Building Your Own Prison
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Building Your Own Prison: The Use of External Structure to Reinforce

Suppression of Transgender Feelings and Behaviors

 

Sandra L. Samons, Ph.D.

(From the journal Gender and Psychoanalysis, Volume 6 #2 Spring 2001)

 

            Clinical observations suggest that male-to-female (MTF) transgendered individuals often use contragender-negative reinforcement to conceal their transgender feelings from others and to support the rejection of these transgender feelings within themselves. However, this remains a theoretical construct that does not appear to have been addressed in research. As a means of controlling, concealing or compensating for these feelings, the person may exhibit an exaggerated transgender negativity, a general disdain for sexual diversity, and/or may exhibit hypermasculine behaviors that serve as a facade to conceal his internal feminine feelings. He may make commitments in his male gender role that are difficult to alter at a later time in his life, when making changes toward a female gender role may appear more desirable. These early decisions become obstacles to change and become a significant factor in the timing of when the person will address his transgender identity. They also make the treatment process more complicated.

 Sandra Samons is a 1976 graduate of the University of Michigan School of Social Work (MSW) and has a Ph.D. from San Francisco's Institute For Advanced Study of Human Sexuality. She is in private clinical practice in Ann Arbor, MI, specializing in issues related to transgender identity.

 

            When a MTF transgendered person enters psychotherapy to address his gender identity issues, a personal history will often reveal that the person has made pivotal choices in the past. These life choices may have been made in a deliberate effort to eradicate his transgender feelings, or in the naive hope that suppressing the transgender feelings will make them disappear in time, as the individual matures. There are several commonly observed ways in which a transgendered individual can do this. These include pursuit of a career choice that is male dominated and characteristically chauvinistic, such as enlistment in military service, adopting a hypermasculine presentation, marriage and choice of marriage partner, and involvement in a religion that prohibits as sinful the expression of sexual diversity. Such choices create external support for his efforts to keep his transgender feelings securely locked in a closet.

            Arising from the lexicon of the homosexual community, the terms closeted or being in/out of the closet refer to the individual being either open or secretive about his sexual preferences. Although it is usually thought of in the social context, the term closeted can be used to refer to either the psychological or the social compartmentalization of awarenesses, feelings, or behaviors, in this case those related to being transgendered. It involves a conscious effort to suppress these feelings from one's own immediate awareness and to conceal them from the attention of others. More rarely, awareness may even be repressed, that is, unavailable to the individual until something triggers a breakthrough into consciousness. When the compartmentalization is psychological, the individual will usually have access to these awarenesses and feelings but will consciously and deliberately attempt to suppress them by focusing his attention elsewhere, ignoring or denying their presence to self.

            When the individual is in touch with these feelings but chooses to keep them private, he may act on them in selected secretive ways, and may even be open about them with certain people or in certain situations. Thus, a person may be closeted about being transgendered in all or only in selected parts of his life. In situations where personal safety is at risk, the choice to remain closeted may imply that the person has good reality testing skills. Being closeted may also reflect a decision to live with feelings of shame, fear, and avoidance of intimacy rather than risk experiencing other unpleasant emotions associated with disapproval or rejection. A distinction should be made between preserving personal privacy and harboring a shameful secret, but being closeted may include elements of both. It should also be noted that this choice is not without cost any may become too costly or impossible for the individual to sustain over time.

            A closet can be a wonderful thing. It can provide a safe haven, a place that is yours alone, a place where you can be and do entirely as you please without any consideration for others. There is no risk of ridicule or rejection. Some transgendered people guard their secret possessively at given periods in their life, literally holding it close to the heart and preferring not to share it with anyone else. Among those who enter treatment, this is a fairly common part of the individual's early history. However, since the person is seeking help for transgender feelings, the comfort of the secret closet evidently did not continue beyond a certain point in life.

            Once the individual begins to accept his transgender and wishes to reexamine options for transgender expression, the closet becomes a trap. As feelings begin to break free from the confinement of suppression-repression, the conflict intensifies between the desire for female gender expression and the fear of potential negative consequences. Clinical levels of depression and anxiety can develop.

            Male pronouns are being used in this discussion when referring to the MTF transgendered person. While this runs the risk of offending some transgendered people, it is not done with that intent. The best policy is to respect the wished of the client regarding how the person would like to be addressed, including the use of a male or female name. Whatever the choice, the pronouns should match. When a client is still very closeted, by choice or otherwise, it is frequently the client's preference to be addressed in keeping with his male gender presentation. Any other approach by the therapist could be perceived as an attempt to move the client along faster than the client is prepared to go. If the client is suggestible to any degree, it could cloud the direction of therapy. If and when the client begins to break down his self-constructed prison and explore the female gender role, therapist and client can reconsider the use of name and pronouns. Since the focus of this discussion is the closeted person, the use of male pronouns seems to be appropriate.

