1
CHAPTER 1
Introduction
The True Colors of Authenticity
I see your true colors
Your true colors
(Written by Billy Steinberg and Tom Kelly)
The quest to know our true identity is a challenging process that evolves over a lifetime.
Transitions are inherent for everyone, yet these shifts of physical, intellectual, emotional, social and spiritual change are even more challenging for transgender or gender non-conforming
(GNC) youth. Transitions include birth, childhood, adolescence, adulthood, death and everything in between those phases that embraces a shift or an adjustment to a life circumstance.
When these life phases also include an evolutionary change of the individual as well, it can be a difficult and seemingly never ending journey.
The journey toward self starts with the pronouncement of our biological or assigned sex.
The moment the declaration boy! specific gender begins. For many of us gender simply is. It is not something that is questioned, debated, or defended.
1 2
What happens to the transgender child when that declaration of assigned sex
or in other words, their gender identity or gender expression does not conform to the sex of their body? How might they adapt healthfully into a world that often rejects atypical presentations of what it means to be a boy or a girl? How can mental health care professionals best guide, assist and support these children and their families through this process? Kate Bornstein (2013), author and transgender activist, stated The genders
well-rounded, creative, loving people I . (p. 73).
When transgender youth are insistent, persistent and insistent regarding their gender, we need to look and listen to what they are really saying because they are providing us with invaluable information about themselves and how they relate to the world.
Transgender children and adolescents are an underserved and poorly researched population that has very specific medical and mental health needs (Olson & Forbes, et.al, 2011).
Finding comprehensive medical and mental health services is extremely difficult for these youth who are at risk for multiple psychosocial problems including family and peer rejection, harassment, trauma, abuse, inadequate housing, legal problems, lack of financial support, and educational problems.
The Purpose of the Study
This descriptive, qualitative study will address the various ways trained counselors may begin to understand concerns facing transgender youth and their families. The author will describe how the expressive arts therapies might be used as an adjunctive modality to help clients navigate and cope with core issues often seen in a counseling setting. This will include timely medical interventions paired with affirmative mental health approaches to minimize 3 negative outcomes and maximize positive futures for transgender youth. Latest research on counseling transgender youth and their families will be discussed, particularly through the use of the expressive art therapies: with an emphasis on poetry and narrative therapy; art therapy and music therapy. After describing a personal relationship to the topic of transgender youth and the expressive art therapies, the study will include three case examples of transgender youth and will incorporate their poems, stories, and drawings. Informed consent informed assent from the clients was obtained prior to the study (see Appendix B). Pseudonyms
The questions that this study sought to explore included: How might a counselor employ solid practices to assist the transgender child and their family develop awareness, obtain professional assessment and treatment approaches and finally foster acceptance that will promote healthy communications, transitions and daily living? What are the various ways clinicians can help trans-variant children to express the unfolding story of their lives in a way that will lead toward psychological fulfillment, balance and maturity?
My interest in studying transgender populations or transsexuals (as it was commonly called then) began in the early 1980s when I was completing a genogram (family tree) for my graduate class in family therapy so that I could understand patterns and connections that made my family unique. However, there were parts of my family tree that were truncated or left blank and I had questions that only certain people could answer. I went to my mother for clarification.
She had difficulty answering at first and finally said, just some things that families
eds to know this, anyway?
sex and other private matters, but I was relentless and needed to complete my assignment. She 4 gave me just enough information to satisfy me for the moment and then never spoke about it again. I completed the genogram with her minimal information, but my curiosity was piqued. I wanted to know more about my cousins in particular, but realized this information would not be forthcoming any time soon, and certainly not from my mother. Did mom swear to secrecy not to reveal certain information about our family that she felt were taboo? Was she embarrassed or
of authority or knowledge to answer?
Sorting out the necessary facts from the assumed or unknown is no trivial matter. It takes steadfast research and acceptance of particular findings. Sometimes what is uncovered is not palatable as this often includes an exploration of the areas of discord or dissonance. Even when equipped with a strong flashlight, accessing these dark spaces can feel a bit intimidating.
Most families have secrets or skeletons that they choose not to reveal. For some, this may include sexual orientation, infidelities, divorce, or mental illness. This emotional baggage can be difficult to carry, let alone unpack. For transgender youth and their families, this developmental process of privately and publicly coming out can be challenging.
Becoming a Gender-Sensitive Counseling Professional
Treatment approaches for gender identity issues in youth generally falls into 1 to 3 categories. The first of these is affirming approaches that are based on certain fundamental concepts, including the idea that being transgender is not a mental illness. Affirmative approaches actively promote exploration of gender identity and assist adolescents and their families in learning about and engaging in appropriate gender transitioning interventions, such 5 as social transitioning and hormone therapy. The second treatment approach involves supportive therapies, which generally endorse a wait and see approach on how gender identity unfolds as the child ages; supportive interventions are not focused on gender specifically and do not advocate any gender- identity with biological sex. The corrective strategy is the treatment that has been researched in the most depth; however, many experts express serious concern about how success is defined in these studies and the harm done to youth by invalidating their sense of self (APA, 2009).
Gender- what they are truly saying about themselves. It is imperative that these children are given a chance to grow, discover and articulate their story in their own time frame and in their own way.
Gender-sensitive professionals offer services not to fix the child, but to build resistance, sort out conflicts, facilitate family and community supports, supply evaluations and recommendations to other health professionals. In addition, they provide a private, creative and safe space when needed for children to express and explore their gender selves, selves that may radically go against the grain of the culture in which they live (Ehrensaft, 2011).
Successful outcomes will rely on the ability to form and network with a team of experts in all areas of emotional, physical and spiritual knowledge and support. Clinicians will need to also be mindful of the possibility of burn out, especially if they are working in a vacuum as a sole practitioner without the support and necessity of such a vital team of experts. The successful clinician works as a liaison for resources regarding family concerns as well as providing contacts within the community to assist with school, medical or social issues. Reinforcement of family acceptance and understanding of transgender youth is also highlighted. 6
For the first time, researchers have established a clear link between accepting family attitudes and behaviors towards their lesbian, gay, bisexual, and transgender (LGBT) children and significantly decreased risk and better overall mental health in adulthood (Family
Acceptance Project, 2010). The study shows that parental support and advocacy fostered greater self esteem and social support in young adulthood. The behaviors of support helped to protect against depression, substance abuse, suicidal thoughts and suicide attempts in early adulthood.
No prior research had examined the relationship between family acceptance and support for
LGBT children.
The LGBT acronym has finally changed to include the T for transgender people.
Sometimes the acronym appears as LGBTQIA, with Q representing questioning or queer people,
I for intersex, and A for allies (straight supporters), or, less frequently, asexual. However, for the purpose of this study, I will use LGBT.
The very act of naming is powerful. It is a declaration and a construct of our own identity. According to Lori Selke, a poet included in the anthology, Troubling the Line: Trans and Genderqueer Poetry and Poetics , (2013) its own rules, its
that cannot be expressed in traditional grammatical forms can be articulated in another way ... through allusion, through sound, through wordplay. Genderqueers like me, do something similar
A good counselor finds the ability to help clients express the inexpressible through their witnessing of an unfolding story with an authentic respect and compassion for the client as well as precise knowledge in their area of expertise. Often, we are the first to hear their particular story unfold. 7
In using affirming treatment strategies, mental health therapists and physicians do not define adolescents as transgender but rather affirm their sense of self, allow for exploration of gender and self-definition and give the message that it is entirely acceptable to be whoever you turn out to be (Olson, 2009).
Gender Transitioning
Gender transitioning is often complicated and requires a series of steps, guidelines and access to people who can assist in all phases of this multi-layered process. Physical, biochemical and environmental influences are some of the aspects of gender transitioning. These occur in phases of reversible, partially reversible and irreversible stages. Counselors will benefit from a general introduction to some of the various treatments available for assisting transgender youth in this process.
There are a variety of paths that clients follow because some will not choose these transitional milestones. Not all transsexual people will follow these steps because they may choose an entirely different path that works in accordance to their specific desires, needs and availabilities.
