Gender Identity and Expression

Over the past 14 years, I have had the opportunity to work extensively with people who have non-conforming gender identities. Gender identity differs from sexual orientation. Gender identity has to do with one’s fundamental, internal sense of whether one is female, male, bi-gendered, or non-gendered. Transgender is a broadly applicable word applying to cross-dressers, transgender and transsexual individuals, intersexed individuals, and others who live in non-conforming gender roles.

Individuals seek counseling services and therapy at many different stages of their gender journey. Some individuals come to therapy to explore feelings of being “different” that may have to do with their sense of gender. Other people come to therapy knowing they are transgendered but struggling with self-hatred or non-acceptance from loved ones. Many are seeking to find a safe place to express their thoughts and feelings and make decisions for their own personal future.

I work respectfully and confidentially with individuals everywhere along the gender spectrum. My approach is non-judgmental and non-directive. I do not tell people what gender they should identify as nor what path to take in expressing their gender. I see my role as providing information, education, and support, and as providing clients with the options available to them in living their lives in more authentic and fulfilling ways.

I also help individuals with coming out to family members and friends, overcoming internalized trans-negativity, accessing support systems and community, and understanding all that is required and involved for accomplishing gender transition, if they choose this path. Transition steps involve assessment, counseling services, hormonal therapy, and surgical interventions if desired. My approach operates in strong accordance with the WPATH Standards of Care for treatment of transgender and transsexual individuals desiring to transition.

Dr. Firestein wrote a monthly Q & A column for the Healthline magazine called Uncommon Sense for seven years. Below are excerpts from previous columns.

Question: I have been struggling for years with a really embarrassing problem. I have been dressing in women’s clothes off and on since I was a teenager.  In the last 10 years, I have often found myself having thoughts that I would be happier if I were a woman and could live that way all the time.  I don’t remember anything that happened to me in my childhood that would cause me to be this way. It makes me hate myself and I have tried many things to get rid of these feelings—like serving in the military when I was younger, but even though I was a very good soldier, it didn’t make these feelings go away.  I am confused and scared. What do I do about this?

Answer: What you are probably dealing with is a fairly rare medical condition that is called Gender Identity Disorder.  This is a condition in which the individual has persistent and recurring distress over the fact that they are born male (or born female). The person often comes to feel significant depression over their gender dysphoria (dysphoria means intense distress) and may even become suicidal.

The diagnosis of GID requires that this is not a fleeting wish or desire based on the feeling that life would be easier as a woman (or as a man) but is, in fact, a strongly felt experience of one’s self that occurs over a long period of time—usually since childhood or adolescence.  Dressing in clothes of the opposite sex does not, by itself, mean that you are transgender or transsexual.  Some people do this for enjoyment and to express a part of him- or herself, but do not believe that they should actually be the other sex.

However, given the feelings you are reporting over the past 10 years, there is a distinct possibility that you may be transgender or transsexual.  I strongly recommend that you seek an evaluation from a psychologist or other practitioner who is a gender specialist. A gender specialist is trained to diagnose and work with Gender Identity Disorder and can help you figure out if this is truly a condition that you have.

If you do have GID, there are specific protocols of treatment (called the WPATH Standards of Care) developed by a highly knowledgeable professional group of medical doctors, psychologists, social scientists, and transgender people. These standards are scientifically based and provide guidance to psychotherapists and physicians for the treatment of this condition. Treatment generally involves assisting you to achieve “gender congruence”, that is, to help make what is on the outside match your deeply felt sense of self on the inside. This is a terribly difficult journey for those who must take it.

While many people consider gender variance to be a lifestyle choice, immoral, or pathological, and deviant, it is actually not a choice. Gender dysphoria is a condition that you were probably born with, possibly as a result of hormonal abnormalities occurring during prenatal development (e.g. Androgen Insensitivity Syndrome) or other causes, such as a chromosomal abnormality. The underlying cause cannot be determined for every person, but the diagnosis and treatment of GID are the same regardless of the underlying cause.

The complexity of this whole subject is far too great to deal with in a column like this, but I urge you to do some research and reading on the subject and to contact a qualified gender specialist for help in sorting this out for yourself. Please know that there are explanations for what you are going through and that qualified help really is available to you.

Question: I have a weird question and I hope you can help me with it.  I am a 39-year-old man in the Loveland area and we have a very close family. I am very close to my brothers and sisters. I was shocked on a recent visit when my brother, who is 45, told us that he is transsexual and has been going through medical treatment and therapy to become a woman! I don’t even know whether to believe him. Can this be true? And if it is, what do I do?

Answer: I’m sure this revelation must have been a huge shock to you and your whole family. I have worked with several transgender and transsexual clients over the years and I can assure you that Gender Identity Disorder is a real condition.  It is a medical condition which also has many psychological, emotional, and social ramifications.

Transsexuals can be male-to-female (MtF) or female-to-male (FtM). Your brother is a male-to-female transsexual and his goal is to make his outside physical appearance, body, and social gender presentation match his inside feelings of being “a woman in the wrong body”. He has probably been holding this secret for many years, possibly decades.

Most transsexual people have been trying to deal with this on their own or with help from medical and counseling professionals for a very long time before telling the family. By the time they tell their family, they are quite sure that they truly have this condition and that they absolutely need to transition. Most are terrified of disclosing this to family and wonder if their family members can deal with this major change.

The World Professional Association for Transgender Health (WPATH) is a group of professionals and people affected by the disorder who have put together official “Standards of Care” that guide physicians, surgeons, and mental health professionals in providing services to transgender individuals and their families. Psychotherapists who are also Gender Specialists follow these Standards of Care so that no one who is not truly suffering from Gender Identity Disorder is inappropriately given hormone therapy or surgery.

I’m sure your brother was scared and nervous to share this with you. Many transgender people are rejected by their families but many are not. Everyone I have ever worked with wants to be accepted and loved by their family.  Don’t be afraid to ask him questions and follow up with suggested books and websites that explain this condition to family members and friends. This is the beginning of a big adjustment for you and your family, but inside, this is the same sibling you have always known, just in a very different packaging. As a result of this transition, she will be more true to herself and that will almost certainly make her a much happier person.