            Sexual orientation, gender identity and gender role are fundamental aspects of human sexuality. Because they are closely intertwined, the distinction between them can be a source of confusion for the mental health therapist as well as the transgendered person. It may be helpful to begin by thinking of them separately.

            The term sexual orientation refers to which gender the individual is erotically attracted. Traditionally, this has been defined as heterosexual or homosexual, and more recently also includes bisexual, but this, too, is problematic when applied to transgendered or intersexed people (having gonadal, hormonal, or chromosomal conditions that result in physical characteristics that are neither exclusively male nor female).

            The term gender identity is used here to refer to the gender or sexual identity with which the person identifies and, as such, is treated as a mental construct independent of the physical form of the body, although, for most people, gender identity is consistent with the body form and genitals. Regardless of how we are perceived by others, most of us have an internal sense of self that includes whether the self is male of female. It is a core construct of personality and may be thought of as how the continuum of masculinity and femininity is perceived and experienced by another person. It is not specifically about eroticism, although most people are more inclined to feel erotic when they see themselves as appearing attractive in the gender role that matches self-perceived gender identity.

            The term gender role refers to how one presents one's self to the world, usually as either male or as female, functioning in social roles associated with a particular gender, and how one's gender is perceived by others. A gender role different from one's natal sex can be played in life, as it can be played on the stage. For most of us, gender role, gender identity, and natal sex are the same. A transgendered person appears to lack this congruence, often from earliest memory, and is usually taught from birth to play a gender role that is congruent with their genitals but incongruent with their core gender identity. An individual may find this dysphoric and increasingly difficult to sustain over time, and may eventually choose to transition, to change his gender role and perhaps his body, sometimes in the face of enormous odds. He may no longer have the emotional energy required to maintain the closet. He may seek outside help either to reinforce the closet or to find a way to break out of it.

            It is probable that there are some individuals who remain reasonably content with secret feelings of transgender for their entire life. We have no way of knowing, because these individuals are not available to be counted. They do not attend transgender support groups or conferences. They do not show up in a therapist's office, requesting help. They remain hidden in plain sight. There is no reason for them to reveal themselves and they may have many personal reasons to remain closeted. We can only speculate that such individuals do exist. The ones we do know about are the ones who either have become exhausted from the expenditure of emotional energy required to maintain the closet, or who have reached a point in life where the closet no longer looks as attractive as it once did. New information may reveal options of which the person was previously unaware. The closet may no longer serve so useful a purpose.

            Many MTF transgendered people seek professional assistance when they find themselves needing help in reinforcing a flagging internal structure for suppressing identification with femininity. This approach to treatment can give the appearance of being the most helpful measure when the person does not yet accept his own transgender. However, when the client is already demonstrating an inability to sustain suppression, attempts to reinforce it usually prove to be nothing more than a Band-Aid. The therapist must be honest with the client about indications for and against this approach and needs to express the concern that it may not be helpful for any length of time: the transgender feelings are not going to go away. A contract can be developed with criteria for reasonable reality testing and an agreement to try a different approach if the client becomes satisfied that reinforcing suppression is not effective in this case. This is respectful of the client's goals and honest on the part of the therapist at the same time.

            The typical age range for MTF transgendered people to seek therapy is between 35 and 50 years. Recently, however, some therapists have begun to report that clients are more often entering treatment at an earlier age (Brown and Rounsley, 1996; Ettner, 1999). Improved availability of information about transgender and a decrease in the social taboo surrounding it may help to account for this. Despite the sleaziness that is often associated with television talk shows and despite how frequently transgender is misrepresented in that venue, such exposure has weakened the taboo against talking about it and increased public awareness of the presence of transgender in the general population. While we recognize that negative social attitudes toward sexual minorities influence lack of self-acceptance, it is impossible to evaluate how far these influences reach until the absence of these attitudes makes it clear. At the same time, although the numbers appear to be shifting, the above mentioned age range is still the norm. It is also the people in this age range or older who have usually made the most concerted efforts to avoid dealing with transgender earlier in their lives.

