DebunkingDebunking Gender ((Worl?ingWorking TherapeuticallyTherapeutically with GenderGender IdentityIdentity))

Transitions Counselling & Consultancy

“"AA Natural ApproachApproach to Life'sLife’s Problems"Problems” Presentation compiled by Madison Amy Webb BACPBACP AccAcc MBACP © Transitions Counselling Consultancy 2015 Version 1.5

pg. 1

“…itl'...1t COWL can bebe saistsaid that actuallyactixatlu wewe areare all Intersexesfritersexes both aiA,atovvacalluanatomically asas well as endocrinologically”.evvotocrIAA,oLoolzatiu"

Harry BenjaminBenjamin-- Sexologist && Endocrinologist 19661966

pg. 2 What isis gendergender identity?

It’sIt's not justjust about Biology.

It isn'tisn’t about sex.

It isn'tisn’t about whomwhom youyou love.love.

It isn'tisn’t about what youyou choosechoose to wear.

It isis about how youyou feelfeel about yourself, and whichwhich gender you sensesense yourself to be. fit

What isis the gender continuum?

Is it this???

Masculine Androgynous Feminine

Or this???

Mts

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The Revolution Starts Here!

111141111111116 It'sTi a Its

So let'slet’s be clearclear from thethe beginningbeginning what we are working with: Sex == PhysicalPhysical BodiesBodies (Male or Female). Gender Identity == what we sensesense or feel ourselvesourselves to be regardlessregardless of sexsex so (Male, Female, or Something Else). Sexuality == what sex/ssex/s we are sexuallysexually attracted tootoo e.g. (Hetero, Homo, Bi,Bi, Polysexual).

The GenderGender Continuum isis moremore complexcomplex than at firstfirst glance:

Diagram of Sex, Gender, & Sexuality -Normative Man- -Normative Woman" Biological Sex (anatomy, chromosomes, hormones) I I male intersex female Gender Identity (psychological sense of self)

man two-spirit/third gender woman

Gender Expression (communication of gender) 1

masculine androgynous feminine Sexual Orientation f identity of erotic response) A attracted to women bisexual/asexual attracted to men

Sexual Behavior (sexual behavior)

sex witil women sex with men & women sex with men

Adapted from "Diagram of Sex Se Gender." Center for Gender Sanity. Mtp.//www.gendersanity corn/diagram Mimi

pg. 4

Transgender Pioneers Richard FreiherrFreiherr vonvon Krafft-EbingKrafft-Ebing 1840 —1902– 1902 waswas an Austro—GermanAustro–German psychiatristpsychiatrist and author of the foundational work?work "Psychopathia“Psychopathia Sexualis”Sexualis" First publishedpublished inin 18861886 and expanded inin subsequent editions. The last edition fromfrom the hand of the author (the twelfth) containedcontained a total of 238 casecase historieshistories of human sexualsexual behaviour.

Psychopathia Sexualis isis a forensicforensic referencereference bothbook for psychiatrists, physicians,physicians, and judges.judges. Written inin an academic style, itsits introductionintroduction notednoted that, to discourage lay readers,readers, the author had deliberatelydeliberately chosenchosen a scientific term forfor thethe titletitle ofof thethe bothbook andand thatthat hehe hadhad wrwrittenitten partsparts of it inin LatinLatin forfor the samesame purpose.purpose. It was one of the first boolzbooks aboutabout sexualsexual practicespractices that studied homosexuality/bisexuality. It proposed consideration of PSYCHOPATHIAhomosexuality/bisexuality. It proposed consideration of SEXUALIS the mental statestate of sexsex criminalscriminals inin legallegal judgementsjudgements of their crimes.crimes. InterestinglyInterestingly although it describesdescribes behaviour we would understandunderstand asas expressionsexpressions of Transgender, it and associatedassociated termsterms are not yet established. This This behaviour was consideredconsidered at the time to be be an expression of homosexuality

Henry Havelock Ellis An EnglishEnglish physician,physician, writer & socialsocial reformer of the late 18/18/ early 19th19th century. At thisthis time there was nono understanding of transvestites or transsexuals.transsexuals. Sexual psychopathology/ deviancy waswas usually regarded asas HomosexualHomosexual "Inverts"“Inverts” inin origin. However he achnowledgedacknowledged that it isis possible for a personperson to feel lihelike the oppositeopposite sex,sex, to adopt that behaviour, and eveneven dressdress asas the opposite sex.sex. Yet the direction of the sexual impulse remains remains the samesame i.e.i.e. homosexual. He referred to thisthis behaviour asas "Eonism"“Eonism” after the 18th18th centurycentury crosscross dresserdresser “Chevalier"Chevalier d’d' Eon"Eon” (Fig 1.).1.). ThisThis term isis rarelyrarely used. pg. 5

Reitiwo• mRe, 1••••••., ••/ Magnus Hirschfeld A German physician,physician, sexologist,sexologist, and advocate for sexual minorities, late 19/19/ early 20th20th century. KnownKnown for hishis work?work in trying to understand and supportsupport homosexuals,homosexuals, hehe also turned hishis attention to crosscross dressingdressing and he created the term "Transvestit"“Transvestit” and wrote the seminalseminal book?book onon the MAGNUS HIRs FELO AND TMC Quesr subject "The“The Transvestites:Transvestites: TheThe EroticErotic Drive to CrossCross Dress"Dress” /OR SEXUAL FREEDOM 1910.

Robert Stoller An AmericanAmerican ProfessorProfessor of Psychiatry, sexual researcher, and Psychoanalyst,Psychoanalyst, 20th20th Century. He undertookundertook? extensiveextensive researchresearch and development around gendergender identity and alsoalso sexual excitement. AndAnd challengedchallenged Freud'sFreud's biological belief in bisexuality. He advancesadvances belief in "Primary“Primary Femininity"Femininity” he posits that the initial orientationorientation of both the physical and psychologicalpsychological identificationidentification inin thethe 8e-t child leansleans towards feminine development. ThisThis gender he seessees asas leading to a feminine core gender Row., stow. M.D. identity inin bothboth boys boys and girls,girls, unless unless a masculine L force isis presentpresent whichwhich interruptsinterrupts the relationship with the mother.

Harry Benjamin GermanGerman-born-born AmericanAmerican endocrinologistendocrinologist and sexologist. Late 19/19/ early 20th Century.Century. InIn 1948 he was ashedasked by the sexologistsexologist AlfredAlfred Kinsey to seesee a childchild whowho "Wanted“Wanted to be a girl"girl” Neither had seenseen anything lamlike thisthis previously. This childchild ledled BenjaminBenjamin to come to understand that there waswas somethingsomething other than the condition of Transvestism. Benjamin eventually treated the childchild with oestrogen, and eventually the childchild underwentunderwent GRS. Benjamin went on to treat several hundred patients with similarsimilar needs.needs. One suchsuch patient Christine JorgensenJorgensen (Fig 2.) finallyfinally brought the subjectsubiect matter into the mainstream.

The Harry Benjamin International Gender pg.Pg. 6 Dysphoria Association was formed with the permission, now known as WPATH.

Fig 1.1. Fig 2. Fig 3.

Virginia Prince Virginia Prince Possibly only thosethose with somesome Knowledgeknowledge of the transgender community before about 1980 willwill bebe aware of the central rolerole that Virginia PrincePrince (Fig 3.) playedplayed inin its development. Primarily a staunchstaunch promoter of heterosexual transvestism,transvestism, her activities have had a significantsignificant impact onon thethe wholewhole transgendertransgender community. Prince waswas bornborn a male onon November 23rd 19121912 in LosLos Angeles 19561956-7,-7, Prince had begunbegun to work?work out her philosophy of transvestism and had begun her mission mission to educate the medical profession,profession, transvestitestransvestites and the restrest of the world, this involvedinvolved the development of the idea of "femmiphilia", or, love of the feminine. Prince preferred to call herselfherself a femmiphile (FP) ratherrather than a transvestite.

Prince claims to have been the first person to abbreviate the term transvestite to 'TV' in Prince claims to have been the first person to abbreviate the term transvestite to 'TV' in about 1955.1955. SheShe alsoalso claims to have 'coined the wordswords "transgenderism""transgenderism" and "transgenderist" asas nounsnouns describingdescribing peoplepeople lihelike myself who have breastsbreasts and live full time asas a woman, but who have no intention of having genital surgery'.surgery‘.

Gender Identity Identity diagnosis diagnosis Table Table of of Harry Harry Benjamin Benjamin ©Harry Benjamin 1966 Type I TransvestiteTransvestite (Pseudo) - Gender "feeling":“feeling”: Masculine. - ConversionConversion OperationOperation (SAS):(SAS): Not considered inin reality. - Hormone Therapy: Not considered/considered/ not indicated. - Psychotherapy:Psychotherapy: Not wanted, unnecessary. - Remarhs:Remarks: OnlyOnly a sporadicsporadic interestinterest inin "dressing".“dressing”. RarelyRarely hashas a femalefemale namename when dressed.

Type II —– Transvestite (Fetishistic) - Gender "feeling":“feeling”: Masculine. - ConversionConversion OperationOperation (SAS):(SAS): May considerconsider in fantasy. Rejected. - Hormone Therapy: Rarely interested. /May help reducereduce libido. - Psychotherapy:Psychotherapy: May be successfulsuccessful inin favourable environment.

pg. 7 - Remarhs:Remarks: May May imitate imitate male male & & female female double double personality personality with with male male and and female names.