Reversible Treatments
The reversible stages of gender transitioning includes the adoption of specific gender hairstyles, clothing, play, using a new name, and suppression of puberty with gonadotropin- releasing hormone (GnRH). The portions of the reversible phase that do not involve suppression of puberty sometimes occur before the age of 10 (Olson & Forbes, et. al, 2011). Transitions that are allowed to happen before the onset of puberty is controversial and should be determined by a close evaluation of both risks and benefits in a thorough decision making process shared among health professionals, parents and children. 8
It is important to note that before the onset of puberty, no hormonal interventions are necessary. However, as soon as a child begins to show signs of puberty, it can be extremely distressing and bring increased body dysphoria and a potential for developing anxiety, depression, increased suicidal ideation and attempts, substance abuse and high risk sexual behaviors (Olson, 2011). The guidelines from The Endocrine Society suggest suppression of puberty at Tanner 2 for patients when GID is diagnosed (2009). This suppression is accomplished in much the same way with GnRH for precocious puberty with good results. The child often makes significant improvements on social, psychological, physical and spiritual levels.
Hormonal treatments can make dramatic changes for the clients, both in how they look and how they feel. Most of these changes are positive, including the immediate sense of well- being that may be more psychological than physiological (Lev, 2004). Females transitioning to male (FTM), as well as males transitioning to female, (MTF), experience an increase in well being, a lessening of tension and a sense of greater relaxation (Cohen-Kettenis, 2009). As clients begin to take hormones and live in their new gender identities, they often grow into their new identity, and like the proverbial snake shedding their skin, it is difficult to remember who they were before since the new skin fits so well. (Lev,2004 p. 262). For both men and women, the emotional freedom of being on hormones, regardless of the actual physical changes, is a great relief.
Of course, there are cautions and concerns that clients and their families have as well.
Long term effects of the hormones for transgender youth is a relatively new field and one that must be explored further, but early findings have been promising, especially with the use of cross-gender hormones. (Olson, 2009). 9
Other common concerns are: insurance companies do not always cover these medical interventions or even recognize the need for GID to be included in health care plans, and there is some debate regarding the effect of these inhibitors on bone density and height (Delemarre &
Kettenis, 2006). There are complicated logistical factors surrounding the initiation of GnRH and cross-gender hormones. Ideally, adolescents should be treated early to facilitate psychotherapy by easing stress, buying time to avoid depression, and prevent unwanted secondary sex characteristics, thereby reducing the need for future interventions (Olson, Forbes, et. al, 2011).
Partially Reversible Treatments
The use of cross-gender hormone therapy is part of the partially reversible treatment for transgender youth. While The Endocrine Society guidelines (2009) recommend deferring partially reversible treatments like estrogen and testosterone therapy, it is often not pragmatic to delay the initiation of treatment with cross-gender hormones until the patient becomes 16 years of age. Delay can lead to similar emotional concerns associated with the delay of puberty.
Unfortunately, this approach is unstudied, so professionals are urged to consider a case-by-case evaluation after potential risks and benefits have been reviewed. Cross-gender hormone therapy for female to male patients (transgender males), means the administration of testosterone and for male to female patients (transgender females), estrogen, usually in combination with an androgen inhibitor such as spironolactone, would be appropriate. (DeVries, 2007). Ideal treatments would begin before the development of secondary sex characteristics. Again, precautions must be taken as some research includes adverse effects of hypertension, decreased libido, increased risk of breast cancer, liver disease, decreased blood pressure and other factors (Futterweit, 1998).
Adolescents undergoing cross- gender hormone therapy need ongoing care, including monitoring for potential medical complications as well as a success assessment regarding 10 masculinization or feminization. In the first year of therapy, patients are usually monitored every
3 months (Olson, 2011).
Irreversible Phase
Sexual reassignment surgery to create a more masculine or feminine appearance are available for transgender youth, but with some precautions and restrictions. Some of these options include vaginoplasty (vaginal construction), labioplasty (Construction of the labia or outer structures of the vagina), tracheal shave, liposuction, breast implants, jaw reshaping, and orchiectomy (surgical removal of one or both testicles) for transgender females; for transgender males, mastectomy, construction of a neoscrotum (surgical construction of the scrotum) or phalloplasty (surgical construction or reconstruction of the penis) can be performed. Female to male patients also may choose hysterectomy (removal of the uterus) and oophorectomy (removal of the ovaries) later in adulthood (Brownstein, 2010).
It is difficult to get surgeons to perform sexual reassignment operations in patients younger than 18 in the United States, although mastectomies in transgender males younger than
18 are becoming more common (Olson, 2011).
The World Professional Association for Transgender Health (WPATH), formerly the
Harry Benjamin Society, created a Standards of Care (SOC) document for the health of transsexual, transgender, and gender non-conforming people (TG/TS/GNC) that outlined in great detail, globally applicable standards which include: mental health; an overview of therapeutic approaches; measurement; and treatment of children and adolescents with gender dysphoria
(2011). It is important to know that the emphasis of the SOC was to provide a trans-affirmative approach to health care. It addressed the differences between gender non-conforming and gender dysphoria, hormone treatment, surgery and post-operative care, as well as lifelong issues of both 11 preventative and primary care. It is an invaluable guide for clinicians and their clients. A summary of the new document (Version 7) is available online at www.wpath.org .
The SOC (WPATH, 2011) can be helpful in educating providers in how best to help and support clients through the use of specific guidelines that are congruent with the quality of care and the reality of resources as well as the need for harm reduction. The basic guidelines for all health care professionals are as follows:
Show respect for all non-conforming gender identities and expression; do not
pathologize.
dysphoria.
Become knowledgeable about and sensitive to the specific health care needs of
the TG/TS/GNC individuals, including the risks and benefits of various treatment
options.
expression.
Seek fully-informed consent before providing treatment.
Facilitate access to appropriate treatments not provided by the particular care
provider.
Offer continuity of care and coordinate treatment with other providers.
Be prepared to provide support and advocacy for transgender
(TG)/Transsexual(TS)/ gender non-conforming (GNC) patients within their
families and communities. ( www.wpath.org , 2011) 12
The SOC Version 7 (WPATH, 2011) provides details regarding treatment options for children and adolescents who present with gender dysphoria. The existing research (Teich, 2012) has found that many gender variant children outgrow the desire to be a different gender, becoming either gay or lesbian as adults, or simply gender-variant heterosexuals, happy with their assigned gender. However, when gender dysphoria appears in adolescence, it is more likely to be both enduring and acutely distressing. For this and other reasons, there are greater cautions and extensive protocols in place for treating gender-variant children.
Competency requirements for mental health counselors who work with gender variant children and adolescents as well as adults, need to have experience and background education in developmental psychology, gender development and diversity, and psychopathology. The guide further outlines the multitude of roles the provider must have including, but not limited to: skills and experience in assessing gender dysphoria (formerly called gender identity disorder or GID), child and family counseling, assessment and treatment of co-existing mental health issues, a referral base for medical support and consultation, education, advocacy and peer support. The assessment phase of care includes the risks as well as the benefits of options that are both available and viable for the individual or their family members (Boedecker, 2011).
The National Center for Transgender Equality (2010) provided SOC for those who are considering or undergoing gender transition. Following these standards is entirely up to the individual and their families, in making decisions about health and mental health care. These standards included:
Counseling with a mental health professional.
period. 13
Learning about the available options and the effects of various medical
treatments.
Communication
readiness to begin medical treatment (usually in the form of a letter).
Undergoing hormone therapy.
Having various surgeries to alter the face, chest and genitals to be more congruent
with the in . (National Center for Transgender Equality,
2010)
for his contributions to the field of transgender assessment and treatment. He and colleagues
Laura Edwards-Leeper, Ph.D, a leading expert in gender dysphoria, and urologist David
Diamond, M.D, have helped launch the first pediatric academic program in the Western
Hemisphere to evaluate and medically treat young transgender people. Their program, Gender
Hospital was started in 2007. It is one of only a handful of clinics in North America to treat transgender children and adolescents. This program is modeled after a Dutch clinic which has been successful in treating transgender youth since the 1990s. The protocol includes a rigorous series of psychological testing as well as a
interventions such as halting puberty with pubertal suppressors or inhibitors (GnRh) may be introduced (Olson, 2011).
Spack (2013) has been criticized for his work in pediatric endocrinology and has been targeted as interfering with nature. He stated that for the appropriate patients, the use of puberty inhibitors not only prevents severe psychological distress, but allows these young adolescents a 14 chance to begin to blossom into their true selves (Hubbard & Whitley, 2012). This can be a difficult process if emotional management is not available or worse, misunderstood.