            One possible way for an individual to reinforce suppression of transgender feelings is through career choice. This decision typically takes place during late adolescence and early adulthood, a time when the transgendered person may well struggle the most with a core transgender identity. Choosing a career to reinforce suppression can be an easy decision, as there are numerous possible careers where being discovered as a cross dresser would be disastrous, and transitioning from male to female out of the question (Brown, 1988). Examples of careers that can serve this function include such things as auto mechanic, commercial pilot, or law enforcement officer (less so for the latter choice, as there have been a few notable examples of individuals who have broken ground in this field). Individuals have joined the family business, which has served to keep them under the influence of their primary male role model and also creates a higher level of parental investment in the son's male identity. This gives the son an increased sense of obligation not to disappoint or embarrass the father. Over time, as the father ages, he may come to depend more and more on the son, also making it harder for the son to disengage. If the parent's health becomes fragile, this increases the pressure.

            A career such as forensic chemistry offers another example. In such a situation, the person will have invested greatly in a career that could be significantly damaged by the secret being revealed or by coming out in order to transition. If the person is required to testify in criminal cases, an opposing attorney could attempt to use the issue of transgender to undermine his credibility. This is only one example among many of a career that reinforces the closet to the point where the closet becomes a prison.

            This brings up two other important points. First, when an employee wants to transition at work, whether or not the employee has direct contact with customers or the public often makes a huge difference in how willing the employer is to support the employee. It is one thing for the employer to deal with the issue internally, among the transgendered person's coworkers. It is quite another thing if the employer must be concerned about the reaction of customers or the public, which is harder to manage and could result in complaints or even loss of business. The result is that young transgendered people lack positive role models with which to validate their transgender identity.

            The second point has to so with the common misperception of emotional or psychological instability on the part of transgendered people, who are as stable or unstable as anyone else. They can be more susceptible to disorders related to depression or anxiety, these being a reaction to membership in a group that historically has been treated with revulsion or ridicule in our society. While it is true that mental health professionals themselves have no particular immunity to mental health problems of their own, their credibility rests on the public perception that they are personally stable. Sadly, the mental health field is among the most hostile professions for a transgendered person who wished to be open, and especially to transition. As if fearful that the distinction between client and caregiver will be lost, mental health agencies tend to be very reluctant to support transgendered workers. However, agencies in large urban areas and especially agencies that serve sexual minorities are less likely to be vulnerable in this way. In the latter setting, employing members of the community being served can become an asset to the agency. Through these employees, acceptance of gender and sexual minorities is demonstrated, while positive role models and hope for successful, productive lives is offered to clients. Only recently have transgendered people made progress in this area, as may be observed by the fact that several transgendered mental health professionals have become members of The Harry Benjamin International Gender Dysphoria Association (HBIGDA) (Meyer et al, 2001), the primary organization in the world that deals with these issues on a professional level.

            Enlisting in the military is a common way in which a MTF transgendered person makes a closet into a prison. The enlistment is designed to "make a man of him." This is often the hope of the transgendered individual, and if his family members are aware of his transgender issues, they may share this same hope. Based on the reports of numerous clients, it simply does not work. True, with no opportunity to engage in contragender behavior, it will succeed in temporarily suppressing the behavior. It will also reinforce the perceptions of others that this is indeed a manly man, providing social validation for this method of dealing with transgender feelings. However, the typical outcome is that the urges return, perhaps with even greater intensity, once the opportunity is present again. And sometimes the individual does not wait for that to happen, but may take unwise risks or become creative in finding opportunities to engage in feminine expression.

            Hobbies such as hunting and fishing, and macho behavior in general are used to hide internal femininity. To the extent that family members and friends have an image of the person as masculine in the extreme, the harder it will be later to give credibility to the person when he comes out and seeks acceptance of his transgendered self from these people. The announcement of wishing to transition seems contradictory and inconceivable to them, frivolous at best and insane at worst.

            Marriage and a religion that considers sexual diversity sinful can also be means of building a closet that becomes a prison. These are choices that can function independently or in concert. Many young MTF transgendered people get married in the belief that marriage will make the gender identity issues go away. Like many of us, they fail to understand the distinction between gender identity, gender role, and sexual orientation. They enter marriage in good faith and may also have children while they continue their painful struggle with secret internal conflict about gender identity.

            In other cases, transgendered people will marry and have children, knowing the trans issues will probably not go away, but believing that he can keep the expression of the feelings to a minimum and maintain the secret, He does this out of the same desire to have a family that motivates others, but with the fear that if he told his prospective wife about the transgender in advance, she would never marry him and he would never have the opportunity to have a family life. Later, when she does find out, she will probably not only object to the transgender itself, but will feel betrayed and lied to for not being told in advance. The marriage trust will be broken as she wonders what else he hasn't told her. She may resent that she was robbed of the opportunity to have a more conventional life with a different husband (Cole et al, 2000).