Type III —– Transvestite —– True - Gender "feeling":“feeling”: MasculineMasculine but with lessless conviction. - ConversionConversion OperationOperation (SAS):(SAS): Rejected but the idea isis attractive. - Hormone Therapy: Attractive asas an experiment. - Psychotherapy:Psychotherapy: If attempted, almost never successfulsuccessful asas a cure. - Remarhs:Remarks: May assumeassume a double personality.

Type IV —– transsexualtranssexual —– Non Surgical - Gender "feeling":“feeling”: UncertainUncertain wavering between TV & TS.TS. MayMay reject gender. - ConversionConversion OperationOperation (SAS):(SAS): AttractiveAttractive but not required. - Hormone Therapy: Needed for comfort and emotional balance. - Psychotherapy:Psychotherapy: Only asas guidance,guidance, mostmost often refusedrefused and unsuccessful. - Remarhs:Remarks: Social Social life life dependant dependant on on circumstances. circumstances. Often Often identifiesidentifies as as “transgenderist”."transgenderist".

Type V —– TranssexualTranssexual —Moderate–Moderate Intensity - Gender "feeling":“feeling”: FeminineFeminine "trapped“trapped inin a man'sman’s body".body”. - ConversionConversion OperationOperation (SAS):(SAS): Often requested. - Hormone Therapy: Need for a substitute for or preliminary to SAS. - Psychotherapy:Psychotherapy: Rejected, unlessunless as to cure. Permissive psychological guidance. - Remarhs:Remarks: Operation hopedhoped for and worhedworked for, often attained.

Type VI —– TranssexualTranssexual —– High Intensity - Gender "feeling":“feeling”: Feminine.Feminine. Total "psycho“psycho-sexual"-sexual” inversion. - ConversionConversion OperationOperation (SAS):(SAS): Urgently requested and usuallyusually attained. - Hormone Therapy: Required for partial reliefrelief only. - Psychotherapy:Psychotherapy: Psychological Psychological guidance guidance or or psychotherapy psychotherapy for for symptomatic symptomatic relief only. - Remarhs:Remarks: Despises Despises her her male male sex sex organs. organs. Strong Strong danger danger of of genital genital self self- mutilation or even suicidesuicide if too long frustrated beforebefore SASSAS isis attained. What isis GenderGender identity? There are two structuresstructures throughthrough whichwhich we can viewview gender and they are: Gender asas either EssentialismEssentialism oror Constructionism. (There(There areare otherother theoriestheories butbut thatthat isn’tisn't necessarily whatwhat todaytoday is about)about)

- EssentialismEssentialism isis the view that, for any specificspecific entity (such(such asas animals,animals, people,people, objects, or concept) to exist there are a setset of attributes whichwhich are necessarynecessary to

pg. 8 its identityidentity and function,function, an essenceessence that makes thosethose thingsthings andand conceptsconcepts thethe way they are. - SoSo Gender EssentialismEssentialism isis informedinformed byby biology, that men have penises, women have vaginas. PlusPlus therethere are socialsocial expectationsexpectations placedplaced uponupon thethe individual duedue to thethe biologicalbiological gendergender presentationspresentations e.g.e.g. menmen areare perceived as tough and strong,strong, and womenwomen areare perceivedperceived asas emotionalemotional andand caring....caring…. - ConstructionismConstructionism claimsclaims that gender rolesroles areare sociallysocially constructed,constructed, andand thatthat the rolesroles are what isis generallygenerally consideredconsidered appropriateappropriate behaviourbehaviour for a person of that specificspecific gender. --ThereThere are many strandsstrands of ConstructionistConstructionist theorytheory rangingranging betweenbetween purepure constructionism, to somesome whichwhich allowallow forfor somesome biologicalbiological element,element, toto othersothers which claimclaim that there are moremore than twotwo commonlycommonly acceptedaccepted genders.genders. - SoSo Gender ConstructionismConstructionism claimsclaims gendergender isn'tisn’t aa stablestable trait,trait, ratherrather itit isis socially constructedconstructed andand may vary overover time forfor anan individual.individual. AlsoAlso itit cancan bebe seen asas an activityactivity ofof "doing"“doing” andand throughthrough thisthis processprocess wewe determinedetermine thethe gender role.

Julia Serano Trion's writer and activist recently challenged essentialism and constructionism in a chapter titled "Performance Piece" in Rate Bornstein! 2010 book "Gender Outlaws (the next generation)".

Instead of saying that all gender is performance, lets admit that - Same-times gender is an act, and other times it isn't And since we can't get inside one another's minds. we have no way of knowing whether any :given person's gender is sincere or contrived_ Let's fess up to The fact that when we make judgments about other people's genders. we're typically basing it on our own assumptions (and we all know what happens when you assume, right?). - Let's stop claiming that certain genders and sexualities -reinforce the gender binary.- In the past, that tactic has been used to dismiss butch- es and femmes. bisexuals. trans folks and our partners, and feminine peo- ple of every persuasion_ Gender isn't simply some faucet -that we can turn on and off in order to appease other people, whether they be heterosexist bigots or queerer-than-thou hipsters_ How about this= Let's stop pretend- ing that we have all -the answers, because when It comes to gender, none of us is fucking omniscient_

Instead of trying to fictionalize gender. let's talk about the moments in ItFe when gender feels all too real_ Because gender doesn't feel like drag when you're a young trans child begging your parents not to cut your hair or not to force you to wear that dress. And gender doesn't feel like a per- formance when, for the first time in your life, you feel safe and empowered enough to express yourself in ways that resonate with you, rather than remaining closeted for the benefit of others_ And gender doesn't feel like a construct when you finally find that special person whose body, personal ity, identity, and energy feels like a perfect fit with yours. Let's stop trying to deconstruct gender into nonexistence, and instead start celebrating it as inexplicable, varied, profound, and intricate_ So don't you dare dismiss my gender as construct_ drag, or perfor- mance. My gender is a work of non-fiction.

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Personal Meaning

- How do we understand ourselves?ourselves? Essentiality,Essentiality, ConstructionConstruction ally or some other way? - Through personalpersonal experienceexperience via our bodies. - InteractionsInteractions with others,others, both positivepositive and negative. - BeingBeing part (or not) of a family. - Through Purpose - Through Interests/Interests/ what we do with our lives. - Friends - Maybe where we live. - AnythingAnything else?

How WasWas Your Gender Identity Shaped?Shaped? - (An Exercise). - TakeTale a moment to think?think backbath over your childhood and seesee if you remember specific moments whenwhen youyou learnedlearned howhow toto behavebehave accordingaccording toto youryour gendergender role e.g. - Maybe you werewere told to change your behaviour becausebecause "Boy“Boy or girls,girls, don'tdon’t behave that way!"way!” - Or maybe you sawsaw thisthis happen to a friend oror siblings….siblings.... - Now thinhthink about a more recentrecent time: - Can youyou rememberremember any moments inin the past few yearsyears when youyou were reminded of how to behave accordingaccording to your "appropriate"“appropriate” gender role and or sexualsexual orientation? -- Hint:Hint:• This might bebe subtlersubtler.. -Do you 14nowknow of any personal experiencesexperiences whichwhich illustratedillustrated howhow socialsocial forces tried to shape your sensesense of gender or sexual identity? -- (If(If notnot youyou maybe somebody youyou know)know)

Personal Meaning

Gender Identity isis fluid it isis evolvingevolving allall thethe time.time. WithWith everyevery individualindividual whowho questions their Gender Identity and affirmsaffirms thisthis inin theirtheir ownown wayway essentially that isis then a new Gender Identity.

pg. 10 Individuals are their ownown creatorscreators of their identity, nono two willwill bebe the same even if they shareshare similar traits.

The following listlist isis asas up to date asas I have been able to research,research, but bear in mind the nature of Gender Identity isis fluid it isis evolvingevolving allall thethe time.time. With every individual whowho questionsquestions their Gender Identity and affirmsaffirms thisthis inin theirtheir own way essentiallyessentially that isis then a new Gender Identity. IndividualsIndividuals are theitheirr own creatorscreators of their identity; nono two will be the same even if they share similar traits.

WorkingWorhing asas a CounsellorCounsellor hashas taught me to ashask the client to "Describe“Describe Themselves"Themselves” rather than to "Explain"“Explain” isis more useruser friendly and hashas better client lead results.results. I have found that usingusing the Philosophical Phenomenological Method,Method, in particular the Rule of "Epoche"“Epoché” alsoalso 14nownknown as “Bracketing”"Bracheting" where the enquirer suspendssuspends all judgementsjudgements of themselves, the world, and the client. ByBy systematically peeling bachback the layerslayers of personal meaning youyou willwill eventuallyeventually be left with thethe fundamental essenceessence of the individuindividualal andand what it meansmeans to be them.

