and_ gay. One of the most visible and well known female-to-male transexuals in recent times was the late Louis Sullivan, journalist and author. As a female-to-male who identified as a _gay_ transexual man and an activist on behalf of sexual diversity, he spoke poignantly of his struggle for acceptance as a gay man: In my experience of living as a homosexual man, I have found the gay men's community very accepting and have enjoyed the companionship of two long-term male lovers. However, along with the good comes the bad. Ironically, I have been diagnosed with AIDS, still seen as a gay man's disease. But somehow it seems like just one more hassle with a body that's never cooperated with me much anyhow. I took a certain pleasure in informing the gender clinic that even though their program told me I could never live as a gay man, it looks like I'm going to die like one.[4] COMMUNITY BUILDING Many gays and lesbians recognize the commonality of experience between transexuals and homosexuals in the prejudice and exclusion that both face in the larger society. In this respect the Gender Identity Project (GIP) fits in with Lesbian and Gay Community Services Center's overall mission to protect and preserve lesbian and gay rights and culture. The GIP mirrors the Center's mission in its efforts to enable transexuals to develop a positive, affirmed identity in an environment of support and self- acceptance. To this end, the GIP has developed as primarily a peer-support, peer-driven project that relies on transexuals to help other transexuals to articulate and to then meet the needs of the transexual population. Transexual volunteers, some of whom are human services professionals, and non-transexual Center staff and volunteers work together to deliver relevant services. The GIP offers individual short-term peer-counseling which for many recipients, is the first time they encounter a peer, someone who not only shares their experience but is also a role model for the successful resolution of the gender identity crisis. BARRIERS AND ISSUES However, even with acceptance and support from the lesbian and gay community, transexuals still fact many barriers in the society at large in their quest for dignity and an integrated identity. The prevailing assumption that the understanding of anatomy is unambiguous -- either wholly male or wholly female -- is challenged by transexuality and raises a primal anxiety in most people and in our society. Society's message serves to produce shame, secrecy, depression, and fear in many transsexuals. The result of this societal prejudice is increased isolation and for some, even suicide. In addition, the reluctance of most physicians and mental health professionals to treat transsexuals contributes to the sense of hopelessness many transsexuals feel about ever finding help for gender identity conflict. To date, medicine lacks valid and reliable, detectable biological markers for transexuality. Subsequently there are controversies about proper diagnosis upon which to base treatment decisions. Many professionals lack training and experience in this area as it is not a routine part of graduate education. Therefore, many professionals do not approve or implement irreversible sex reassignment surgeries. The incredibly high cost of hormone therapy, psychological evaluation, and sex reassignment surgery -- not to mention the costs of related cosmetic surgeries, electrolysis, and legal fees -- also serve to prevent many transexuals from access to the medical, psychological, and legal resources that do exist. Insurance companies and Medicaid generally refuse to pay for these services. An ongoing frustration for the peer counselors at the GIP is the difficulty in securing any competent and affordable treatment services for many of their counselees. The predominant psychological model of transexuality also serves to further the societal view of transexuals, and subsequently transexuals' views of themselves, as sick people for whom there is no "cure." Derived from psychoanalytic and object relations theory, this model views transexuality as psychopathology related to insufficient identification with the same gender parent and/or overidentification with the "opposite" gender parent, during infancy and early childhood.[5] This model advocates psychotherapy to remediate transexuality by "restoring" congruency with sexual anatomy. This theory fails to explain: all of the people with similar childhood experiences who are not and never have been gender dysphoric; the many transexuals whose childhood experiences do not fit this model; why gender dysphoria is notoriously impervious to psychotherapy and therefore has a poor prognosis for change through psychotherapy. EMPOWERMENT Even when transexuals receive professional support to live fully in their gender identities as men or women, a common experience for many is the persistence of internalized shame and feelings of unauthenticity that can haunt their attempts to affirm themselves. The emphasis of the community-based, peer