Challenging Cases for Experienced Therapists

Abstract

The authors, both experienced gender therapists, engage in an interactive discussion of two cases that involve ethical dilemmas and complex psychological presentations. Three themes are discussed: (1) writing letters of recommendation for hormonal or surgical treatment when the clinical presentation involves complicating factors, (2) providing support for transgender persons who are not expressing their authentic gender and choose to remain closeted, and (3) the flexible use of the World Professional Association for Transgender Health's (WPATH's) Standards of Care. The authors each present a case and then discuss various strategies that are affirming of transgender identities.

KEYWORDS:

• transgender
• transsexual
• crossdresser
• nontransitioning
• standards of care
• sex reassignment surgery
• gender affirmation
• gender therapy
• hormonal therapy

Notes

1. “The SOC are intended to provide flexible directions for the treatment of persons with gender identity disorders. … individual professionals and organized programs may modify them. Clinical departures from these guidelines may come about because of a patient's unique anatomic, social, or psychological situation, an experienced professional's evolving method of handling a common situation, or a research protocol” (Meyer et al., 2001, p. 2).

2. Spironolactone suppresses testosterone. Effects of this medication include (but are not limited to) softening of the skin, reduced growth of body hair, breast growth, and reduced libido. In many people it affects sexual functioning by not only decreasing drive but also diminishing erectile and orgasmic response. This varies from person to person. Most of the transgender people who enjoy the effects of Spironolactone enjoy the absence of the feeling of testosterone in their system. They are relieved by cessation of ego-dystonic erections and the changes in thought and energy that result from a decreased focus on sex and reduced aggression. Spironolactone works through suppression. People who want to undergo full gender transition will usually supplement this with estrogen in order to strongly feminize their body in a more dramatic way.