Glossary GenderGender-- isis expressedexpressed inin termsterms of masculinity and femininityfemininity whichwhich is determined and isis assignedassigned at birthbirth basedbased onon the sexsex of the individual. It affects how people perceive themselvesthemselves and how they expect others to behave. Gender Identity-Identity- The gender to whichwhich oneone feelsfeels oneone belongs. Personal MeaningMeaning anan Exploration Identity, howhow dodo we 14nowknow whowho we are?are? We are who we are....are…. AndAnd forfor the most part we accept that. We may not lihelike certain partsparts of ourselves at times, but we 14nowknow and accept they are part of usus and we are consistentconsistent in presenting thisthis to ourselvesourselves and othersothers daily. SoSo how do you 14nowknow what makesmaims youyou ....…. You? TaheTake a few minutes to thinmthink about this.this. What isis it that informsinforms your knowledgehnowledge of who you are? Knowing youryour lamslikes and dislihesdislikes are easier to figure out, butbut what about knowinghnowing youryour sexuality or your gender....gender…. How cancan youyou bebe suresure of anything you believe/d or sensesense about yourself? Glossary Gender Dysphoria-Dysphoria- an anxietyanxiety or persistently uncomfortable feelings experienced by an individualindividual aboutabout their assignedassigned gendergender whichwhich isis in conflict with theirtheir internalinternal gendergender identity.identity.

pg. 11 The Gender RecognitionRecognition Panel statesstates that gender identity disorder is: "characterised“characterised byby aa strong andand persistentpersistent cross--gendergender identification”identification"which which “does"does not arise from the cultural advantagesadvantages ofof beingbeing thethe other sex,”sex," And that it shouldshould not be confusedconfused with "simple“simple nonnon-conformity-conformity to stereotypical sexsex role behaviour."behaviour.” DSM V (Diagnostic(Diagnostic & Statistical Manual of Mental Disorders). This isis an AmericanAmerican publicationpublication endorsedendorsed by the APA (American(American Psychiatric Association), May 20132013 the latest edition statedstated that: Gender Identity Disorder will bebe replaced by the term "Gender“Gender Dysphoria”Dysphoria"

TheThe APA saidsaid the reasonreason forfor the change was:

- “They"They wantedwanted toto send thethe message thatthat thethe Therapists job isn’tisn't toto pathologized thethe Tran’sTran's clients.”clients." - “This"This was aa step to follow howhow homosexualityhomosexuality has been changed inin regards to public opinion.”opinion." - Between the yearsyears 19731973 —– 19871987 the DSMDSM slowlyslowly changedchanged their classification ofof homosexualityhomosexuality andand ceasedceased regardingregarding itit asas aa paraphilia.paraphilia. Gender, Acquired-Acquired- The role that a Tran'sTran’s personperson achievesachieves through the process of transition. It isis the legal term inin relation to the issuingissuing of a Gender Recognition CertificateCertificate whichwhich givesgives a transpersontransperson fullfull legallegal rightsrights inin this gender. Gender Attributed-Attributed- The gender and sexsex that one isis tahentaken to be by others.others. This is usuallyusually an immediate categorisationcategorisation ofof a personperson asas beingbeing a man oror woman irrespective of their mode of dress. CissexualCissexual-- (aim(aka Cis)Cis) wherewhere an individual'sindividual’s self-self- perception of their gender matches the sexsex they were assignedassigned at birth.birth. ThisThis will oftenoften be the casecase that the individual willwill have never challenged oror questioned their Gender Identity. Transgender-Transgender- a general umbrellaumbrella term appliedapplied to a variety of individuals and behaviours. TheThe Individual responsesresponses will vary from personperson to person and from conventional gendergender roles.roles. EachEach personperson will feelfeel that their Gender Identity does not match their birth sex. It’sIt's important to note that Gender Identity isis totally separate to sexual orientation. Transsexual-Transsexual- thisthis isis a conditioncondition wherewhere an individualindividual identifiesidentifies with aa gendergender inconsistent or not culturally associatedassociated withwith theirtheir assignedassigned sex.sex. AA medical diagnosis cancan be made if the personperson experiencesexperiences discomfortdiscomfort asas a result of the desire to be a member of the oppositeopposite sex.sex. They may wishwish to choose to undergo SRSSRS (Sex(Sex ReassignmentReassignment Surgery). Trans person/person/ people-people- are inclusiveinclusive terms adopted inin the latelate 1990s1990s by the UK government and nownow commonly alsoalso usedused by membersmembers of the crosscross-dressing,-dressing, transgender, and transsexualtranssexual population to refer to themselves.

pg. 12 Trans man-man- isis a female-to-male-to-male 'transgender`transgender or would have been lamslikes to be assigned female at birth. Iran'sTran’s female-female- isis a male-to-to-female-female (M2F)(M2F) asas above. Note that some people, following treatment, stronglystrongly prefer asas a woman. PLEASE NOTE! The label of Transgender Male/ Female is not the same as Transsexual Male/ Female. TheThe difference being that a TransgenderedTransgendered individual will be more likely to identify with the opposite gender identity. WhereasWhereas the Transsexual may also wish to align their body and Gender Identity. Transvestite/ CrossCross-dressing--dressing- the act of wearing clothingclothing commonlycommonly associated with the oppositeopposite sexsex within that respectiverespective society.society. The individual concerned may adopt feminine behaviour or traits. It doesdoes not however indicate a Transsexual identityidentity and asas suchsuch do not seek?seek hormoneshormones or surgery. En Femme-Femme- Drag or CrossCross-Dressing-Dressing withinwithin the field of thethe performingperforming arts.arts. DragDrag-- hashas severalseveral differingdiffering meaning dependingdepending onon whichwhich subgroupsubgroup you are focused on,on, here I willwill covercover the 3 mostmost common.

Drag Queen-Queen- A male impersonatingimpersonating a female. Often forfor the purposepurpose of entertainment in cabaret or social clubs. Both the clothing stylestyle and the mannerisms will be exaggerated. The Drag QueenQueen may be a gay man. It is worth notingnoting that Drag formsforms a strong part of Gay Western culture.culture.

Drag King-King- A female impersonating a Male. PleasePlease seesee Drag Queen.Queen. May be a Lesbian. Faux Queen/ King-King- isis another term forfor both thethe above.

Pantomime Dame-Dame- Female characters in a stagestage performance whowho are played by men inin drag, either in extremely ccampamp stylestyle or elseelse by men actingacting butch in woman'swoman's clothing. This isis a continuation of "En“En Travesti"Travesti” (disguise) wherewhere women played malesmales in the theatre within the 1880's.1880’s. ThisThis is somsomethingething whichwhich hashas carried onon in “P"Panto"anto” up to the current day.

Gender Neutrality-Neutrality- refersrefers to the useuse of language whichwhich aimsaims to minimize assumptions about gender or biological sexsex during speech.

pg. 13 The AmericanAmerican singer songwriter JustinJustin BondBond who identifies asas transgender,transgender, adopted the gender inclusive honorific "Mx"“Mx” toto bebe usedused before hishis name instead of Mr or Mrs E.g. Mx. JustinJustin Bond. And personalpersonal pronounpronoun V (e.g. vself instead of her/himself).

IntersexIntersex-- an individualindividual displayingdisplaying bothboth male and female sexualsexual characteristics and organs.organs. They may be raisedraised asas a certain gendergender but may identify with another in later life or they may considerconsider themselvesthemselves to not be exclusivelyexclusively Male or Female. Others will notnot become aware they are intersexintersex unlessunless they receive genetic testing. For somesome the ambiguousnessambiguousness will be clear and manageable.manageable. For others surgery will taketale place to enable the individual to fit into a sociallysocially accepted gender category.

Androgyny-Androgyny- the combination of M & F characteristics,characteristics, no one identity is more dominant than the other, thisthis may include Fashion,Fashion, Gender Identity, Sexual Identity,Identity, and SexualSexual Lifestyle.

Intersex cancan bebe confusedconfused withwith androgynyandrogyny butbut it isis very different in that androgyny isis seldomseldom usedused to describedescribe an individualindividual with the biological aspects found inin intersex.

GenderqueerGenderqueer-- people who identify as Genderqueer may thinhthink of themselves as overlapping or with blurred lineslines between gender identity and sexualsexual orientation. Being both M & F or neither M & F, moving between genders (gender fluid), they will have theirtheir own name and identity for their gender.

pg. 14 GenderfucGenderfuch,k, Gender-bending,-bending, Gender-fluid-fluid The consciousconscious effort to mothmock or "Fuck?“Fuck with"with” traditional notionsnotions of gender identity, gender roles,roles, and gendergender presentation whichwhich assumesassumes one'sone’s identity. It challenges the common belief that an individual will assume the normative values of the common belief that an individual will assume the normative values of masculinity or femininityfemininity depending onon the biological gender.

Examples of those who "Genderfucle“Genderfuck” AnnieAnnie Lennox,Lennox, BoyBoy George, Prince, Marilyn Manson, and Lady Gaga.

Within the Tran'sTran’s community there isis currently a hierarchy developing where those who align moremore with gendergender-fluidity-fluidity seesee thosethose whowho are M2FM2F oror F2MF2M asas following conservativeconservative valuesvalues of gender binary and thusthus not supportingsupporting Tran'sTran’s activism againstagainst CissexualCissexual Privileges.Privileges. Shemale or sheshe-male--male- isis a term usedused primarilyprimarily (but not exclusively)exclusively) inin sex workwork? to describedescribe a transsexualtranssexual womanwoman with male genitalia and augmented female breasts,breasts, either from breastbreast augmentation andand oror hormones.hormones. UsingUsing the term ShemaleShemale towards a transsexualtranssexual womanwoman isis consideredconsidered highlyhighly offensive,offensive, for it impliesimplies sheshe isis worhingworking inin thethe sexsex trade. SissySissy// Sissification-Sissification- thisthis formform crossingcrossing thethe gendergender binarybinary isis basedbased inin "Negating"“Negating” or the partial removalremoval of one'sone’s gender identity (usually within somesome form of erotic role-play.role-play. ThisThis usuallyusually includesincludes removingremoving bodybody hair, "Gaffing"“Gaffing” the tying up of the penispenis and testicles,testicles, and wearingwearing moremore often a maid'smaid’s outfit or uniform of servitude. TheThe SissySissy will engageengage inin thesethese activities at the demand of a mistress.mistress. What isis fundamental to the concept isis that the SissySissy isn'tisn’t regarded as beingbeing worthy of hishis masculinity, yet neither are they worthy of being regarded asas completely female. TheyThey are to existexist inin a gendergender "hinterland".“hinterland”. BigenderedBigendered-- a personperson whowho feelsfeels they exhibit qualities of two genders.genders. ThisThis may include any gender from thethe gendergender spectrum,spectrum, sometimessometimes they may switch between gendersgenders (14nown(known asas gender switching).

