Gender Variant Persons and Trauma

By jane heenan, ms mfti <TSANevada@aol.com>

"People are blamed for their own oppression, and the mental health system works in conjunction with the legal and criminal justice systems to maintain the status quo." -- James I. Martin, 1997,
"Political aspects of mental health treatment," p.43. In T.R. Watkins & J.W. Callicutt (Eds.), Mental health policy and practice today, Thousand Oaks, CA: Sage Publications.

Given the context of our transphobic and heterosexist culture, it would seem non-controversial to state that gender variant persons are at increased risk of traumatic victimization in a variety of ways, in a variety of environments, by a variety of persons. Some of these assaults are overt and take the form of verbal or physical abuse, while other kinds of abuse are the result of employment, health care, and housing discrimination, or exclusion from family and other social and spiritual gatherings and groups.

A variety of wounds -- physical, psychological, spiritual, economic -- also accrue in response to more subtle enforcement of normative gender rules in our simultaneously anti-sex and sex-pre-occupied culture: diagnosis as mentally disordered as defined in the Gender Identity Disorder found in the DSM-IV (APA, 1996); stereotyping via media images; and victimization and revictimization by law enforcement officers, and legal and political systems. These cultural demands are often internalized and create additional difficulties for gender variant persons who shame and sometimes hate themselves in what may be recognized as an understandable response to prejudice, hatred, and violence.

Additionally, many gender variant persons know others like them who have been murdered or mutilated as a result of expressing their individual gender identity and, like others who struggle with survivor's guilt, may suffer from the complicated affects of being a survivor in what may be characterized as a gender "war." An ongoing fear of victimization, even after many years of passing as a nondescript member of one's chosen gender, often adds yet another layer to the exploration of the trauma endured by gender variant persons.

Indeed, professionals often encourage their patients to pursue a status as "normal" men or women, even, to cite a common example, telling persons to fabricate personal life histories about their childhood. It has been my experience as a helping professional that even trans persons who seem to pass even in such intimate places as in their marriages and in their gynecologist's office cannot pass in all places. Additionally, they often live in fear of meeting someone either from their past or who has a well-developed sense of reading trans persons. Some of the results of this fear of being read are not unlike the symptoms listed in the DSM-IV diagnosis for post traumatic stress disorder (PTSD): persistently re-experiencing distress as evidenced by, for example, intense psychological distress and physiological reactivity on exposure to reminders of one's lived gender history; persistent avoidance of stimuli associated with one's lived gender history; and persistent symptoms of increased arousal such as irritability or outbursts of anger, or hypervigilance, in a variety of contexts. What is even more tragic about the persons with whom I have worked who struggle with these contradictions is that a powerful component of healing, coming out, is simply not available to them. It is as if they had traded one lie for another during their transition from living in the role of "one" gender to living in the role of the "other" and that to tell the truth at this stage would threaten their very existence.

DSM-IV Diagnosis
There is presently a high degree of agreement on diagnosis of PTSD among the general population. Briefly, the DSM-IV diagnosis of PTSD includes four criteria: the person has been exposed to a traumatic event and responded with intense fear, helplessness, or horror; this event is persistently re-experienced; the person persistently avoids trauma-related stimuli and is emotionally numbed following the event; and the person has persistent symptoms of increased arousal following the event. Horowitz discusses a variety of causes of PTSD, including social, biological, and psychological causes. Biological responses to trauma, including chronic alteration of synaptic transmission of brain-alerting systems and changes in serotonin subtype chemistry, can cause a trauma-response cycle which leaves the person increasingly vulnerable. Psychological reorganization of internal cognitive maps or activation of latent, weak, damaged, defective, or bad concepts of self or of other persons in response to acute or cumulative trauma may cause dependent self-positioning, impoverishment of self-competence, or may lead to chronic emotional vulnerabilities such as depression, rage, shame, or fear. Failures in expected social support and exploitation of culturally less powerful persons by culturally more powerful persons are among the social causes of PTSD. These social causes happen to gender variant persons with great frequency and in many arenas.

The effects of these traumas and effective ways to promote healing for gender variant persons are not well documented within the professional literature of psychotherapy nor are they well understood by the vast majority of those who practice psychotherapy. This lack of documentation and understanding is the "epidemiological invisibility" of gender variant persons within a variety of arenas which include social, political, spiritual, and governmental institutions. However invisible, the trauma endured by trans persons is no less hurtful to these individuals.

Trauma and Gender Variant Persons
Gender variant persons face social and employment discrimination and are at considerable risk for victimization in a variety of arenas, yet there is no available research describing interventions for the unique population of gender variant persons who have been victimized or who are suffering from the aftereffects of trauma. In addition, my perspectives as author, helping professional, and trans person inform my recognition that specific interventions which emanate from a transphobic culture and which are defined as modernist "treatments" for "symptoms" cannot be applied to gender variant persons without more careful consideration than effect sizes can show.

J.J. Sherman, in a 1998 article, "Effects of Psychotherapeutic Treatments for PTSD: A Meta-analysis of Controlled Clinical Trials," published in the Journal of Traumatic Stress, describes general goals of treatments for symptoms of posttraumatic stress. These goals include developing a realistic appraisal of threat, overcoming avoidance of the cues and reminders of trauma, making meaning out of traumatic experiences, and working through trauma via re-exposure and subsequent reinterpretation.