            It is not uncommon for a transgendered person to marry a woman who is extremely unlikely to ever accept transgender in any form. This woman may also be committed to a fundamentalist religious belief system that would never accept transgender. The transgendered husband may even join her in that faith. Imagine a scenario in which a MTF transgendered person in mid-suppression marries a woman who belongs to such a faith and he converts to be able to worship with her. Imagine she was brought up in that faith and that her entire extended family and entire social circle and support system is within this faith. We will not even attempt to make this closet stronger with a career choice and a highly macho presentation. Imagine the fear and anxiety that would be aroused in the transgendered husband by the very thought of disclosing his transgender to his wife in this situation. How truly effective this would be in reinforcing suppression, how formidable an obstacle to change!

            Consequently, the person may take considerably longer than he would otherwise have taken to reach the point where he risks coming out and being more open about his transgender, regardless of the consequences. His parents may now be elderly, so he must worry about the impact this disclosure would have on them, not just the risk of their possible rejection. The children are now old enough to be solidly involved in the family faith, so he has to worry not only about the harmful effect his disclosure might have on them, but the risk that they might reject him. Furthermore, children who are coming to terms with having a transgendered parent are directly affected by the reaction of the other parent, to such an extent that this can be the decisive factor in their ability to adjust. Think about how a wife in this circumstance would have a strong commitment to marriage, but even if she was willing to stay with her husband in the face of social disapproval, she too would risk rejection and ostracism by her extended family and entire support system. This closet has unquestionably become a prison. It was a closet while he wanted to be in it, but it is a prison once he wants to exit but cannot. Transgendered people have been known to suicide in such a situation.

            Why does the MTF transgendered person so often wait until well established in an adult male role before venturing out of the closet or trying to break out of his self-made prison? Is it just a matter of needing less social acceptance as he matures? While that is unquestionably a factor, several other factors are at work here as well. Information is much more readily available in today's world, but it is still more easily accessed by adults than by children, so obtaining needed information about transgender may take a few years of adulthood to accomplish. Along with information comes misinformation that takes time to sort through. This is especially true for information obtained from the internet, but is also true for outdated books available in libraries.٭

            The need for a few adult years to obtain and sort out information is especially important if our concept of information includes finding means of access to other transgendered people. Such contact with others who feel the same way can prove to be a tremendous confidence builder and support for most transgendered people, especially early in the process of self-discovery. However, if this person is unprepared and this first experience turns out to be an encounter with a segment of the world of transgender with which he cannot identify, it may also be a major turn off. There is a tremendous amount of diversity within this population and he may be frightened until he learns more about this diversity. For example, if he prefers an androgynous appearance or wishes to pass easily in public as female, and his first experience with a peer support group brings him face to face for the first time with drag queens and others who, for whatever reason, simply look to him like "guys in dresses," he may feel revulsion and not identify at all with these people. He may even be confronted with his own worst fears about himself....that he too might never look like anything but a guy in a dress. An experience like this could result in further delay in facing his transgender issues, with possible further reinforcement of his prison/closet.

 ٭The International Foundation for Gender Education (IFGE) is a peer resource and an excellent source of information. They can be reached at: P.O. Box 540229, Waltham, MA 02454-0229; phone: 781-899-2212 or email: <info@ifge.org>.

 

            Then, there is the matter of each individual's level of emotional maturity, including the capacity for introspection and the ability to stand alone in the face of opposition, whether from parent, friends, or society in general. The gender identity therapist must take personality traits into account when helping the client to assess his situation and decide how to proceed. Does the person tend to be cautious or does he take risks? Is he comfortable with a lot of solitude or is he an extrovert who feels a strong need for human companionship? Is he a concrete thinker or does he have a high tolerance for ambiguity? Is he inclined to be self-reliant or dependent? Is he trusting or distrustful? Is he flamboyant or unobtrusive? Is he confident or fearful and unsure of himself? These traits will influence how he reacts to initial information he obtains about transgender, how quickly he considers coming out, and how well he copes with the subsequent challenges he encounters.

