Shifting paradigms? Making the move to transgender clinical practices

Journal of Sex Research, Nov, 2005 by Karl Bryant

Transgender Subjectivities: A Clinician's Guide. Edited by Ubaldo Leli & Jack Drescher. New York: Harrington Park Press, 2004, 162 pages. Paper, $19.95.

The relationship between mental health professionals and their transgender/transsexual clients has a long and complicated history--one that has been often characterized in negative terms. Much (though not all) of the service provided to transgender and transsexual populations has been clouded by misunderstandings, misrepresentations, and condescension. Transgender Subjectivities: A Clinician's Guide is part of a growing countercurrent within psychiatry, psychology, and allied disciplines, aimed at redressing the shortcomings of that legacy. It contributes to the trend toward affirmative approaches to understanding and meeting the needs of transgender/ transsexual clients.

Several of the contributors explicitly state their commitment to transpositive approaches. Perhaps this is most clearly seen in the title of the volume itself, where the possibility of true transgender subjectivities--their existence and their plurality--is made manifest. This may seem like a small point. However, the authenticity and complexity of transgender people's lives, both psychic and material, have often been denied or ignored in existing mental health models.

In one sense, then, this volume is part of the larger project of recognizing and valuing transgender and transsexual people. Such a project is often fraught with tensions, and Transgender Subjectivities symptomatically displays some of those tensions. In these kinds of recuperative projects, there is sometimes an impulse to present groups in their best light. Sometimes inclusion within the ranks of "human variation" is bought at the price of capitulating to existing standards of "normal" (or even "optimal"). With a few exceptions, this volume focuses its attention on middle-class White clients, often with an assumption that they will be seen in private-practice clinical settings. It is important to understand the risks of such an approach, especially at the moment that a project of recognition is underway. The mainstreaming of lesbian and gay politics in the U.S. has demonstrated the ways that existing hierarchies of race, class, citizenship, and gender (among others) can become reproduced and reinforced through bids for "normalcy." Such a move, even made unwittingly, within the context of developing clinical practices, runs the risk of ignoring the specific therapeutic needs of entire subpopulations.

Transgender Subjectivities opens with two first-person accounts: one on the subjective effects of testosterone; the other a glimpse into less than supportive therapy. These set the tone of the volume, with its focus on understanding transsexual/transgender people's lives and experiences. Entries that follow include theoretical interventions, research findings, and clinical reports. Data come from autobiographical, survey, interview, and case study materials. Several of the contributors are transgender or transsexual. This range of approaches and perspectives is laudable. However, like many edited volumes, the quality of work is sometimes uneven.

Although Transgender Subjectivities does have an impressive range of approaches and perspectives, its coverage is spotty at best; at a slim 162 pages, this is not surprising. For example, none of the chapters focus on transgender/transsexual youth. Additionally, with a few exceptions, the volume focuses heavily on fully transitioned or transitioning transsexuals, resulting in less attention to gender-variant people who do not fit that model. This would not necessarily be a problem if the book did not make claims to comprehensiveness. However, the copy on the back cover hails Transgender Subjectivities as "a comprehensive guide for understanding the issues and concerns of the emerging transgender phenomenon." The editors take a more modest (and accurate) approach, describing the book as "several snapshots of transgender presentations and subjectivities" (p. 1), for those seeking comprehensiveness this volume will not be satisfied (instead see Ettner, 1999; Israel & Tarver, 1998; and Lev, 2004).

In the introduction, the editors express their hope that the volume will prove useful for clinicians who work with transgender patients but have little training or experience in the area. With that goal in mind, as well as wanting "to be of interest to the general public" (p. 2), they should have provided more tools to help the uninitiated reader get the most out of the essays. Their introduction is probably sufficient for the readership of The Journal of Gay and Lesbian Psychotherapy, where the volume was concurrently published, but not for the more general readership they say they hope to engage.

In particular, a discussion of terminology would have been helpful. In the introduction, the editors use the terms "transgendered," "transsexual," "gender dysphoria," and "gender-blending," among others, without providing an adequate sense of what these terms mean to them. Even more useful, however, would have been a discussion of the contested nature and multiple uses of these and related terms. This is not simply a matter of helping readers through the text; it is also of real clinical importance. Such a discussion could direct readers, especially clinicians, to the potentially charged nature of applying these labels, and signal the need for a sense of patience, openness, tolerance, and respect concerning their varied uses.