Third Gender or Third sex-sex- describes individuals who are categorizedcategorized by their will or socialsocial consensusconsensus asas neither man nor woman. There are some societiessocieties whichwhich do acknowledgeachnowledge 3 or even more genders e.g. the “Hijras”"Hijras" of India, Bangladesh,Bangladesh, and PaI?istan.Pakistan. Or the "Fa'afafine"“Fa’afafine” of Polynesia.

pg. 15 UnlikeUnlit e mostmost westernwestern culturescultures who have adopted heteronormativity they are usually the Third gendersgenders are seenseen as acceptable sexualsexual partnerspartners to regular males, asas long asas the male partner maintains the active role. See example right the "Berdaches"“Berdaches” of the Native American American Nation.

Crossdreamers - AA manman oror woman whowho get aroused by the idea of being the opposite sex.sex. Many crossdreamerscrossdreamers identify with their birth sex,sex, while othersothers are gender dysphoric.dysphoric. Many crossdreamerscrossdreamers understand themselvesthemselves asas transgender, while othersothers considerconsider themselvesthemselves fetishists. It seemsseems a majority of crossdreamerscrossdreamers are attracted to personspersons of their own birth sex.sex. CrossdreamersCrossdreamers may expressexpress their feelings through crossdressingcrossdressing and/or creative crossdreaming,crossdreaming, e.g. by writing stories,stories, comicscomics and TGTG captions. Crossdreamers - Male to female crossdreamerscrossdreamers are labelled paraphilic "autogynephiles" inin thethe AmericanAmerican PsychiatricPsychiatric Manual (the DSM-5),DSM-5), while the female to male crossdreamerscrossdreamers are not mentioned with a word.word. SomeSome female to male crossdreamerscrossdreamers are miffed by thisthis omission,omission, whilewhile mostmost of them seemseem to sincerely enjoyenjoy thisthis unexpectedunexpected lathlack of stigmatisation. Not all crossdreamers are crossdressers. Autogynephilia - Sexologist Ray BlanchardBlanchard coinedcoined the term inin 19891989 to describe MtF transsexualstranssexuals who were sexually arousedaroused by the idea of being women.women. He stated that while they lathedlacked a specificspecific term toto describedescribe thethe concept,concept, therethere was evidence for the conceptconcept among cliniciansclinicians of the early 20th20th century. HavelockHavelock? EllisEllis usedused the terms eonismeonism and sexo-aestheticsexo-aesthetic inversion to describe similar crosscross-gender-gender feelings and behaviours. • TransvesticTransvestic Autogynephilia:Autogynephilia: arousalarousal to the act or fantasy of wearing typically feminine clothing. • BehaviouralBehavioural Autogynephilia:Autogynephilia: arousalarousal toto the act or fantasy of doing something regardedregarded asas feminine. • PhysiologicPhysiologic Autogynephilia:Autogynephilia: arousalarousal to fantasiesfantasies of body functions specific toto peoplepeople regardedregarded asas female.female. • AnatomicAnatomic Autogynephilia:Autogynephilia: arousalarousal to the fantasy of having a normative woman's body, or parts of one. Autoandrophilia -The-The term refersrefers to a personperson assignedassigned female at birth whowho is sexually arousedaroused byby the thought or image of being a man. It waswas classifiedclassified as a type of transvestic fetishismfetishism inin a proposedproposed revisionrevision to the DSM-5DSM-5 butbut not included inin thethe final version.version. LessLess work?work hashas beenbeen donedone onon Autoandrophilia.Autoandrophilia. ! Closeted - meansmeans being aware of one'sone’s lesbian,lesbian, gay, bisexualbisexual orientation or true gender identity yet averse to revealing it becausebecause of the variousvarious personal or socialsocial motivations.motivations. It cancan alsoalso includeinclude denial oror refusalrefusal toto identify asas LGBT. Overall, mostmost reasonsreasons not to come out stemstem fromfrom transphobia.

pg. 16 On a personalpersonal level,level, there are internal conflictsconflicts involvinginvolving religiousreligious beliefs,beliefs, upbringing and internalizedinternalized transphobiatransphobia inin addition to feelings of fear and isolation. Also,Also, there are potential negativenegative social,social, legal,legal, and economic consequences suchsuch asas disputesdisputes with family and peers,peers, jobjob discrimination, financial losses,losses, violence,violence, blackmail,blackmail, legallegal actions,actions, criminalization,criminalization, oror inin somesome cocountriesuntries even capital punishment. ! Coming out-out- isis a figure of speechspeech forfor Lesbian,Lesbian, Gay,Gay, Bisexual,Bisexual, andand Transgender (LGBT) people'speople’s disclosuredisclosure of their sexualsexual orientationorientation and/ or gender identity. Often framed and discusseddiscussed asas a privacy issue,issue, comingcoming out of the closetcloset is described and experiencedexperienced asas a psychologicalpsychological processprocess or journey, decisiondecision-- makingmthing or risks-tahing;risk-taking; a strategystrategy or plan; a speechspeech act or a matter of personal identity; a riterite of passage; liberationliberation fromfrom oppression;oppression; an ordeal, a means towards feeling TransTrans pride insteadinstead of shame and socialsocial stigma,stigma, or even suicide. Transition-Transition- the social,social, psychological,psychological, emotional and economiceconomic processesprocesses that a Tran'sTran’s personperson undergoesundergoes to move from theirtheir assignedassigned gendergender role into their cchosenhosen or acquired gender.gender. TheThe time thisthis tahestakes isis variable and dependsdepends on the individual’sindividual's ability to embrace significantsignificant changechange inin theirtheir life.life. IfIf requiring genital surgery,surgery, the individual willwill have to undergo a soso called "Real“Real Life Test",Test”, i.e.i.e. livingliving inin thethe acquired gendergender role for a minimum of 11 year. PassingPassing-- InIn thethe contextcontext of gender "passing"“passing” refersrefers to a person'sperson’s ability to bebe regarded asas a member of the sexsex whichwhich they physicalphysical present.present. Typically, passing involvesinvolves a mixture of physical gendergender cuescues (e.g. hair style, or clothing) as well asas certain behavioural attributesattributes that tend to be culturally associated with a particular gender. Irrespective of a person'sperson’s presentation,presentation, many experiencedexperienced dressersdressers assertassert that confidence isis farfar moremore importantimportant forfor passingpassing thanthan thethe physicalphysical aspectsaspects ofof appearance. The failure to "pass"“pass” asas the desireddesired gendergender isis referred to as "being“being read".read”. Also PassPass-- Can now mean living openlyopenly inin youryour identified gender. It cancan bebe worth chechingchecking out what thisthis wordword meansmeans to the individual. StealStealth-th- Living inin a way where nobody hnowsknows your previous gender history. Pre-op/-op/ Post-op--op- Pre-operative-operative and postpost-operative;-operative; havinghaving had oror not had gender-confirmation-confirmation surgeries.surgeries. PrePre-operative-operative impliesimplies that the personperson desiresdesires gender corrective surgery. Non-op--op- A personperson whowho doesdoes not desiredesire surgery,surgery, or doesdoes not need surgerysurgery to feel comfortablecomfortable inin hishis or her body. Gender ReassignmentReassignment Surgery (GRS) - Medical term forfor what transsexual people often callcall gendergender-confirmation-confirmation surgery:surgery: surgerysurgery toto bringbring thethe primary and secondarysecondary sexsex characteristicscharacteristics of a transsexual person'sperson’s body into alignment with hishis or her internal-perception.-perception.