The introduction of puberty suppressors and hormone therapy for children and adolescents is a heated issue. In fact, there is probably no area of transgender health care that elicits as much controversy as the issues raised regarding the psychotherapeutic and medical needs of gender-variant and gender dysphoric children and youth (Lev, 2004). There are also emotional landscapes that must be thoroughly explored. Olson reminds clinicians that therapy is recommended to ensure that transgender youth have the support they need and a safe place to explore their identities and process the transitioning experience not because they are inherently disturbed (Olson, 2011).
Shame, fear, doubt and despair are four of the inner demons that Boedecker (2011) referred to as primary obstacles to gender transitioning. Shame is a constellation of related emotions that includes regret, self consciousness, remorse and guilt. In addition to the shame, many transgender youth have developed complex defense mechanisms to protect their authentic identities. Often, this internalized shame is related to their gender dysphoria and is accompanied by dislike of their genitalia, confusion over their sex role behavior, difficulty with sexual expression, sexual feelings and the expression of relational intimacy (Bockting et al., 2007). In its most basic sense, shame makes us feel vulnerable and can leave a lasting scar.
Most transgender youth may remember a time of ridicule or disapproval, teasing, harassment or even cruelty because of their being and feeling different from typical gender representations and this may create a pervasive amount of fear. Fear is a common emotion that can be both an ally, when it serves to protect or warn a person or an enemy when it is constant, intermittent, known or unknown. 15
Coming out as transgender often carries a substantial weight of conflict and anxiety, such as fear of being rejected, being misunderstood, bullied, harmed or humiliated. The impact of these concerns are influenced by various factors such as age, race, sexual orientation, and level
feel safe publicly or privately. They are threatened by the looming reality of puberty, and the lack of resources and support to cultivate security in that area of development. It is important to evaluate, assess and take action on the fears that keep bogging down the process toward authentic transitioning. Facing fear is paramount to realistic expectations and outcomes and helps individuals and families accept the possibility of resistance as well as restoration (National
Center for Transgender Equality, 2010).
When doubt and despair permeate, it is a reminder that as counselors, our work may just be starting. An intense emotional state signals a need to assist in the exploration of solutions or
endocrinologists, gender specialists, psychologists, advocates and other support systems is paramount to successful resolutions for emotional and medical needs.
Beemyn and Rankin (2011) found that the younger the person, the greater the likelihood the person felt unsafe because of their gender identity/expression. The study found that 19% of participants who were 18 years old or less and 18% of those who were 18 to 22 years old reported that they often feared for their physical safety, as compared to just six percent of respondents who were at least 53 years old. In addition, transgender youth who met sociocultural expectations (i.e., were attracted to people of a different gender) were less likely to have experienced harassment, and this probably contributed to their being less likely to fear for their physical safety. 16
Personal Perspective on the Unfolding of Gender Narratives
All of us have an ancestral closet that requires a certain key to gain entry. I was naturally curious when it came to my family because even though some of us were geographically distanced, we were emotionally close. This often is not the case. My particular family tree included some diversified branches. I learned about an openly gay cousin who had a life partner for over 30 years and was an extremely successful and creative individual and a transgender cousin that completed her transition late in life. Both were artistic, accomplished people in their own right, yet they had been somewhat marginalized and perhaps judged by not only members in our own family, but society as well. , respected or easily understood roles or identities. I was slowly becoming acquainted with the full meaning of what it meant to be different and what the possible costs might be as well.
Family therapists often talk about family secrets and
act of suppression is for self-preservation or a way to manage pain. In the past few decades, the issue of gay, lesbian, bisexual and transgender
only as sick as our secrets. This can be interpreted that the more we hide a truth, the greater the chance of a negative impact to our bodies, mind and spirit because of stuffing emotions that need to be heard or stopping actions that need to be taken. Honest expression with a trained, compassionate professional toward a mutual goal may eliminate many of the stressors experienced by transgender youth and their families.
This was a jump start into my research about sexual orientation and gender variations because now it included family members. I felt the impact of conversations around me on a more personal level. I did not yet know just how crucial these early experiences of curiosity 17
would be and how they would further shape and reshape my professional career. Soon, I would learn about the importance of allowing the authentic self to emerge.
Expressive Arts Therapies
I studied English and mass communications as an undergraduate and learned about creative avenues of expression through the lens of the camera as well as the pen. As both a photographer and a writer, I knew how helpful the expressive arts had been as a cathartic release for complex emotions that evaded expression through simple conversation.
I learned how pen, paper, paint and poetry could be life saving and transformative. The act of creating art for relief or release helped to clarify thoughts and reduce angst on a physical as well as an emotional plane.
Dr. James Pennebaker (1990) conducted the first landmark study to link the ability to express oneself on paper with enhanced emotional and physical health. Pennebaker (1997) asked students to write their deepest thoughts and feelings about the most traumatic events in their lives for a short period of time over four consecutive days. This was in comparison to control subjects who wrote about trivial daily activities. The results showed significant increases in the
on. In further studies, chronicled in The Writing Cure (Lepore & Smyth, as cited in Reiter, 2009), the most recent comprehensive collection of studies in the field, it was noted that writing not only affects heart rate, blood pressure and the immune system, but the act of writing, in and of itself, resulted in the restoration of emotional equilibrium and stress reduction.
Expressive therapies are those that introduce action to psychotherapy and that action within therapy and life is rarely limited to a specific mode of expression. According to the 18
National Coalition of Creative Arts Therapies (NCCATA) , the expressive art therapies encompasses the use of art, music, dance/movement, drama, poetry/creative writing, play and sand tray within the context of psychotherapy, counseling, rehabilitation or health care.
Additionally, expressive therapies are sometimes referred to as integrative approaches when purposively used in combination in treatment (Malchiodi, 2005).
Early creative art therapists have identified the need for innovative education that
Edith
Kramer (1971), a pioneer in the art therapy field, stated a means of supporting the ego, fostering the development of a sense of identity, and promoting
p. xiii). Kramer (1958) further explained how making art and the act of creativity itself, was central to the healing process: make available to persons the pleasures and satisfaction which creative work can give and by this insight and therapeutic skill to make such experiences meaningful and valuable to the total
(pp. 5-6).
Whitmont and Kaufmann (1973) discussed art in the context of analytic psychology:
All too often, artistic products are analyzed reductively, traced to the family constellation of the
something universal and timeless, exist is neurotic, but may because he is creative and has to contend with powerful forces within himself (as cited in Mazza, 2003, pp. 108-109).
I immersed myself in the arts and studied to become a Certified and then Registered
Poetry Therapist through the credentialing board of the National Federation of Biblio-Poetry
Therapy (NFBPT). This entailed completing a rigorous program of study and direct supervision 19 under a trained clinician. A total of 440 hours are required for the Certification track alone. I accumulated over 975 hours in Poetry Therapy in both the developmental and clinical tracks in the specific areas of didactic studies, peer group hours, supervision and facilitation.
I returned to school for my Masters in Counseling Psychology and two years after graduating, continued my education and became a Certified Sex Therapist with the American
Association of Educators, Counselors and Therapists (AASECT). I worked with a wide range of people during this time in my private practice that also included work in nursing homes, corporations, hospitals and schools, utilizing the arts as adjunctive tools to help people express and release emotions that had been stuck, bound and chained to secrecy, ignored or unrealized.
Poetry has an evocative tone and entices through both rhythm and language an emotional response. We use it to call forth a feeling and use the language of recognition and of association that ultimately produces understanding. We use the poetic language of primary process: analogy, symbol, condensation, displacement, and by observing the written and spoken poetic words, we explore primary and secondary process for greater self-understanding and expression
(Heller, 2009). The focus of this work is never on the product or what may have been created in a session, but rather on the process; the vehicles and realizations that take us from entry points of confusion toward conclusions of clarity or completion.
The reading and writing of poetry, short stories, songs and other literature can be a cathartic and integrative healing practice that allows an individual to open a door to profound expression and emotional freedom. It encourages reflection as well as integration and may be helpful for resolution of conflicts, reduction of anxiety, and the rechanneling of psychic energy for problem solving purposes (Alschuler, 2006). 20
Poetic language often creates mirror images and word pictures that help individuals deflect difficult emotions or reflect on inner processes. Poetry and expressive writing has always been a balm for me. It provides a template as well as a tool kit for bridging hurt with healing.