For gender variant persons, Sherman's first goal, developing a realistic appraisal of threat, would include considerations in general areas such as personal, family and other relationships, work, and community. Personal considerations may include questions like how well does ze pass; how well does ze wish to pass; does ze seek a more stable or more fluid gender expression; and does ze have any experiences of positive acceptance of hir gender variant expression from others with whom ze has regular contact. Concerns about employment for persons with a job may include such things as what is hir work environment; is ze out at work; what is the status of hir state-issued documentation; what workplace policies, or legal or statutory employment protections exist; and are there particular threats to safety or the existence of positive support in hir work environment from specific persons. For those who are unemployed, considering employment issues may include asking questions like what work environments match hir skills, interests, and abilities; how might ze best go about gaining employment as a trans person; will ze be out on the job; how has ze been generating income without formal employment; and what fears does ze have about possible homelessness.

Appraisal of family and other relationships may include such matters as what is the status of hir primary relationship; is ze out in hir primary relationship; is ze out to all or part of hir family; does ze have children; do child custody disputes exist with hir partner or other family members; what local legal precedents or statutes, if any, exist regarding a trans parent's child custody; and what is the status of hir available personal support structure. Community considerations might include such questions as what is the status of the local trans community; how are trans persons recognized within the local sexual minority community; how does local law enforcement view trans persons; and is ze aware of the frequency of assaults and murders of trans persons. The review of these issues and others more applicable to particular individuals will help identify which areas are of greatest possible threat.

Sherman's second goal, overcoming avoidance of the cues and reminders of trauma, can be especially difficult for gender variant persons. Trans persons cannot remove themselves from our transphobic culture which informs each of us in a variety of ways and through a variety of persons and institutions that the expression of gender variance is shameful, sinful, evil, immoral, disordered, illegal, profane, and wrong. These cues and reminders of trauma are prevalent in so many and in such seemingly innocuous places even from out of nowhere that they can be overwhelming. In addition, persons may have internalized society's transphobia. Helping the trans persons with whom we work to have a healthy or at least non-pathological perspective regarding gender variance is important and can be facilitated through the person's greater immersion in trans culture and the recognition of or identification with other seemingly more successful trans persons. Suggesting readings or web sites of trans persons which document a positive history of gender variant expression and spending time considering cultural myths of a rigid, genital-based bi-polar gender order may aid in overcoming avoidance. Also helpful for many trans persons is gaining a greater awareness of one's own gender-role expectations by explicit discussion of definitions and expectations of concepts like woman, man, husband, wife, daughter, son, transition, sex-change, and gender variance. By identifying individualized constructs and goals in a supported and safe environment, persons can begin to create positive change in their lives. As progress is made toward gender goals, greater resilience and lesser avoidance can result.

This sort of meaning-making can also be helpful in gaining greater control over particular traumatic experiences, which is Sherman's third goal. Engaging in the process of becoming more aware of the (gender) water in which we swim as a culture and as individuals can allow for new vantage points for viewing situations and experiences to be found. These changes in perspective may help lead to new ways of seeing old things. Additionally, greater control can be gained by participating more actively in local trans communities. This participation might include advocating for changes in statutes and policies, sharing personal experiences with gender variant persons and others, or doing outreach education in more marginalized groups within the trans community, such as working with sex workers around issues of sexually transmitted diseases. Active participation can be empowering; helping to generate concrete, external, and generalizable differences can be a powerful elixir for personal healing.

Working through trauma via re-exposure and subsequent reinterpretation, Sherman's fourth goal, is potentially complicated for gender variant persons who live in a transphobic culture. Unlike trauma victims whose struggles result from singular events, trans persons may not be able to remove themselves from the experiences of trauma in their everyday lives. Re-exposure can be a regular occurrence and often happens outside the safety and structure of counseling. As a result, ongoing reinterpretation of traumatic events is often a part of the healing process as traumatic events reoccur in the lives of trans persons. In addition, a trans person's interpretations are likely to change as well in response to hir changing experiences in expressing hir personal sense of gender identity more openly. Counselor sensitivity about and awareness of these processes can create safer places for trans persons to occupy during counseling and can keep counselors from additional victim-blaming when clients continue to report traumatic events.

Affirmative Counseling with Gender Variant Persons
In considering the available professional discussions regarding diagnosis and treatment of gender variant persons, therapeutic goals for Gender Identity Disorder would include elimination of gender variant behavior, thoughts, and feelings. Treatments to reach these goals have typically included induction into a process of gender transition of physical and hormonal modification with the goal of living as an unambiguous member of the opposite gender with a heterosexual orientation in that gender role. Additionally, treatment of trans persons has often included counsel for the client to expunge hir gendered past in order to complete the elimination of gender variance. Treatments have assumed that the culture, roles, and values of stable and unchanging bipolar gender constructs are inherently superior. As a result, research regarding trans persons has focused on the efficacy of hormonal regimens and surgical procedures and has invisibilized the existence of trans persons who do not fit the expected constructed outcomes in relation to stable gendered identities, sexual orientation, medical procedures, or desire for passability.

When working with disadvantaged minority persons, it is important to recognize that helping professionals have a choice either to promote the reigning social discourse or to empower persons to tell their own story. Empowerment involves interventions designed to reduce clients' powerlessness stemming from the experience of negative valuation and discrimination. By acknowledging environmental, social, economic, and political factors which can cause and maintain a person's problems, affirmative counseling can reduce blaming the victim in counseling.

Specifically in relation to gender variance, affirmative helping professionals accept a person's gender identity and do not work to change a person's gender expression. They abstain from reinforcing the less-than messages which emanate from our heterosexist society and refrain from labeling a person's gender variant expression as a pathology in and of itself. The work may proceed in identifying difficulties related to gender variance, even as there is an effort to distinguish between a person's inner struggle and the culture-bound oppression which may be its source. Affirming helping professionals must work to recognize the complex layers of cultural expectations which may be present for any one person. They need also to attend to a person's support networks, which can function as sanctuaries in an oppressive society, by exploring a person's level of engagement with similar others and by helping them to identify more fully, engage more actively, and develop sources of support with these others.