pg. 17 HRT or Hormone Replacement Therapy-Therapy- For transsexual menmen and women HRT cause the development of many secondarysecondary sexualsexual characteristicscharacteristics of their desiredesiredd gender. However, many of the existingexisting primary and secondarysecondary sexual characteristics cannot be reversed:reversed: - can induceinduce breast growth for transsexual women but not for transsexualtranssexual men. - HRT can prompt facial hair growth for transsexual menmen but cannot regressregress it for transsexualtranssexual women. - HRT may, reversereverse somesome characteristicscharacteristics suchsuch asas the distribution of body fat, as well asas menstruation inin transsexualtranssexual men. “Do"Do-it-yourself"--it-yourself”- somesome individualsindividuals choosechoose to self-administerself-administer their medication, often becausebecause available doctorsdoctors have too little experience in thisthis matter, or no doctor isis available inin the firstfirst place. Sometimes,Sometimes, Tran'sTran’s personspersons choosechoose toto self-self- administer because their doctor will not prescribeprescribe hormoneshormones without a letter from thethe patient'spatient’s gender specialist stating that the patient meets the criteria for Gender Identity Diagnosis. In thesethese circumstancescircumstances the individual may self-administerself-administer until they can get the authorizations, feeling that they shouldn'tshouldn’t have to wait for a medical professionalprofessional to be convincedconvinced of their situation. However, self-- administration of hormones isis potentially dangerous and orally delivered hormones cancan causecause an elevationelevation inin enzymes. Gender Recognition-Recognition- A processprocess whereby a transsexual person'sperson’s preferred gender isis recognisedrecognised inin law, or the achievement of the process. Gender Recognition ActAct 2004 (GRA) - TheThe UK law whichwhich allowsallows transsexual people to obtain gendergender recognition. Gender Recognition Panel (GRP) - A group of lawyers and doctorsdoctors appointed to considerconsider applications for gender recognition, and to approve them if the transsexual personperson hashas met the relevant criteria. See www.grp.gov.ukzwww.grp.gov.uk Gender RecognitionRecognition CertificateCertificate (GRC) - AA certificatecertificate whichwhich isis providedprovided toto those who have been successfulsuccessful inin their application for gender recognition. The document hashas nono standing other than asas a meansmeans to enable the register of births and Department of Work?Work & PensionsPensions systemssystems to be updated inin line with the decision. WPATH (World ProfessionalProfessional AssociationAssociation for Transgender Health)Health) - formerly known14nown asas the "Harry“Harry Benjamin International GenderGender Dysphoria Association"Association” HBIGYA isis a professionalprofessional organisationorganisation devoted to the understanding and treatment of gender identity disorders. Standards of Care (SOC) - the overall goalgoal of the SOCSOC is: “To"To provide clinical guidanceguidance for health professionalsprofessionals to assist transgender, transsexuals, and gendergender nonnon-conforming-conforming peoplepeople with safesafe and effective pathways to lasting personalpersonal comfortcomfort with their gendered selves.selves. In order to maximize their overall health,health, psychologicalpsychological well-being,well-being, and self-fulfilment."self-fulfilment.”

pg. 18 ! A transsexual/ transsexuals-transsexuals- termsterms lihelike thesethese shouldshould not be usedused asas a noun; they are best usedused asas adjectives to qualify other descriptive characteristicscharacteristics i.e. “transsexual"transsexual people";people”; "trans“trans people";people”; "transsexual“transsexual woman";woman”; "trans“trans woman"woman” Otherwise it isis similarsimilar to referring to someone asas "black?"“black” oror to the "disabled".“disabled”. Note thatthat some Tran’sTran's people maymay preferprefer toto be described asas woman or men.men. ! Chosen Gender-Gender- TransTrans people are very sensitivesensitive about the suggestionsuggestion that they have "chosen"“chosen” their gender. Professionals are recommended to talk?talk about "acquired“acquired gender"gender” or "true“true gender”.gender". If in doubt,doubt, ashask the individual concerned. EffemimaniaEffemimania-- the cultural obsessionobsession with anythinganything focusedfocused with male femininity. It isis underpinnedunderpinned byby traditional sexism,sexism, and that femininity is inferior to masculinity. ! Sex Change, tranny, "the“the Chop"Chop” etc. - TheseThese terms stillstill appear in the media are regarded asas offensiveoffensive and inaccurate.inaccurate. Note that somesome Tran'sTran’s people are beginning to "reclaim"“reclaim” the word "tranny"“tranny” inin muchmuch the same way that lesbian and gay people have reclaimed "queer".“queer”. ThisThis isis not recommended for anyone who isis not a member of those communities. Birth Privilege-Privilege- being bornborn intointo a physicalphysical bodybody (where the gender matches the subconscioussubconscious gender). Socialisation Privilege-Privilege- being socializedsocialized into a gender which isis consistentconsistent with their subconscioussubconscious gender. Cissexual Privilege-Privilege- gendered individualsindividuals considerconsider themselvesthemselves gender legitimate and unquestionable. This cancan be the rootsroots of Transphobia. CissexuCissexualal Prejudice-Prejudice- whichwhich isis the belief that transsexuals'transsexuals’ identifiedidentified gendersgenders are inferior to, oror lessless authentic than thosethose of cissexuals.

Personal Meaning-Meaning- TheThe PhenomenologicalPhenomenological Method The Rule of Epoch&Epoché- "to“to Bracket”Bracket"or or set asideaside our initial biasesbiases and prejudices, to suspendsuspend ourour expectations and assumptions.assumptions. SoSo asas to imposeimpose an "openness"“openness” to our immediate experience. The Rule of Description-Description- "Describe“Describe don'tdon’t explain",explain”, to peel bachback the layerslayers of personal meaning. The Rule of Horizontalization (the EqualizationEqualization Rule)Rule) - avoid placingplacing initial hierarchies of significance oror importanceimportance onon thethe subjectsubject matter.matter. TreatTreat themthem asas having equal valuevalue or importance/ significance.

pg. 19 Personal MeaningMeaning thethe ProcessProcess R.IC.E.S R.IC.E.S So what followsfollows areare thethe 55 typestypes of phenomena whichwhich wewe asas therapiststherapists cancan bebe mindful ofof and whichwhich ifif present inin thethe clientclient areare thethe perfectperfect avenuesavenues intointo exploring howhow theythey areare "Transgendering".“Transgendering”. RR-- Redefining II-- Implying CC-- Concealing EE-- Erasing S5-- Substituting Ultimately the clientclient willwill bebe involvedinvolved inin alteringaltering theirtheir gendergender signifiers,signifiers, andand usually one isis moremore dominantdominant thanthan thethe others. “Redefining”"Redefining"-- the individual'sindividual’s personalpersonal dialoguedialogue withwith andand ofof themselves.themselves. TheThe clients ownown understanding/understanding/ interpretation ofof themthem self,self, whichwhich isis basedbased inin thethe phenphenomenaomena of them genderinggendering theirtheir self. “Implying”"Implying"-- subsub processprocess of indicating specificspecific gendergender signifierssignifiers ofof thethe intendedintended sex i.e.i.e. wearingwearing "Breast“Breast Forms",Forms”, oror placingplacing somethingsomething inin underpantsunderpants asas aa “Substitute"Substitute Penis".Penis”. However, thisthis cannotcannot occuroccur without the processprocess ofof themthem understanding/understanding/ interpreting theirtheir genderedgendered selfself beingbeing a phenomenonphenomenon inin itsits ownown right. “Concealing”"Concealing"-- subsub processprocess of hiding bodybody partsparts e.g.e.g. "Binding“Binding Breasts"Breasts” "Tuching“Tucking Penis & Testicles".Testicles”. “Erasing”"Erasing"-- eliminating aspectsaspects of physical bodybody whichwhich aren'taren’t identifiedidentified withwith e.g. growing hair, cuttingcutting hair,hair, shavingshaving bodybody hair,hair, wearingwearing aa hairhair piece.piece. Wearing/ not wearing maheupmakeup etc. Substituting”Substituting"-- dressingdressing style,style, posture,posture, gesture,gesture, speech.speech. TheThe degreesdegrees toto whichwhich thethe individual undertahesundertakes thisthis willwill dependdepend onon varyingvarying factorsfactors suchsuch asas positionposition onon the continuum, if they are "out",“out”, andand finances. The 4 StagesStages of Demystification andand EstablishmentEstablishment ofof the IndividualsIndividuals TransTrans selfself-image.-image. The Clothing Phase-Phase- Starting 5 at yearsyears through to late 20's:20’s: Being drawn to clothing, fabrics,fabrics, textiles,textiles, anythinganything whichwhich wouldwould bebe deemeddeemed not conventionally part of the gendergender identity. InIn particular I wouldwould bebe drawn to texture, colour,colour, form,form, andand howhow thethe fabricfabric plays over the body. Minor body alterations e.g. body hair removal, exploringexploring cosmetics,cosmetics, andand seeing how clothing and shoesshoes changedchanged the body and behaviour. Once finances permit purchasingpurchasing aa hairhair piece,piece, breastbreast formsforms andand thisthis allowedallowed the connecting togethertogether for the firstfirst time ofof thethe internalinternal GenderGender IdentityIdentity andand a construction of a matching externalexternal image.

pg.pg. 20 The Mirror Moment-Moment- The point where the individual'sindividual’s effortsefforts are first recognised, where all the componentscomponents have been assembledassembled and the individual willwill standstand inin frontfront of the mirror and seesee reflectedreflected bachback thethe imageimage of self that connectsconnects themselvesthemselves to the internal gendergender identity. However, there isis always that moment where the individual mustmust return bachback to their regular appearance. I wouldwould try to preservepreserve thosethose momentsmoments by photographing myselfmyself to enable me to have the persistencepersistence of image. The PsychoanalystPsychoanalyst JacquesJacques Lancan developeddeveloped a conceptconcept not too dissimilar called the "The“The Mirror Stage"Stage” at itsits corecore isis that the childchild will look?look into the mirror and seesee their image and themselvesthemselves asas a whole. He alsoalso spohespoke of this beibeingng a fundamental aspectaspect of the development of the Libido. The Public Phase-Phase- The individual willwill makemale tentative stepssteps to go out into the world, usuallyusually very secretively and asas safelysafely asas they can maimmake it. They will probably not maimmake contact with others. The Interaction Phase-Phase- The individual nownow will notnot only go out asas their preferred GenderGender Identity but will maimmake contact and interact with those around them. The may not be full time but they will certainlycertainly be living part of their life inin the identified gendergender role. The internet hashas obviouslyobviously made thisthis stagestage a little easiereasier to plan.plan. However,However, in my mind the internet hashas alsoalso corrupted what isis an already difficult journey for the Tran'sTran’s individual e.g.e.g. sleazysleazy websites,websites, cliques,cliques, bitchingbitching onon forums,forums, and misguided adviceadvice giving.