Utilizing the arts as a healing agent has profound possibilities, especially for marginalized populations.
Parents and Other Strangers : A Creative Guide to Better Relationships (Grayson &
White, 1987) was one of the first books to utilize all of the creative and expressive art therapies as adjunctive tools in a counseling setting. It was written as a collaborative effort of over 20 years of experience in the field of mental health counseling, to show how effective the expressive arts can be to help alleviate family tensions and unravel both the trauma and the victories of relationships within ourselves as well as with others. Using actual case histories, the book emphasized the therapeutic value of the expressive arts with multiple word and art exercises to help the reader experience the expressive art therapy process on a deeply personal level. This study expands that initial premise to include specific work with transgender youth and their families in order to incorporate the latest research and therapeutic modalities available for maximum mental, emotional and physical health.
The use of expressive art therapies and their valuable contributions for transgender youth have only recently been recognized. Innovative and multi-faceted youth organizations and publications have evolved over the past five years and continue to grow. The Haven Youth
Project, created by founder, author and artist Dylan Scholinski (2013), is a Denver- based studio where LGBT youth express, create and reclaim their stories, identities and lives, through art.
The Haven Youth Project, created to support art as suicide prevention for LGBT youth is now nationally known. Scholinski, author of The Last Time I Wore a Dress: A Memoir (1997) was 21 born as a biological female, was labeled mentally ill and was institutionalized from ages 15 to 18 for being transgender. He credited expression through art for saving his life and stated:
y purpose is to encourage the sympathetic indulgence of emotions...to reacquaint
autobiographical and
if we came to terms with being would beg (Sent (a) Mental Studios.weebly.com).
While the phenomenon of transgender is uncommon, the media has begun to cover the subject more frequently since 2003. This is particularly true when it comes to queer youth, but we do not necessarily have enough information on how to deal with the specific concerns with this population in therapy (Kleinplatz, 2012). It seems that more adolescents and children are coming out as transgender at an earlier age yet it is difficult to know if this is due to better diagnostic developments, biological determinants, or socio cultural acceptance. In spite of this emergence, transgender children and adolescents are still an underserved and poorly researched population that has specific, necessary needs in the mental health and medical arena.
I have maintained a private practice, consulting and teaching schedule since 1978, and I have noticed the various shifts of my practice throughout the years regarding the LGBT population and the services they seek. Many of the services they seek are not only for emotional support or discovery, but for resources as well such as web sites, forums, books, social events and organizations. I have experienced that more creative outlets versus the traditional talk therapies help to access unconscious processes and seem to cast a wider net on effective communication as well as actions that need to be taken. Simple tools like writing, listening and responding to music and being involved in the process of art are transformative and necessary agents for change. 22
the talking cure and the more contemporary writing cure are built from the same foundation; that self expression and the freeing up of inhibitions are
learn how to write. Then when mandatory education was enforced, writing became a tool that was available to everyone (Reiter, 2009).
Dr. Caryn Mirriam-
Transformative Language Arts (2000) and the author another leader in the field, Shaun McNiff for recognizing the worth and need for words. As
Shaun McNiff, a leading scholar on the expressive arts said transformation, shamanic horses that carry (p. 12).
Poetry and narrative therapy, as well as bibliotherapy, terms used synonymously to mean the use of literature to promote healing, is an interactive process (Hynes & Hynes-Berry, 2012).
The triad of participant-literature facilitator means that there is a dual interaction: The
to the literature used is important, but the dialoguing with the facilitator about that response can lead to a whole new dimension of insight and healing. In other words, the process of growth comes from confrontation with genuine feelings (p. 5). There is a
heard as well.
The art of deeply seeing, bearing witness to an unfolding story and listening with careful reverence needs to be appreciated for its worth. Poet and poetry therapist John Fox (1995) stated in his book that:
meone deeply listens to you,
Your bare feet are on the earth 23
And a beloved land that seemed distant
is now at home within you.
Careful listening allows us to decipher mysterious puzzle pieces about ourselves in order to put together a more comprehensive picture.
I was deeply engaged in the art of listening while attending a family barbeque at my
This one particular family outing changed the course of my professional career and became the cornerstone of the work I continue to do today.
We were relaxing in the backyard, sharing our usual conversations and insights when I was surprised to hear about my cousi -year old son. He was a vibrant and cuddly child who was quick to smile and laugh and he loved to be carried and coddled.
On this one particular day, I was holding my little cousin in my arms and he was happily playing with my earrings. He was dressed in a long t-shirt and diapers as he had already taken off his shorts and would cry if a -filled eyes caught me from across the room and she mouthed the words,
roblem. I need to talk to you. Help!
developmental guideline. Not only was this her fourth child, she also had her masters in
Counseling and she knew all about typical and atypical behaviors. She had been telling me for awhile that something about her youngest son was askew and maybe he needed a professional
h and she needed my assistance. What was my take on what I was observing and what did I think the next step might be? 24
Many children like to be free from the constraints of clothing whenever possible, so if
behaviors demonstrated then, but we kept reminding ourselves how creative and gender fluid children are at that age so we took a wait and see approach.
Over time, we observed a deepening of certain patterns. For example, he would unsnap his one piece and pretend it was a dress, reach for more stereotypical girl toys and gravitated toward feminine clothing that was frilly, pink or purple. He had frequent nightmares about growing a beard like Daddy and wanted boobies like Mommy.
nightmares and night terrors fairly com
individuality and identification?
Ehrensaft, author of Gender Born, Gender Made : Raising Healthy Gender-
Nonconforming Children (2011) has stated the importance of re-teaching ourselves as adults to listen and respond rather than to guide, enforce or worst of all, force a child when it comes to socializing or providing treatment for gender creative children.
Still, when faced with uncertainty, it is difficult to remember words of wisdom such as
Adults tend to guide more and listen later.
We were trying to understand what this child was telling us, but we still the puzzle pieces together.
siblings were older brothers and an older sister, so perhaps these behaviors were present due to sibling rivalry, asserting his independence, competition or even jealousy.
Maybe he wanted to have the equal attention of his male and female siblings, or his Mom and 25
Dad in order to not be lost in the shuffle of being the youngest child. Any of these scenarios would typically satisfy basic questions of typical toddler behavior. However, this was not the usual acting out behavior that required a disciplinary action or plan.
fostered a hypothesis or two, but knew that something was definitely different. At one point, we wondered whether this effeminate child might be gay and resolved that no matter what, this child would be loved and supported so their
It can be harmful to try to push a child into transitioning genders simply because adults
- variant child boxed into the societal norms or constrictions of his or her birth sex. An important thing to remember is that not all gender-variant children grow up to be transgender (Teich,
2012).
However, it was his insistence that he was a girl that became a main concern. This insistence continued to grow and take on new characteristics. He would become sullen and even combative if he was forced to wear boy As the authors of True Selves,
Understanding Transsexualism (Brown & Rounsley, 1996) have said,
what behaviors to simulate. They only see two gender roles to pick from, so they will instinctively identify with the role that most closely matches their emotional temperament (pp.
46-47).
fun to dress up and pretend you are a girl versus stating you are a girl. It became a struggle for 26 him to live daily as a boy. Everything became a fight; whether it was taking a shower, getting dressed or being with family out in public.
One day, on his fourth birthday, he received a phone call from his grandfather. I was at
room to take the phone call there. He had crawled under a chair, not wanting to be seen or heard and was whispering into the phone something he only wanted his grandfather to hear. I happened to walk by on my way out to my car for something and heard him distinctly say,
KNOW
To this day, I can only remember mine. I wondered how a child so young could be so clear about their gender and who they were in relation to the world. How did we miss the obvious and various details? I realized in an instant what this child had been communicating all along; that he was really a she but we
nd the meaning of those words or the significance of his behaviors.
Without a context, it is easy to miss important cues. In that moment, I felt a bit like the early discoverers and astronomers, upon discovering that the world was round and not flat and that the earth revolved around the sun. The support of evidence for the world being round had always been there but it takes time for belief and fact to meld together. The proverbial light bulb went off and the synthesis of fact over fiction began to then take shape. His drawing done at age
5 is listed under Appendix A, Figure 1- Drawing by Jazz, age 5.