            Confrontation of his own internalized homophobia and transphobia will also play a part in the timing of this coming out process. We are all exposed to these forces in varying ways throughout our formative years and after. The degree to which this poses a problem for the individual depends in part on geographic and cultural influences. We know that this kind of learning can happen in a variety of ways, overt and subtle. Exposure to negative stereo types in motion pictures is an example of how one learns cultural norms. These influences can shape our attitudes in positive as well as negative ways.

            Clinicians who specialize in transgender identity issues have speculated about the seemingly increased need to come out of the closet during the middle years as representing a sort of mid-life crisis. Although it does not tend to have the character of the "middle-aged crazy" phenomenon, there may be an element of truth in this assessment. Emotional exhaustion from the sustained effort at suppression can gradually undermine the MTF transgendered person's ability to maintain the defensive system needed to contain transgender desires. As the years go by, there is a growing realization that life is passing by and he has not explored his transgendered self. The person experiences an increasing sense of despair that the opportunity will fade away altogether. There can be risk of the person bursting out of the closet too fast, in a manner that is not well thought out and is potentially self-defeating. A transgender therapist must be prepared for the possible need to reign in the client until the best approach to coming out can be more carefully considered.

            In contrast, there are some transgendered people who build up so many exaggerated fears about what would happen if they came out of the closet that what they imagine is far worse than is likely in actual reality They become like someone looking in the window of the candy store but never daring to go in and sample the fare. Although it is usually not appropriate for a therapist to push a client in any particular direction, there are times when a nudge is indicated. Just getting this client across the threshold of the closet door can result in the client experiencing a tremendous sense of relief. For some clients, that is all that is needed, but for others, a cautious nudge at each benchmark is required. Being fearful of experimenting with new behaviors may represent a personality pattern that is consistently exhibited by the client, but the therapist should also examine the possibility that these fears could be an indication of underlying ambivalence.

            Is it possible that lack of success in the male role can be a factor in the desire to change gender roles? This does not usually appear to be the case. More typically, MTF transgendered people have been quite successful in the male role, sometimes so much so that it is difficult to convince people who know them that this is not a spur of the moment impulse, as was commented upon above. For those who have not experienced this success, it then becomes a chicken or egg question. Does the person want to change to the female gender role because of lack of success in the male role, or has the person been unsuccessful in the male role because of the underlying female gender identity? Most men who have been unsuccessful in the male role for other reasons just get depressed or angry about their failures. They don't appear to see becoming female as a solution. However, some MTF transgendered people report that they never felt motivated to invest in a gender role with which they could not identify.

            The fields of biology and genetics still have a great deal to contribute to our understanding of gender. One theory in current favor suggests that all forms of transgender could be prenatally determined, perhaps by variations in the delivery of hormones to the developing fetus at one or more critical times. If this proves to be the case, then we will have to view transgender as a special form of intersexuality, located in the brain. Many transgendered people already define themselves this way, insisting that this fits better with their internal experience than any other explanation.

            This discussion has been entirely predicated on the concept that being transgendered does not preclude the person being a psychologically stable individual. Clinically this is true for the majority of transgendered people. The caveat mentioned above bears repetition. When a minority group, especially a sexual minority in our society, is subjected to social disrespect, rejection, and discrimination, this affects the emotional well-being of the individual members of that minority group. It creates a higher level of stress in life, and predisposes the individual to reactive depression and anxiety, and feelings of being unworthy. Of course, an unrelated comorbid mental health issue can be present. Being transgendered does not afford the individual automatic immunity for all the other ills of the general population. When such a condition does exist, it must be treated concurrently with the transgender and, while not prohibitive of gender transition, it does require extra caution on the part of the therapist. It is necessary for the therapist to be certain that the gender issues are not symptomatic of the other condition, as is sometimes the case with the diagnosis of schizophrenic disorders, and can also be a feature of bipolar disorder or of borderline personality disorder on occasion. However, this does not appear to be the norm and should not make a therapist excessively reluctant to treat transgender issues.

            In conclusion, it appears that the far-reaching effects of negative social attitudes toward sexual minorities and lack of understanding of transgender issues are major factors in the lack of self-acceptance and fear of ridicule and rejection that prompt many transgendered individuals to stay in the closet. We recognize that being closeted, while offering some short term benefits, is costly to the individual and difficult to sustain in the long run. It does offer a degree of safety and privacy from which the person can try to gain understanding of self and make decisions about what to do with his transgender feelings. At the same time, being closeted contributes to the building of a wall of defenses that keep him out of touch with his own conflicted feelings, thus delaying their resolution. The effort to maintain the closet is a drain on emotional energy and limits the capacity of the transgendered person for emotional intimacy with others.