Approaches to Tran'sTran’s people'speople’s needsneeds - CareCare Pathways Introduction: Formal servicesservices dealing with gendergender issuesissues inin the adult population beganbegan to be establishedestablished under the NHS in the late 60's.60’s. TheseThese developments grew into what isis now the main gendergender identity clinicclinic within the Charing CrossCross Hospital in London.

Prior to thisthis time transsexualtranssexual peoplepeople had been generally obliged to obtain hormoneshormones from the blackblach-marhet-market sourcessources and to travel abroad for surgery. TheThe autobiography by the Tran'sTran’s woman JanJan MorrisMorris documents this well. TheThe 1974 book Conundrum by Jan/an Morris (see(see left) Faber && Faber.Faber.

In timetime other NHS-run-run gendergender identity clinicsclinics (GICs)(GICs) havehave been established, but thesethese are far smaller than CharingCharing Cross.Cross. Coverage throughout the country isis uneven though,though, with entireentire regionsregions e.g. TheThe North WestWest with no clinic at all.

pg. 21 ThisThis situationsituation createscreates the risk?risk of over-dependence-dependence upon a solesole provider (Charing Cross).Cross). With thisthis meaning consequentconsequent lathlack of choice, inevitable bottlenecksbottlenechs awaiting referral and the requirement for long-distancelong-distance travel by some serviceservice usersusers for appointmentsappointments.. The emergence of private practice to meet patient demand for an alternative has servedserved to create a dual mathetmarket for provision;provision; albeit accessibleaccessible only to the few who cancan affordafford the consultationconsultation fees. The Internet hashas now created a third mathet,market, whichwhich bringsbrings with it serious implications forfor public health. TransTrans peoplepeople whowho have difficultydifficulty accessingaccessing thethe NHS, and whowho cannot afford to attend a reputable private clinicclinic are nowadays increasinglyincreasingly liable to purchasepurchase hormoneshormones online. With thisthis comes great risk?risk of inferiorinferior products/ inappropriate products, and nono external health assessments. Similarly, servicesservices usersusers who cannot wait for NHS surgicalsurgical treatment, and cannot afford private surgerysurgery by the same consultantsconsultants inin the UK,UK, are increasingly lihelylikely to gogo abroad to wellwell-advertised-advertised centrescentres in the Thailand or the United States. However, gender reassignment tourism raisesraises concernconcern about aftercare and the funding of any postpost-operative-operative complications.complications. Similarly, there are public health concernsconcerns associatedassociated with patientspatients selfself--prescribingprescribing crosscross-gender-gender hormones without locallocal monitoring. Care Pathways The goal isis to find the bestbest wayway inin whichwhich thethe individualindividual cancan achieveachieve "lasting“lasting personal comfortcomfort with the gendered selfself in order to maximize overall psychological wellbeingwellbeing and self-fulfilment"self-fulfilment” WPATHWPA TH StandardsStandards ofof CareCare Version 6 www.wpathwww. wpath .org.org

NHS care pathways generally Care Pathways begin with an approach by an Private care individual to their GP. Some referral policiespolicies enable GP'sGP’s to Patient sees private gender GP Monitors refer direct to the GICGIC or specific specialist consultant by name. Some people may at thisthis point decide to go for 41W the private route to transition if Unless the specialist provide a range of specialist services in a clinic setting, the range of personal funding permits.permits. (fig 1.) additional services such as speech therapy may be limited and will probably not be coordinated in a multi•disclplinary approach Fig 1. In thethe majority of cases,cases, patients are generally referred firstfirst to aa locallocal psychiatrist, whosewhose principal rolerole shouldshould be to eliminate the possibilitypossibility of an underlyinunderlyingg psychiatricpsychiatric condition (Fig(Fig 2.).2.).

pg. 22 Care Pathways TriniftPsCrioreePing A provisional diagnosis of gender Dysphoria relies onon eliminatingeliminating Conventional Care Path other Iknown-mown reasonsreasons for a patient to exhibit concerns about their gender role. SoSo now the GP refer to local Patient see GP patient isis referred on to psychiatrist a psychiatrist at a gender identity clinic Psychiatrist GIC. If successful,successful, the (local cm h tj patient will be able to access the appropriate Psychiatrist treatment from the GIC. Shared care for hormones treatment from the GIC. refers to GIC only The client will be expected to passpass 2 assessments from to gender specialists before a full diagnosisdiagnosis isis given and treatment can Fig 2. commence.

However modern thinhingthinking allowsallows for alternative approaches. TheseThese can be designed inin orderorder to provide patient-centred-centred locallocal treatment, whilst remaining faithful to good clinicalclinical governance. It shouldshould notnot be assumedassumed that the optionsoptions forfor commissionerscommissioners are limited to a narrow choicechoice between oneone traditional externalexternal referralreferral and nothingnothing else.else. As there isis evidence to showshow that somesome commissionerscommissioners recogniserecognise the benefits in offering referral to a suitably accredited private clinicclinic asas one of the options for patients.

Where a local General Care Pathways Practitioner with Special Interest (GPwSI)(GPwSI) exists including professional GP-centred local care development it isis now possible for many of the component parts in the overall care of the Trans Patient sees other person to be delivered local NHS and locally (Fig 3.). private services Patient sees The servicesservices which could GP be included here are endocrinology, speech therapy, and counselling GpwSl GP ks gateway to GP rah 5pecallet Interest services. Fig 3. GP acts as a gateway to all the services which the patient coordinated local and tertiary needs and is in the position to GP monitors monitor overall progress services

Fig 3.

pg. 23 Towards a TranspositiveTranspositive TherapeuticTherapeutic Model Transposivitiy == meaningmeaning havinghaving respectrespect forfor andand acceptanceacceptance ofof peoplepeople whowho identify andand beingbeing somewheresomewhere onon thethe transgenderedtransgendered spectrum.spectrum. Historically medicalmedical serviceservice providersproviders pathologizedpathologized thosethose withwith gendergender Dysphoria (GD)(GD) andand gendergender variancevariance (GV).(GV). ThisThis isis nownow beingbeing regardedregarded asas aa form ofof “Transphobia”."Transphobia". (This(This bred suspicionsuspicion and poorpoor trust ofof thethe therapeutic world). Hyper-vigilance-vigilance Suspicion and abuseabuse that Tran'sTran’s peoplepeople havehave experienced,experienced, hashas resultedresulted inin them beingbeing hypervigilanthypervigilant inin anyany givengiven situationsituation toto signssigns ofof hostility. This isis somethingsomething whichwhich isis possiblepossible toto occuroccur eithereither consciouslyconsciously oror otherwiseotherwise inin the consultingconsulting room. This mightmight presentpresent itselfitself in thethe form of the clientclient ashingasking quitequite directdirect questions about your understanding/ feelingsfeelings around gendergender identity. Therapeutic practitioners willwill needneed toto be: Ethically and morallymorally responsiveresponsive toto thisthis diversediverse clientclient group.group. Whist not underestimatingunderestimating thethe restrictionsrestrictions that have beenbeen placedplaced uponupon Tran'sTran’s people in pursuitpursuit ofof determining theirtheir healthhealth carecare needs. I seesee our therapeutic rolerole isis underpinnedunderpinned byby exploringexploring thesethese fourfour areasareas withwith our clients: - How they experience one'sone’s innerinner self. - How the world perceivesperceives one'sone’s outer self? - Sexual orientationorientation (who(who oneone isis sexuallysexually oror romanticallyromantically attractedattracted to).to). - And sexualsexual (orientation)(orientation) identity. II seesee an aspectaspect of the work?work focusesfocuses onon howhow thesethese fourfour waysways ofof beingbeing-in-in-the-the- world mutually impact onon oneone another.another. Which couldcould facilitate the clientclient toto reachreach fullfull integrationintegration intointo aa consolidatedconsolidated self/ actualisation. A potential outcomeoutcome of the work?work isis thethe affirmationaffirmation andand validationvalidation (of(of andand byby the client) towardstowards their gender/ sexualsexual identityidentity (even(even thoughthough itit willwill bebe a work?work in progress). Aiming possiblypossibly to achieve somesome comfortcomfort withwith theirtheir currentcurrent body configuration. This couldcould itselfitself diminish guilt/guilt/ shameshame and enhanceenhance self-esteemself-esteem inin the client. Trans-phobia-phobia in the Therapeutic Relationship Trans-phobia--phobia- within the contextcontext of the professionalprofessional worhingworking relationship between clinicianclinician and client:

pg.pg. 24 “Any`Any belief,belief, attitude, act oror behaviourbehaviour whichwhich negatively values, denies, undermines,undermines, discourages or disempowers transtrans-- identifiedidentified clientsclients in terms ofof theirtheir uniqueunique identities andand subjesubjectivective realities”.realities': WPATH Transphobic attitudes from medicalmedical serviceservice providersproviders are somethingsomething that Iran'sTran’s people are all too familiar of. Transposivitiy aimsaims to challenge thisthis with: - Positive values - Affirming - Supportive - Encouraging - AndAnd empowerment. History payspays testament of the mistrustmistrust by the transgendered community towards the mental healthhealth providersproviders due to transphobic attitudes that have and are stillstill taking place: “..".. Some things said toto me atat my last appointmentappointment e.g. that I/ shouldshould acceptaccept thatthat mmyy wifewife andand daughtersdaughters would bebe betterbetter offoff ifif II leftleft them,them, upset meme greatly. I/ leftthe the GICG/C andand satsat in the carcar cryingcrying forfor overover anan hour. I/ decideddecided therethere andand thenthen never toto go back.”back." So bearing the above in mind,mind, the professionalprofessional workingworking relationshiprelationship between cocounsellorunsellor and clientclient shouldshould ideallyideally be one that isis collaborative. With the scopescope for the therapist act asas an advocate for them. The overriding factor hearhear would be appropriateness and contractedcontracted into the work.work?. This way of working isis commoncommon outsideoutside of the UK, where a therapist will often act asas a "Gatekeeper".“Gatekeeper”. (Where(Where the client’sclient's progression through the layers ofof medicalmedical servicesservices is is supported byby thethe therapist).therapist). In thethe UKUK the involvement/ rolesroles of CounsellorsCounsellors andand PsychotherapistsPsychotherapists isis less clear, and at timestimes vague. Why Tran'sTran’s clientsclients accessaccess therapy? • OwnOwn motivation-motivation- selfself exploration. • NoneNone Gender Identity matters. • ContemplativeContemplative (exploring their gender, with a view to transitioning). • RequestedRequested to do soso asas part of transitiontransition processprocess by the hospital, (medical servicesservices are not convincedconvinced the client isis ready). • RequestedRequested to do soso asas part of the "Real“Real LifeLife Experience"Experience” transition process.