According to Malchiodi, (2005), there are six stages of artistic expression. In stage III, human forms and beginning schema are presented by the child between the ages of 4-6. The major milestone of this stage is the emergence of rudimentary human figures, often called 27 tadpoles, cephlapods and prototypes (p. 29). Here, the child begins to place labels on the important aspects of their world and their relationship to it. The meanings for certain shapes
naming stage where children want to talk about the stories that are happening in their lives.
Looking back, I can remember certain fine details as clearly as a picture in a photo album. There were so many snapshots of specific moments like when he would be calmed by playing with his Barbie dolls or delightfully entertained when he put wigs on his head and would
when he was walking out the front door in his old to be a big girl like her and be called pretty. He would draw pictures of girls smiling in brightly colored skirts and boys frowning in pictures that were devoid of color. His beautiful almond shaped eyes with long eyelashes would always be watching and recording.
he skipped into the kitchen in his frilly pink princess outfit and glittery slippers and grabbed his favorite cookie with rainbow sprinkles and a glass of chocolate milk. He was satisfied for the moment and waited patiently for his time to bloom. His drawing at age 6 is listed under
Appendix A, Figure 2- Drawing by Jazz, age 6.
In stage IV of artistic expression, the child between the ages of 6-9 rapidly progresses in their artistic abilities (Malchiodi, 2005). The first and foremost is the development of visual 28 symbols or schema for human figures, animals, houses, trees and other objects in the environment. It is normal at this age to use variations in size to emphasize importance (p.29).
I continue to have a front row seat to the unfolding of this brave story of transgender emergence, solidification and acceptance. I am especially proud of the new advances my now
13 year old cousin, Jazz (her chosen name, which is used with permission by her and her family) and her bold, loving parents and siblings have made for all of us by not only going public with their story, but who continue to fight for the rights, the needs and basic human dignities for all transgender kids and their families.
New Advances
The difficulties in raising a transgender child, especially before books on the topic were readily available, made the task that much more daunting. This was before the ground breaking books, Transgender Emergence , by Arlene Istar Lev (2004) and The Transgender Child (2008), by Stephanie Brill and Rachel Pepper, were published. There were no trans-positive programs or research methodologies in place to best guide families on how to navigate this difficult terrain to insure safe and successful social, spiritual, physical and psychological transitioning.
The need for support, access to good care and a sense of safety and community are paramount. One only needs to imagine the isolation that is encountered on a daily basis to know its profound effect on an individual or their family. This isolation is difficult for many to
Transitions of the Heart:
Children (2012). Her book is a collection of stories that speaks not only to the isolation and ridicule that families often endure, but also to the lesser known aspects of recognizing that 29 clothing is not a costume but a necessary statement of truth, that correct pronoun mastery is a true victory and that the disapproving glances of strangers in a supermarket can be the most hateful and damaging act of disrespect.
Kim Pearson, Executive Director/ Co-Founder of TransYouth Family and Allies in her
ir heart. (p. xi)
th The annual Philadelphia Transgender Health Conference (PTHC), now in its 13 year, offers over 60 workshops spanning a three-day period that focus on matters of the heart, mind, body and spirit. Workshops range from Transgender 101 to those on genital surgeries. There are tracks for professionals, families and youth and the conference is offered for free.
I attended and presented for the first time at the Philadelphia conference in June, 2013.
Nothing could have prepared me for the cacophony of delight, recognition, enthusiasm, kinship, adoration and freedom that I witnessed first-hand as 3,200 people (the largest attendance to date) filled the hallways of the convention center. The workshop I presented with my cousins and other panelists was called Parenting with Pride which was attended by about 100 people from all over the country. They shared stories of legal battles and victories as well as stories of pain and liberation.
Transgender youth in attendance had a chance to praise and thank their parents for their support and unconditional love and parents returned that love and acknowledgement to their children. my hero (ine) standing ovations, true confessions, tears and lots of laughter. 30
When Jazz participated in the transgender youth panel, she was asked what she would do with a magic stick that would make her a cisgendered [biological]
living her life any other way and how happy she was to be transgender because it meant being different or unique.
She did not feel it was fair to refer to being transgender as a disorder or impairment because that implied that something was wrong or bad.
She stated to the audience that she enjoys opportunities to educate other people on the importance of accepting differences and expressed how grateful she is for her parents and for her family because of their unconditional love. She knows this is often not the case.
One 16- year old who was transitioning from male to female (MTF) spoke to me at the conference and told me of how she was physically abused by her father and was forbidden to live
even though
t least with her, I could always blame her behavior on the drugs. I felt sorry for my Mom, actually. She was beat regularly by my Dad too and turned to drugs for
half man, hal was forced to live on the streets for a few months when she was 14 at 15 and is now finally temporarily adopted by another MTF and her family. She stated that she was tired of being seen as a specimen instead of an expert and is relieved to know that this family truly understands the meaning of this mature perspective. For the first time, she feels respected, loved and safe. 31
Whatever words or labels people use to define themselves: transsexual, transgendered, cross-dresser, trans man, trans woman, butch, drag queen, drag king, bi-gendered, queer or simply men or women they have become comfortable with who they are and where they stand in their transgender continuum. They have synthesized a key element of their identity their gender identity- into a greater whole of who they are (child, teenager, artist, musician, student, friend, etc.). The development of their gender identity, a process that was stifled a long time ago by a society that could not allow for difference, has finally caught up with the rest of their development (Lev, 2004, p. 268).
I heard many stories of trauma and pain at this yearly conference and not just from the youth. Many parents feel isolated and at best, inept in trying to find physicians, counselors, clergy, school administrators and places of worship that can understand, accept, support and guide transgender youth and their families. However, I was also taken by what seemed like the majority of stories about hard fought love, triumph and celebration. I tuned my trained ears closely to the buzz of conversations going on around me at the conference and tried to stay focused. Here are pieces of the conversations I heard there:
Child:
Mom:
Child: Yes! Finally!
Teen to another teen : ever met me. All they have ever met is THIS (pointing to outer presentation of self). They have
Parent to another parent (crying): 32
Parent to parent: Disneyworld. This is magical. so alone anymore. For the first time, this actually feels like the norm.
Finally, we now have various publications, resources, web sites and foundations to turn to for assistance. In fact, these resources have nearly tripled in the past decade. There is an increasing need for publications on all aspects of what it means to be transgender by a population that continues to grow.
No one really knows how many transgender people there are in the world because labeling and research in this area has been problematic. The first issue is no one is scientifically collecting this data at the present and secondly, many transgender people are not public about their identities. However, the National Center for Transgender Equality (NCTE) estimates that between one quarter and 1% of the population is transsexual (NCTE, 2013). Furthermore, current estimates of transsexualism are about 1 in 10,000 for biological males (people identified as male at birth) and 1 in 30,000 for biological females (people identified as female at birth).
However, these numbers are probably greatly underestimated because this population has been underrepresented.
One of the statistical problems is that these statistics are reported by professionals in the mental health and medical fields (therapists, physicians and surgeons) and others who work with transgender people to facilitate individual growth and transition. Therefore, those people who have sought out therapeutic and medical interventions from professionals are the only ones being counted. because it is not a part of the regular census that is taken (APA, 2013).
My cousins were and continue to be, pioneers in transgender equal rights and education.
In 2005, at the tender age of five, my cousin formally transitioned socially to her kindergarten 33 class as the girl she continues to be today known to the world as Jazz. The proper feminine
beginning of this new emergence was in motion. At that time, there were co-ed bathrooms available for use, co-ed sports and activities so the transition was not yet as difficult as the coming years ahead. Jazz was the youngest child to publicly transition to date.
In 2006, they appeared on a Barbara Walters 20/20 special called , share their story with the world. It was not an easy decision to make, but the need to go public with their story was vital because too many children and their families were suffering unjust consequences just for being born into a binary world that sees gender as either female or male.
They wanted to share their experiences and knowledge and give voice to the voiceless and a true picture for those who had become invisible or worse, ignored, bullied or even killed.
Their organization, Transkids Purple Rainbow Foundation (TKPRF) , was formed in
2007, and is dedicated to enhancing the future lives of transgender kids by educating schools, peers, places of worship, the medical community, government bodies, and society in general, in an effort to seek fair and equal treatment. The Foundation has already funded research to study the current plight and challenges of the transgender child, sponsored trans family gatherings and specialty programs, provided scholarships to trans friendly camps, provided financial assistance to other trans youth organizations, and support to homeless transgender youth and individual families in need of assistance.