            Choice of career, marriage partner, and religious practice, as well as an exaggerated macho presentation, can provide external reinforcement of the closet, but make it harder for the person to come out at a later time. By not addressing transgender issues in a timely manner, the individual goes about building a life that does not take these issues into account. When the issues can no longer be avoided, the person has a confining life structure to tear down and rebuild. The lives of other people are affected more profoundly than would have been the case if the person had faced his transgender earlier.

            There is a sense of loss for what must be torn down, guilt about the harm or pain caused to other s, and grief about the loss of youthful years that could have been spent as female. An otherwise emotionally stable individual may experience reactive depression and anxiety at being so in conflict with himself and the world around him. As social attitudes become more open and accepting of diversity, we should see positive change in this area. Frank Zappa is alleged to have said, "Without deviation from the norm, progress is not possible." That being the case, we may eventually appreciate the increased capacity for creative thinking that we all develop as we become more open to diversity in our fellow human beings.

 

 

References

 

Brown, G.R. (1988), Transsexuals in the military: Flight into hypermasculinity. Arch.

             Sex. Behav., 17:527-537.

Brown, M.L., & Rounsley, C.A. (1996), True Selves: Understanding Transsexualism-For

             Families, Friends, Coworkers, and Helping Professionals. San Francisco:

             Jossey-Bass.

Cole, S.S., Denny, D., Eyler, A.E., & Samons, S.L. (2000), Issues on transgender. In

             Psychological Perspectives on Human Sexuality, ed. L.T. Szuchman & F.

             Muscarella. New York: John Wiley, pp. 149-195.

Ettner, R. (1999), Gender Loving Care, A Guide to Counseling Gender-Variant Clients.

             New York: Norton.

Meyer, W., Bockting, W., Cohen-Kettenis, P., Coleman, E., DiCeglie, D., Devor, H.,

            Gooren, L., Hage, J., Kirk, S., Kuiper, B., Laub, D., Lawrence, A., Menard, Y.,

             Patton, J., Schaefer, L., Webb, A., & Wheeler, C. (2001), The standards of care

             for gender identity disorders-6th ver. Intnat. J. Transgender 5(1). Retrieved from:

             www.symposion.com/ijt/soc_01/index.htm

 

Mailing address:

 

Sandra L. Samons, M.S.W., Ph.D.

Homestead Counseling Center

1480 Shevchenko Dr.

Ann Arbor, MI 48103-9001USA

Phone: (734) 663-7871

Fax: (734) 663-7441

e-mail:  slsamons@umich.edu


 

References

 

 

 

American Psychiatric Association.

            Diagnostic and statistical Manual of Mental Disorders, 3rd Edition (DSM-III)    (1980). American Psychiatric Press, Washington DC.

           

            Diagnostic and statistical Manual of Mental Disorders, 4th Edition (DSM-IV). (1994). American Psychiatric Press, Washington DC.

 

Brown, G.R. (1988), Transsexuals in the military: flight into hypermasculinity.

            Arch. Sex. Behav. 17:527-537.

 

Brown, M. L., & Rounsley, C. A. (1996). True Selves: Understanding Transsexualism...For Families, Friends, Coworkers, and Helping Professionals.        Jossey-Bass Publishers, San Francisco.

 

Cole, S. S., Denny, D., Eyler, A. E., & Samons, S. L. (2000), Issues of transgender.    Psychological perspectives on Human Sexuality. Ed. L. T. Szuchman & F.       Muscarella. John Wiley & Sons, Inc., New York.

 

Ettner, R. (1999). Gender Loving Care, A Guide to Counseling Gender Varient Clients.            Norton & Co., New York.

 

Meyer, W., Bockting, W., Cohen-Kettenis, P., Coleman, E., DiCiglie, D., Devor, H.,   Gooren, L., Hage, J., Kirk, S., Kuiper, B., Laub, D., Lawrence, A., Menard, Y.,         Patton, J., Schaefer, L., Webb, A., & Wheeler, C. (2001). Harry Benjamin          International Gender Dysphoria Association's Standards of Care for Gender      Identity Disorders. 6th Revision. International Journal of Transgender, 5 (1).

            Available online at: www.symposion.com/ijt/soc_01/index.htm.

 Rottnek, M., Ed. (1999). Sissies and Tomboys: Gender Nonconformity and Homosexual          Childhood. New York University Press, N.Y.

 Sedgwick, E., (1993). Tendencies. Duke University Press, Durham, NC.

 

Last modified: 12/24/13