pg. 25 Advocacy and AllianceAlliance Building These reasonsreasons to accessaccess therapytherapy areare anan importantimportant aspectaspect inin thethe buildingbuilding therapeutic alliancealliance whenwhen workingworking withwith aa largelylargely marginalizedmarginalized andand discriminated populationpopulation likelike Transpeople.Transpeople. The TherapistTherapist asas advocateadvocate mightmight feelfeel likelike aa majormajor departuredeparture forfor mostmost therapists. Yet II believebelieve that with firm:firm: - Boundaries - InformedInformed hnowledgeknowledge - Clear client/ therapisttherapist contracting - Regular reviewing thisthis conceptconcept isis notnot unachievable. Dependant of the clientsclients presentingpresenting issue,issue, andand alsoalso ifif theythey areare transitioningtransitioning willwill determine if there willwill bebe thethe requirementrequirement toto introduceintroduce thethe rolerole of advocacy. If the clientclient isis !oohinglooking toto movemove towardstowards aa clinicalclinical transition,transition, andand theythey willwill bebe accessing medicalmedical services,services, nownow wouldwould bebe thethe timetime toto introduceintroduce thethe rolerole ofof collaborative advocacy. The Tran'sTran’s client'sclient’s rolerole isis toto describedescribe theirtheir experienceexperience inin termsterms of “themselves"themselves being in the world”,world", exploring andand determiningdetermining theirtheir needs. The therapist journeysjourneys withwith thethe clientclient observingobserving andand reflectingreflecting onon thethe client'sclient’s experiences. AndAnd liaisingliaising withwith thethe clinicalclinical servicesservices (thus(thus takingtaking thethe rolerole ofof healer/ advocate).advocate). Advocacy couldcould meanmean contractedcontracted clinicalclinical work?work ofof providingproviding appropriate,appropriate, boundaried, and clientclient agreedagreed updatesupdates ofof the therapeutictherapeutic work?work undertakenundertaken to the medical services. Advocacy asas a functionfunction of social activismactivism andand rolerole modelling. The Therapist actsacts asas an expressionexpression ofof power for their client.client. ThusThus enablingenabling thethe client to develop their own selfself--advocacyadvocacy skills.shills. These are examples of what isis calledcalled thethe "best“best fit"fit” approachapproach toto treatment. “Best"Best fit"-fit”- when workingworking transtrans-positively,-positively, meansmeans puttingputting thethe therapeutic contract to the test in termsterms of the collaborativecollaborative working. Willingness of the therapist and clientclient toto bebe openopen toto honesthonest negotiation around SOC. IncludingIncluding reasonablereasonable requestsrequests byby thethe client to accept realistic limitslimits givengiven byby clinical discretion. Trans-positivity-positivity within thethe clinicalclinical contextcontext impliesimplies a collaborativecollaborative working relationship basedbased onon mutualmutual trust,trust, respect,respect, andand flexibility,flexibility, withwith aa jointjoint commitment to operate in goodgood faith. ThuThuss delivering objectivesobjectives forfor clientclient-directed-directed counselling/counselling/ psychotherapy, aiming to foster the development of: SelfSelf--actualisationactualisation and selfself--empowerment.empowerment.

pg.pg. 26 There are currently very few TranspositiveTranspositive modelsmodels of treatment for GD. However, by taking an integrative approach the therapist standsstands a better chance for a sensitivesensitive approach to the client'sclient’s needsneeds whichwhich isis gender affirming. Clinical Orientation/Orientation/ Treatment Philosophy Don’tDon't assumeassume that becausebecause youyou knowknow you are client/ personperson centredcentred that the client will hnowknow this. The usualusual rulesrules apply asas with any new client work?.work. Building up mutual trust,trust, through the usual conditionsconditions of: Empathy, caring,caring, sensitivity,sensitivity, validating, acceptance,acceptance, compassion,compassion, and supportiveness. Remember you are likely to be thisthis person'sperson’s first positivepositive experience.experience. So be mindful of language we useuse which are inappropriate around Tran'sTran’s people (already covered today). Replacing thesethese with clientclient affirming language: - Gender distress/distress/ discomfort - Gender variance/ diversity - AndAnd transgendertransgender care Core values/ approaches that underpin the work?work are: - Client Centeredness - Individual treatmenttreatment plan Also I remindremind youyou of the "Standards“Standards of Care"Care” for the guidelinesguidelines of patient care: And I would remind youyou to useuse the phenomenological rulerule of EpocheEpoché "Explore“Explore don’tdon't assume”.assume". (No(No two transsexuals areare the same in terms ofof theirtheir personalpersonal expectations).expectations). The SOCSOC alsoalso statesstates that for those wishingwishing to undertake sexsex-reassignment-reassignment surgery are recommendedrecommended to complete the "real“real-life-life experience".experience”. The individual liveslives full timetime inin theirtheir identified gendergender usuallyusually aa minimumminimum ofof a year. The "real“real-life-life-experience"-experience” isis supposedsupposed to remove any lingering doubtsdoubts that an individual isis totally prepared forfor the irreversibleirreversible impact of sexsex-reassignment-reassignment surgery and theirtheir gender identity.identity. AndAnd isis seenseen asas a real-life-life "rehearsal".“rehearsal”. However, the RLERLE hashas beenbeen seenseen asas quite controversialcontroversial by somesome TransTrans people, because it has been felt that if a trans personperson waswas able to have what would be seenseen asas a successfulsuccessful experienceexperience (how doesdoes the psychiatristpsychiatrist interpreted that?) then clientclient would movemove to the next stage of medicalized treatment (usually hormones). So if the individual doesdoes not have what the psychiatristpsychiatrist would deem a successful RLERLE and thereforetherefore doesn'tdoesn’t think?think that the individual wouldwould be reareadydy

pg. 27 for the next stage of the transition what doesdoes that say about the transperson, their situation, and the feelingsfeelings they have regarding their gender? Are they then not Trans? Or not Trans enough? Yet more damage can occuroccur to the medical relationshiprelationship by tahingtaking a hard-linehard-line against supporting hormonehormone treatment. Provided the client isis wellwell informedinformed asas to the impact of tahingtaking hormones. Armed with thisthis information the client shouldshould be trusted asas to hnowingknowing what is the appropriate way forward inin thethe actualisationactualisation of their GI. Therapy isis somethingsomething whichwhich isn'tisn’t always needed or required by Tran'sTran’s people. Much himlike anyone elseelse really. However, for thosethose who do wishwish to accessaccess TranspositiveTranspositive Therapy it should be made available prior to and duringduring the transitional process.process. AndAnd if required post transition. The therapeutic benefits at eacheach ofof thesethese developmentaldevelopmental stagesstages cannotcannot bebe underestimated to helphelp clientsclients consolidateconsolidate their gender and sexualsexual identities. In thethe view of trans-supportive-supportive clinicians,clinicians, the view of therapy isis not to "Cure"“Cure” cross-gender-gender identification/ Dysphoria (as(as isis believedbelieved toto be thethe casecase byby some theologically bathedbacked therapists). RathRatherer to assistassist individuals to function moremore comfortably in the world with their identified gendergender identity. Therapy can alsoalso be beneficial forfor thosethose whowho mightmight bebe inin thethe earlyearly stagesstages of questioning, confused,confused, or conflicted aroundaround theirtheir gender/gender/ sexualsexual identity.identity. Therapists worhingworking with TransTrans clientsclients must exerciseexercise vigilance around potential counter-transference-transference issuesissues whichwhich arisearise during the coursecourse of therapy. An example of this would be "over“over-encouragement".-encouragement”. Where the therapist findsfinds themselvesthemselves overlyoverly investinginvesting thethe wormwork towardstowards aa particular outcome of change for the client. Consciously or otherwise, placing emphasisemphasis onon the client to relinquish hishis or her transsexual self-identity.self-identity. Or the pursuit of sexsex reassignmentreassignment (changing one'sone’s sexsex == body) As opposedopposed to adoptiadoptingng a gendergender identity (changing one'sone’s gender == body) and or sexual identityidentity gay/ lesbian, bisexual. Due to the diversity of the gender population, and the practical implications of the individual'sindividual’s needs. It cancan bebe essentialessential forfor the therapist to be aware of the various permutations of outcomes that clientsclients may request.