support model serves to move transexuals, regardless of their stage of development, away from a shame-based or pathological self-concept and toward a sense of empowerment within a unique identity. This necessary support is well illustrated in the response to the issue of _passing_ written by transexual women who are members of a self-help support group called Survivors of Transexuality Anonymous (Passing refers to transexuals being perceived of by others as "real" men and women.): ... It's not about passing. "Passing" entails attempting to fool non-transexuals into believing we are something we are not. Often we want to pass as non-transexuals because of an unexpressed conviction that only non-transexual women define femaleness, and, therefore, the best we can do is imitate them and work for their acceptance. For many of us this meant that our transexual femaleness, in its own God-given form was somehow not enough, "less-than" ... [As one of our members described it] I used to say, "Well sometimes I still sound like a man. And then it occurred to me. I don't sound like a man. I sound just exactly and precisely like a transexual woman... I used to feel embarrassed because I had "man's hands" or a "man's build." But I don't. I have the hands and build of a transexual woman. I stopped defining myself in terms of other people's categories and started defining myself in terms of me. Gains and losses in social power based on gender is an issue that confronts many transexuals. For male-to-female transexual women, it is adjusting to the loss of social power that occurs when they move from being perceived of as male to being perceived of as female. It often comes as a shock to male-to-female transexual women to be sexually harassed by men, or to find that their earning power as women in the same occupations they held as "men" has decreased drastically. Giving up male power, even if it was not particularly valued in the first place, is often experienced as loss. Female-to-male transexual men often express feelings of wanting to act, or more often being expected to act, somewhat macho, to be perceived as masculine; and to fit in with the guys. For many, these feelings conflict with sensibilities and sensitivities developed over a lifetime of being perceived of and socialized as women. Many transexual men value the qualities associated with being female in our culture and seek to integrate such qualities into their identities as heterosexual men. The emphasis that the Gender Identity Project puts on empowerment counters the conventional advice given to transexuals by many professionals, and some other transexuals, on the best way to achieve post-transition adjustment. The traditional approach was to start over in the "new" identity, and to somehow forget or close off one's former existence and thereby be reborn. This not only proves impossible for most transexuals to achieve but undermines attempts to develop an integrated and affirmative sense of identity. The need to heal from internalized shame demands coming to terms with one's past, including the transexual experience, and incorporating it as meaningful and special. Elaine,* a peer counselor for GIP, expresses her experience with this process as follows: I am not a man who became a woman. I was never a man. I was always a woman. My experience of developing my identity as a woman differs, of course, from the experiences of non- transexual women but is just as female and just as valid. Today, after surgery and with lots of support, I look back on all of my experiences as being part of who I am including my transexuality. The problems I faced made me stronger and I am sensitive to the issues that all of us face, as men, as women, gay and straight. Because of my transexuality I feel I am a better person, a more whole person and life, although not perfect, is pretty good. There has been an overwhelming response to the Gender Identity Project in its two years of existence as part of the Lesbian and Gay Community Services Center, not only in the New York metropolitan area, but via telephone and written requests for information and assistance from around the country. This outpouring confirms that there is a tremendous need for a non-judgemental, educated, affirming and _community-based_ response to the needs of so many people in our society who are experiencing gender identity conflict. Barbara Warren is a psychologist, a consultant, and diversity trainer. She specializes in issues of addiction. AUTHOR'S NOTES * Most of the names in this article are fictionalized, as indicated by an asterisk. [1] Bolin, A. _In Search of Eve: Transsexual Rites of Passage_. New York: Bergin & Garvey, 1988. [2] _Questions Many of Us Ask_. New York: Survivors of Transexuality Anonymous, 1990. [3] Benjamin, H. _The Transsexual Phenomenon_. New York: Julian Press, 1966. [4] Sullivan, L. "Sullivan's Travels." _The Advocate_, June 1989, pp. 69-71. [5] Docter, R.F. _Transvestites and Transsexuals: Toward a Theory of Cross-Gender Behavior_. New York: Plenum Press, 1990.