A couple of years ago, my cousins won a long law suit against the U.S. Soccer
Association because they had banned Jazz nine. She was initially banned from playing on the team and had to sit out on the sidelines as her 34 team mates played and she sat sullenly on the bleachers. She longed to continue to play with them as she had always done, but because she was born biologically as a male this was not an option. There were conditions and rules in place and they had to be abided.
Authorities argued they felt she was aggressive and she would hurt the other players. If she wanted to continue to play soccer, she would only be allowed to play on the soccer team something she had never done before and thankfully, nothing she will ever have to do now that this precedent has been set to allow transgender people to play on the team of their congruent gender.
This fear of Jazz being aggressive or harmful in any way to the other players was not only unreasonable it was not pertinent in any way yet it speaks to the assumptions that are often made when we address stereotypical behaviors and gender typing. Unfortunately, stereotyping often sets up standards that only accentuate more misrepresentations and confusion, making it difficult for gender creative individuals to fit neatly within a particular structure. This gender stereotyping and bias affects us all much like racism. No one has grown up in a genderless culture. In fact, we have grown up in one replete with gender stereotyping and demands for gender norms, with all the bias that go with that ( Ehrensaft, 2011 ).
Transgender youth can teach all of us about perspective, especially as it relates to transformation. The arts provide a template to communicate these aspects clearly. GR Keer, a poet in the anthology, Troubling the Line, Trans and Gender Queer Poetry and Poetics, (2013)
states
button lint, molten 35 boy? Are you in the wrong place? What makes you this way? To be queer is to be queried.
P and a place of encouragement, communication, compassion and resistance (p.227).
Jazz has also been instrumental in keeping all of us stoked with her relentless positivity and advocacy for others who have been treated unfairly. Among some of her many contributions: she is a panelist and guest speaker at universities, conferences and medical facilities around the country as well as within her community. She was awarded the prestigious
Colin Higgins Youth Courage Award when she was 11, making her the youngest recipient of an award that champions the bravery and resilience of LGBT youth.
In addition to being listed on Out Magazine and The Advocate as the youngest advocate for transgender rights, accepting an award from the Gay and Lesbian Alliance Against
Defamation (GLAAD), Jazz also speaks at more somber events such as the Transgender Day of
Remembrance, a day set aside to honor and memorialize those who were killed due to anti- transgender hatred or prejudice. The first Transgender Day of Remembrance was held in 1999 in
San Francisco as a vigil to transgender people who have been killed because of their identity
(Teich, 2012).
Jazz and her family were also featured in the OWN documentary
Chaz Bono, the transgender son of Cher. Both shows placed emphasis on the various transitions a family experiences when a family member is transgender. In addition, it was an update of how well families and individuals may transition when the proper support of medical, emotional, spiritual and educational resources are in place. 36
Much of the media attention around these families has been used as a template for others experiencing the same struggles and has been helpful in educating, supporting and networking with other professionals in the field. Families have also used these programs to teach other family members about their process in order to open lines of communication and to garner support. Families no longer feel estranged dealing with the multiplicity of emotions, questions and events surrounding transgender issues when they know this uneven path has already been traveled by others.
Mental health professionals are in a prime position to help transform old views and inaccurate information about being transgender. Up until recently, the subject of gender identity was not well known or discussed in the media, schools, or in the medical or psychological professions. Many clinicians had to scramble for information if a transgender individual came for counsel.
Obtaining information is easier now due to the internet, specific transgender advocacy groups and social media, yet there are still many professionals who lack valuable information on how to counsel or treat transgender youth. Some will abide by a wait and see approach, some will research old psychology texts for answers and yet others will favor a reparative approach.
The reparative approach (also known as conversion therapy) means that counselors may actually force the child to become happy with the sex she or he was assigned at birth. Without proper training and knowledge in this ever expanding field, the clinician may actually do more harm than good for their patients (Teich, 2012).
The multidisciplinary use of the expressive art therapies offers a viable tool for accessing emotions that may be buried beneath feelings of angst or depression or emotions that are readily at the surface waiting for the invitation to be expressed. Poetry therapists help their clients not 37 only describe loss, but they also help them find words that illuminate and offer hope. (Malchiodi,
2005, p. 121).
Recently, my cousins and a panel of medical and mental health experts appeared on
Huffington Post Live to address the continuous concerns of growing up transgender. Dr. Maddie
Deutsch, Transgender Health expert at University of California San Francisco (UCSF), addressed issues of puberty blockers, cross sex hormones, predictors of successful transitions, risks, benefits and other mental health and medical concerns. They also stressed the importance of listening to what our children and teens are telling us as they creatively navigate a new path on a road that is often blocked by resistance.
Poetic Medicine, The Healing Art of Poem-Making, (Fox, 1997) utilizes exercises and quotes to help stimulate ways to alleviate resistance and support creative expression. The allowance of self emergence unfolds most effectively when we have unconditional support from others as well as respect for ourselves. Poet John Welwood said,
Someone who loves us can often see our soul potential more clearly than we can ourselves. When this happens, it has a catalytic effect, it invites and encourages the dormant, undeveloped part of us to come forth and find expression (p.135).
Jazz has shown us through multiple examples of expressive art what she has been feeling every step of the way in her remarkable life. At the age of 10, she drew this mermaid stating that this was a perfect symbol of who she felt she was deep inside. She loved the beauty, freedom and colors of this magical creature. See Appendix A- Fig. 3 Jazz drawing, mermaid age 10.
Many transgender girls seem to gravitate to mermaids, perhaps because they are the epitome of femininity and fantasy or perhaps because of the media exposure or to some, media hype and misrepresentation on such topics. This is difficult to study because the number of 38 transgender children being researched is so small, but it is an interesting topic, just the same.
Whether it is hype or happenstance, many transgender girls are enamored by the story of Ariel in
but ultimately, she loses her tail for a couple of legs. That story combined with her feminine beauty while having a non-traditional body is mesmerizing for many transgender girls (Beck, 2013).
Also, a popular web site in the United Kingdom, Mermaids.freeuk.com is an online resource for families in support of children and teenagers with gender identity issues. They provide not only the latest research on transgender topics, but also reprinted articles for families, children and teens and support on a worldwide basis. The web site has been effective in not only neutralizing the stigma of being transgender, but has showcased artistic accomplishments of other transgender children and adolescents all over the world.
Over the past summer, Jazz started making life-like silicone mermaid tails as part of a project to raise money for transgender youth world- wide. She has created a web site for her work and it is called Purple Rainbow Tails by Jazz. She continues to create through the various expressive arts of writing, drawing and sculpting.
At 9-12 years of age, Malchiodi (2005) states that children become interested in depicting what they perceive to be realistic elements in their drawings. This includes more detail and differentiation in gender characteristics such as hair, clothing and build. The final stage of artistic expression levels off at adolescence. This is when many children discontinue making art due to other interests (p.30). However, when that child continues to make art or has art training, they will have increased mastery over their developmental process. 39
Finding Support for Families of Transgender Youth
Families often come to counseling seeking various services and support (see resource list at the end of this study). Some of these include PFLAG, The Family Acceptance Project, The
YES Institute, Mermaids, Transgender Law and Policy Institute, Gender Spectrum Education and Training, and TransYouth Family Allies (see Appendix D).
I have worked with the LGBT communities since the late 1970s and have been witness to both the horrors and the victories of what it means to be non-heterosexual or gender variant on an individual scale as well as a world based view. The LGBT population is at increased risk for major depression, anxiety, panic disorder, alcohol and drug abuse, eating disorders, and poor self esteem when compared to the general population (Cochran, Mays, Alegria, Ortega, & Takeuchi,
2007).
Gender-variant people and their families usually seek professional help for numerous reasons ranging from emotional support, grieving issues and most of all, information. They are looking for ways to understand the constant battle between their brains and their bodies and to cope with the hopelessness, despair and angst that sometimes accompanies gender incongruence or confusion. which has sometimes been labeled as obsessive, can best be reframed as the power of their life force, and their insistence to live true to their own nature (Lev, 2004).