pg. 28 Possible desired outcomesoutcomes being: • SexSex hormoneshormones and sexsex reassignmentreassignment surgery (unless(unless they identified as nonnon-- operative) • TranssexualsTranssexuals asas opposedopposed to Transgendered (who might want only hormones or surgery, not both, or who might want no form of medical intervention). Marginalized SubpopulationsSubpopulations within thethe TransTrans demographic. Youth Parents & prospective parents Seniors & grandparents People of colour & newcomers Sex trade wormersworkers People with disabilitiesdisabilities People living with HIV/ AIDS Low Income & homeless people Incarcerated oror institutionalized Individuals

Marginalized SubpopulationsSubpopulations within the Trans demographic. The acceptable Tran'sTran’s Narrative: This isis the now familiar storystory which getsgets brought out inin thethe popular tabloid media regarding Tran'sTran’s people, usuallyusually describingdescribing a white, employed, and well educatededucated individual. They are familiar storiesstories by now they soundsound almostalmost generic e.g. “Ever"Ever since childhood, so-and-soso-and-so feltfelt theythey werewere trappedtrapped inin the wrong body”body".... …. …....".” EventuallyEventually theythey gotgot thethe help they neededneeded andand transitioned,transitioned, and thingsthings areare better now,now, but theythey stillstill havehave struggles from time to time”time" The storiesstories we don'tdon’t hear: We are not familiar with the storiesstories lamlike this: “…Of"...Of innerinner-city-city Tran’sTran's women ofof colour,colour, who grew upup disadvantaged, below thethe poverty line, poorly educated,educated, disowned byby family,family, and turnsturns to sex workwork oror livingliving on the streets to survive, using drugs to cope, and vulnerablevulnerable to abuseabuse by punterspunters andand pimps…”pimps..."

We don'tdon’t hear thesethese storiesstories but they do happen over and over. AndAnd usually do not conclude on a hopeful note.note. EachEach year "The“The Tran'sTran’s Day of Remembrance" is a roll-call of those who have been murdered in the last Remembrance” is a roll-call of those who have been murdered in the last year purely becausebecause of their gender identity and Tran'sTran’s statusstatus e.g. "Chrissie“Chrissie Azzopardi 2009"2009” or "Lucy“Lucy Meadows 2013"2013” (See(See Below)

pg. 29 r:IIITTLEJOHN - He's not only in the ersadle!()c6e wrong body... he's It/e wards? in the wrong job Lg-W.

Also we don'tdon’t hear about thethe largelarge part ofof thethe Tran'sTran’s populationpopulation that rails against goinggoing fromfrom oneone gendergender toto thethe other,other, againstagainst ourour notionnotion ofof whatwhat isis male and female. But thesethese people are all out there and onon thethe continuum,continuum, andand somesome may find their way to youryour consultingconsulting roomroom door.door.

Your PossiblePossible ConcernsConcerns withwith WorhingWorking withwith ThisThis ClientClient Group:Group: - I don'tdon’t think?think II cancan actact asas anan advocateadvocate forfor thethe client,client, it'sit’s not what I'mI’m trained in! HowHow doesdoes thisthis fitfit inin withwith mymy clinicalclinical practice?practice? - Do I needneed to be a speciallyspecially trained therapist?therapist? Obviously when ashingasking yourselfyourself thesethese questionsquestions givegive considerationconsideration toto the:the: BACP EthicalEthical Framework?Framework for GoodGood PracticePractice inin CounsellingCounselling && Psychotherapy,Psychotherapy, in particularparticular the "Values"“Values” andand "Principles"“Principles” Values of Counselling & Psychotherapy - RespectingRespecting human rightsrights and dignity - Protecting the safety of clients - EnsuringEnsuring the integrity of practitioner-client-client relationships - EnhancingEnhancing the qualityquality of professional Knowledgeknowledge and itsits application. - AlleviatingAlleviating personalpersonal distressdistress andand suffering - FosteringFostering a sensesense of self that isis meaningfulmeaningful toto the person(s)person(s) concerned.concerned. - IncreasingIncreasing personalpersonal effectiveness - Enhancing the quality of relationshipsrelationships between people - AppreciatingAppreciating the variety of human experienceexperience andand cultureculture - Striving for the fair and adequate provisionprovision ofof counsellingcounselling and psychotherapy services. Ethical PrinciplesPrinciples of Counselling & Psychotherapy - BeingBeing trustworthy:trustworthy: honouringhonouring the trusttrust placedplaced inin thethe practitionerpractitioner (also referred to as fidelity)

pg.pg. 30 - Autonomy:Autonomy: respectrespect for the client'sclient's right to be self-governingself-governing - Beneficence:Beneficence: a commitmentcommitment to promoting thethe client'sclient's well-beingwell-being - NonNon-maleficence:-maleficence: a commitmentcommitment toto avoidingavoiding harmharm toto the client - Justice:Justice: the fair and impartialimpartial treatmenttreatment of all clientsclients and thethe provision of adequate services - Self-respect:Self-respect: fosteringfostering the practitioner's self-knowledgeself-knowledge and carecare for self. I don'tdon’t think?think I cancan actact asas an advocate for the client, it'sit’s not what I'mI’m trained in! (And howhow doesdoes thisthis fit inin withwith mymy clinicalclinical practice?) Ultimately advocacy could mean providingproviding somesome form of a written acknowledgment of the work undertaken, that the client can showshow to medicamedicall practitioners. As longlong asas thisthis isis client contracted and permissionpermission granted, thisthis cancan run smoothly. Is youryour concernconcern about shillsskills oror confidence? Familiarize yourselfyourself with the "Standards“Standards of Care"Care” containedcontained inin the WPATH. “To"To provide clinical guidanceguidance for heahealthlth professionals toto assist transgender,transgender, transsexuals,transsexuals, and gendergender nonnon--conformingconforming people with safe andand effectiveeffective pathways to lasting personal comfortcomfort withwith their genderedgendered selves.selves. In orderorder toto maximize their overalloverall health,health, psychological wellwell-being,-being, and selfself-fulfilment."-fulfilment.” Is thisthis notnot what we do with allall ourour clients? Most TransTrans People know the Care Pathways quite well. If you’reyou're not suresure of something don'tdon’t be embarrassedembarrassed to ask?!ask! Do I needneed to be a speciallyspecially trained therapist? A lot of what I have been talking about here today asas part of the “Transpositive"Transpositive Model"Model” isis what you dodo with your clientsclients already. Tran'sTran’s clients just want to be treated like anyoneanyone else. You have already developed youryour knowledge through thisthis CPD. The Information givengiven today isis a strongstrong tooltool that cancan bebe built upon. This dependsdepends onon the level/ depth of work your consideringconsidering undertahing.undertaking. Some Tran'sTran’s clientsclients will have needsneeds whichwhich youyou are able to accommodate and some not. ThisThis CPD hashas addressedaddressed all areasareas youyou are likely to encounter. Ask questionsquestions of what the client needsneeds might be, and what they seesee progress as being?being? ThisThis will enableenable you to gauge if the client isis presenting something you cancan work?work with. CheckoutChechout with yourselfyourself how youyou feelfeel about the potential work?,work, and like any other piece of clientclient work know your limits. Also if I may return too two specificspecific aspectsaspects ofof thethe "BACP“BACP EthicalEthical Framework?Framework for Good Practice":Practice”:

pg. 31 Beneficence: a commitmentcommitment toto promotingpromoting thethe clientsclients well-being.well-being. Non-maleficence:-maleficence: a commitmentcommitment toto avoidingavoiding harmharm toto thethe client. Remind yourselfyourself that the client relationship isis of upmost importance for delivering a positivepositive outcome. And of coursecourse useuse your supervision. Thank youyou forfor your time and interest,interest, andand if you have questions after today pleaseplease do get inin touch: 07891 400934 [email protected] Resources Books: Gender Trouble, Judith Butler, 1999,1999, Routledge, ISBN0415924995 Please Select Your Gender, Patricia Gherovici,Gherovici, 2010, Routledge,Routledge, ISBN9780203872222 S/he, Claudine Griggs,Griggs, 1998,1998, BERG,BERG, ISBN1859739164 “Whippi"Whippingng Girl:Girl: A TranssexualTranssexual Woman on SexismSexism and the Scapegoating of Femininity”,Femininity", Julia Serano,Serano, 2007, SealSeal Press,Press, ISBN1580051545 The TranssexualTranssexual Experiment, Robert J.J. Stoller, 1975,1975, Hogarth Press,Press, ISBN0701204001 Blending GendersGenders (Social(Social AspectsAspects of CrossCross-dressing-dressing and sexsex changing), Edited by Richard Ekins & Dave King, 1996,1996, Routledge,Routledge, ISBNO-415-11552-3ISBN0-415-11552-3

Websites:

GIRESGIRES-- Gender Identity & Education Society,Society, www.gires.org.uhwww.gires.org.uk UK charity that sponsorssponsors research and education onon gendergender identity.

Gender Trust, www.gendertrust.org.uhwww.gendertrust.org.uk The largest registered charity helping TransTrans people and all thosethose affected by gender identity issues.

The Beaumont Society, www.beaumontsociety.org.uhwww.beaumontsociety.org.uk The largest and longestlongest establishedestablished transgenderedtransgendered support group.group.

Gender Matters, www.gendermatters.org.uk We provide a comprehensive programme of practical support, counselling,counselling, advice and information.

FTM, www.ftmlondon.org.thwww.ftmlondon.org.uk A peer support group for female to male transgender or transsexual people.

The UK Angels,Angels, www.theangels.co.uhwww.theangels.co.uk An internet based support group aimed at promoting the positive side of transgenderism.transgenderism.

pg. 32