In our current health care system, parents sometimes bring their gender variant children for counseling because the child is anxious and distressed, occasionally to the extent that he or she tries to harm him- variance because they fear they will grow up to become gay or lesbian, or because of other life 40 stresses that have become unmanageable such as staying in school, abusing drugs or self injurious behaviors.
Of course, not all children are distressed about the same things and certainly not to the same degree (Fausto-Sterling, 2012). In fact, there are some children that show little if any distress but this seems to be more common in children who transition at an earlier age. Many parents value, love and even admire their gender variant children and more than anything, these latter adults seek support and advice as they help their kids navigate some very difficult terrain
(Hill, Menvielle, Sica, & Johnson, 2010; Menvielle & Hill, 2011).
There were no trans-positive programs or research methodologies in place to best guide families on how to navigate this difficult terrain to ensure safe and successful social, physical and psychological transitioning. Many parents felt isolated and at best, inept in trying to find physicians, counselors, school administrators and places of worship that would understand, accept, support and guide trans youth and their families. This, in part, is why various publications, resources, web sites and foundations have blossomed in the past decade there is an increasing need for it as well as trained clinicians to help support and direct the care of that individual and their families.
Outline for the Study
In the following chapters, the author will define and clarify what it means to be transgender, and the various implications for counseling as outlined in the Standards of Care
(SOC). In addition, the expressive art therapies will be defined and applications for transgender youth will be explored through the use of research and case studies. Specifically, the chapters will be outlined as follows: 41
Chapter 2 defines the terminology of what it means to be transgender and the broader concept associated with this particular population as well as definitions of the expressive art therapies. Poetry and narrative, music and art will be the primary arts utilized to better understand how transgender youth may benefit from these creative approaches for authentic expression. This chapter will also include an overview of historical perspectives of the use of the expressive art therapies and how they may be applied to working with transgender youth.
Chapter 3 covers special considerations and benefits regarding the expressive therapies and answers the question, why the arts versus traditional talk therapy? The specific role of the arts for expression by transgender youth and common themes such as masks, mermaids and other symbols often used to reflect inner and outer conflicts or questions will be explored.
Counseling issues that are most pertinent to transgender youth are the focus of chapter 4.
The topics of self esteem, sexual and social development, anxiety, depression, grief counseling, school issues, safety measures, bullying, identity, and self empowerment are also addressed.
This chapter will also introduce clinicians to basic tools and supplies for the office as well as guidance for professional readiness to feel best prepared to work effectively with expressive arts tools and the transgender youth population. A selection of writing prompts and warm up tools to activate the poetic and narrative process in therapy such as sentence stems, unsent letters, lists, word clusters, acrostics, and telling the new or revised story of our life will be featured. These techniques will be introduced as an invitation to uncover and discover both unconscious and conscious processes. In addition, this chapter will introduce art prompts as an invitation for individuals to picture or explore hidden aspects of self will include mask making, drawing and collage work. 42
Three case studies of transgender youth; Jess, Adam, and Conrad and their journey through art and narrative techniques will be featured in Chapter 5.
Chapter 6 will conclude with research that is still needed in our collective field and a summary of research trends for the future. Works cited, glossary bibliography and resources will close the study. 43
CHAPTER 2
Defining and Clarifying Gender
Be patient toward all that is unresolved in your heart.
Try to love the questions themselves like locked rooms
And the point is, to live everything.
--Rainer Maria Rilke
-Security agent at Customs Building in Philadelphia
A gender evolution and a radical shift in how we view gender and gender variance has erupted in the past ten to fifteen years. Today, gender is seen as multi-faceted and variable versus the former reductionist, binary view that used to see gender as a two-option category at best: either male or female.
The narrow confinement of these distinct options is slowly shifting to encompass a spectrum that looks closely at science, biology, sociology and philosophy to understand gender and all of its complexities. This declaration of gender forms the moment we are assigned the label at birth or the moment our biological sex is known. 44
There is a Sufi folktale that tells the story of a wise man running through the streets
surprise,
This simple story of how our two culturally sanctioned genders of male and female have shaped our vision of gender in general. Some definitions are needed for clarification. Appendix
B contains a glossary of the most frequently cited words related to the LGBT community, with an emphasis on transgender terminology.
Transgender or cross gender is an umbrella term that refers to an individual whose gender identity, or how they identify themselves, does not match or is not congruent with their assigned birth gender. sense of gender identity.
The word transgender is a non-pathologizing umbrella term coined by the transgender community to include all people with diverse gender behavior and identifications, including cross dressing, transsexual, pansexual, transgenderist, androgyne and intersex persons. It is not a diagnostic medical term (GLAAD, 2012). The root of the word transgender comes from the
transnational issue affects all people all across the country, and so on. Transgender literally
No one chooses to be transgender. It is almost an absurd notion when we take into account the price that is paid. It is not a phase that one grows in and out of either. In fact, quite the opposite is true. Once a child realizes they are transgender, the consistent and persistent behaviors usually become even more apparent. 45
How do we define what makes an individual male or female and on what factors is this definition based? Genetic testing may answer the question of whether there is a typical XX
(female) or X
. Therefore, this would be an invalid and inaccurate way to test gender overall. The same would be true of relying only on the presence of gonadal sex (ovaries and testes), reproductive organs, hormones, or assigned gender (Boedecker, 2011).
th A tragic debacle of 20 century medicine regarding gender is chronicled in John
As Nature Made Him: The Boy Who was Raised as a Girl (2000). The true story is about a botched circumcision in 1965 that left an 8 month old boy, a twin, Bruce Reimer, without a penis. His parents took him to see Dr. John Money, a prominent sexologist. Money convinced the parents to raise young Bruce as a girl and subjected him to genital reconstructive surgery and later, hormone therapy. He was raised as Brenda and secret from her. Money was trying to prove that gender is a product of how we are raised
(nurture) versus how we are born (nature). The experiment was a complete failure.
By age 14, Brenda refused to continue with this treatment and eventually transitioned back to living as a male (p. 22). He changed his name to David. His life was fraught with depression and an inability to adjust emotionally and physically. He did marry and was a father to three step-children, but ultimately separated from his wife. He eventually committed suicide in
2004 at age thirty-eight. Some of Davi 2000 interview reveal a bit of prophecy
else are you going to listen to?...Is it going to take somebody to wind up killing themselves shooting themselves in the head 46
money in poor investments and he was still haunted daily by his childhood. Many feel the horror of his childhood was the main contributor that led to his eventual demise. The Reimer case, sometimes called the John/Joan case, is still cited today in the nature-nurture debate. (p. 66)
Fortunately, we are slowly learning from mistakes made in the past and researchers are committed to finding answers to questions we never thought to ask from past theories and applications.
Most of us know we are more than our biological sex. We are a composite of biological, psychological and social factors that contributes to the core of every individual. Yet, a transgender person is one whose gender identity and/or expression are not congruent with their anatomy. This distress regarding the incongruence of the brain not matching the body is a core component of gender dysphoria.
The DSM -5 (American Psychiatric Association, 2013), the fifth edition of the
Diagnostic and Statistical Manual , states that gender dysphoria refers to the distress that may
assigned gender. Gender dysphoria in children, (302.6) includes the following criteria:
A. A marked
following:
1. A strong desire to be the other gender or an insistence that one is the other gender
(or some alter 47
2. In boys (assigned gender), a strong preference for cross-dressing or simulating
female attire; or in girls (assigned gender), a strong preference for wearing only
typical masculine clothing and a strong resistance to the wearing of typical
feminine clothing.
3. A strong preference for cross-gender roles in make-believe play or fantasy play.
4. A strong preference for the toys, games, or activities stereotypically used or
engaged in by the other gender.
5. A strong preference for playmates of the other gender.
6. In boys (assigned gender), a strong rejection of rough-and-tumble play; or in girls
(assigned gender), a strong rejection of typically feminine toys, games, and
activities.
7. exual anatomy.
8. A strong desire for the primary and/or secondary sex characteristics that match
(pp. 452 )
Gender dysphoria in adolescents and adults (302.85) encompasses the following:
A.
the following:
1. essed gender and
primary and/or secondary sex characteristics (or in young adolescents, the
anticipated secondary sex characteristics). 48
2.
in
young adolescents, a desire to prevent the development of the anticipated
secondary sex characteristics).
3. A strong desire for the primary and/or secondary sex characteristics of the other
gender.
4. A strong desire to be of the other gender (or some alternative gender different
5. A strong desire to be treated as the other gender ( or some alternative gender
6. A strong conviction that one has the typical feelings and reactions of the other
gend (APA,
2013, pp. 452-453)
Although not all individuals will experience distress as a result of such incongruence, many are distressed if the desired physical interventions by means of hormones and/or surgery are not available. In other words, a five year old transgender child may self identify as a girl and insist on frilly dresses in pink or purple, reach consistently for typical girl toys yet be biologically male. She may be content as a girl but highly distressed and possibly dysfunctional if there is an insistence that she wear
It is important to be careful of assigning specific sexual orientation and to steer clear of assumptions because transgender people may additionally identify as straight, gay, lesbian, bisexual, asexual, androgynous, or anything in between. In simple terms, sexual orientation is how a person is romantically or sexually attracted to another person. Here is where we question 49
(and answer) what our earliest sexual and romantic fantasies were and with whom. We know who we wanted to be with and how we would be with them (Krieger, 2011).
In the most general terms, sex is a classification of people as either male or female. It is nearly impossible for a transgender person to identify comfortably within this binary and limited
being a boy/man or a
assigned sex. Gender identity is assumed to be trans people, gender identity is discordant with the designated sex at birth and is experienced as dysphoric, or dystonic, to their physicality (Lev & Sennott, 2012).
Money et al., (1955), coined the ter
degree, especially as it is experienced in self awareness and behavior; gender identity is the private experience of gender role, and gender role is the public expression of gender identity, while gender role is defined as everything that a person says and does, to indicate to others or to the self the degree that one is either male or female, or ambivalent; it includes but is not
expressed through masculine or feminine or gender variant behavior, clothing, haircut, voice or body characteristics. A transgender person will try to match their gender expression to their gender identity rather than their birth sex.
Gender identity and gender orientation are not the same. Transgender people may also identify as female-to-male (FTM) or male-to-female (MTF), as a trans-male or trans-female, simply as male or female, two spirit, gender congruent, bigender, trigender, gender fluid, gender 50 non-conforming, affirmed male, affirmed female, gender queer, gender outlaw, non-gendered or heterosexual. It is important to keep in mind that this is a list that is evolutionary at best, as new terms seem to develop daily ( National Center for Transgender Equality, 2010).
Anatomy and gender are two entirely different subjects yet children are more gender fluid and flexible than we realize. Sexuality educators report some interesting findings when they go into classrooms to teach about these differences when a boy may feel like a girl or vice versa.
They ask middle school aged children, for a show of hands from the kids who feel that they are a boy, those who feel that they are a girl, and those that feel they are some of both. The results have been rather amazing, especially in the younger grades. The younger the children, the more hands go up saying they are some of both (Brill & Pepper, 2008).
Children appear to embrace differences more readily without the inherent stereotypes of social learning that adults have encountered. They have not yet developed adult experiences or lessons of prejudice, bias or shame and appear to be more flexible and accepting in terms of gender. In fact, children are usually more creative and accepting in general at younger ages because they have less to unlearn.
In 1978, American singer-songwriter Harry Chapin
(Living Room Suite, 1978) which clearly depicts this point. The song begins with these
have him joining the parade by the end of the term. The song tells of a story about a little boy on his first day of school drawing pictures of flowers in different colors until his teacher tells him this is wrong. He is instructed s the way they have always been. because 51
in the morning sun, so many colors in a flower, and I see every ut the teacher insists this is wrong, and punishes him by making him stand in the corner. After being punished, he finally agrees with the teacher and robotically draws the way he was instructed. One day, when he finally goes to a new school, an innovative teacher sees him coloring inside the lines mechanically drawing red flowers with green stems and reminds him that rainbow, (Elektra Entertainment, 1978 ). This is a good illustration of the importance of allowing children to express freely so they can develop their most authentic selves.
Another story of how readily children teach us about the world is reflected in this quote by another singer song- me that happiness was the key to life. When I went to school and they asked me what I wanted
( Posted on the internet, December, 2013).
Art facilitates communication more readily than words for some individuals. This is especially true of young adults who may have difficulty expressing through words alone. In an
existence. In Therapeutic Storytelling for Adolescents and Young Adults (Slivinske & Slivinske,
2014), the authors stress the importance and power of intertwining narrative with the expressive arts to propel people to tell, write and produce different ways to tell their stories, including the use of the oral tradition, written narrative and artistic expression (p. xvi). In this sense, therapists may engage individuals to ponder their place within the scope of their broader world 52 through various modes of expression. This expression may then assist in seeing the congruencies and development of the individual.
Questions abound regarding the age that most transgender children emerge with gender congruency. According to Lev, (2004), children and youth experience their own emergence through similar paths or stages of adults except they have often not submerged their gender variance. The differences between adults and children coping with being transgender are perhaps more a matter of conscious awareness and ability to put into language their experiences
(p. 344).
Many children are clear about having a cross gender identity from as early as two years of age, so it is clear to see their struggles in our schools when they try to keep up with grades and social protocol yet feel forced to conform to an identity that is not only foreign, but also emotionally distressing (Hubbard & Whitley, 2012).
This is the child who persistently and strenuously resists typical gender conformity. For
iological boy who is fitfully crying on his first day of school because Mommy or
Daddy are trying to force him to wear his boy uniform to school when all he wants to wear is a flowered skirt and a matching pink top just like his new Barbie doll that is now being held in his clenched, little hand like a life line. These children are aware of being a boy or a girl within the first year of life. It is confirmed by how they discover and then relate to their genitals.
Between the ages of one and two, children become aware of how they differ from other children on a physical level by noticing different genitalia from their own. Usually, before the age of three, they acquire a strong concept of self and label themselves as a boy or a girl. This 53 self labeling happens as a result of identifying through dress and haircuts of other boys and girls their age. For example, it is not uncommon for a three year old to declare with much authority,
the age of four,
& Whitley, 2012). This is a part of typical child development, expectations and outcomes and is outlined in depth in various psychology texts and resources.
Developmental Stages
Developmental psychologists state that it is natural and necessary for a child to learn about independence and self will and to develop the unique characteristics that will enable them to be an individual. Erik Erikson emphasizing the influence of society on the developing personality. A pioneer in taking a life- span perspective, he created an eight-stage theory of psychosocial development. His developmental stages give a framework of what to expect as a child grows. The virtue or what is hoped to come through as a result of the stage is listed first. Briefly, the stages are as follows:
1. Hope/ Trust vs. Mistrust (infancy, 0-2 years)
In this stage, the child is learning about their own truthfulness as well as
trustworthiness. Basically, the baby develops a sense of whether the world is a
good and safe place. If the environment or the parents fail to provide a sense of
w of the world will be that of mistrust.
2. Will/ Autonomy vs. Shame and Doubt (Toddler, 12-18 months to 3 years)
Children begin to explore their surroundings, are encouraged to foster autonomy, 54
and develop interests. The child develops a balance of independence and self-
sufficiency over shame and doubt.
3. Purpose/ Initiative vs. Guilt (preschool, 3-6 years)
In this stage, children are developing a sense of courage and independence. They
face challenges of truth and consequences and initiative versus guilt. Basically,
They are exploring self limits.
4. Competence/ Industry vs. Inferiority (Elementary & Middle School, 6-12 years)
Children at this age become acutely aware of their individuality. They long to be
responsible, cooperate, share and learn complex skills like reading, writing,
personal grooming and so forth. If children are put down or ridiculed, they
develop feelings of inferiority. They learn skills of their culture or face feelings of
incompetence. If not allowed to discover their talents, they may lack motivation
and develop low self-esteem.
5. Fidelity/ Identity vs. Role Confusion ( High School, 13-19 years)
continue to be. They develop a sense of sexual identity and are transitioning from
childhood to adulthood or may even experience confusion about their roles.
6. Love/ Intimacy vs. Isolation (Young Adulthood)
know who they are and who they desire as a partner in life. They are able to
foster intimate, loving relationships, make compromises and sacrifices and learn
about isolation versus socialization. 55
7. Care/ Generativity vs. Stagnation (Middle Adulthood, 25-64 years)
In this stage adults want to know if their life counts and has meaning. This stage
focuses on relationships of family, work and society. It also encompasses role
reversal of taking care of aging parents, monitoring leisure activities and
developing a sense of unity with a partner that goes beyond sexual activity.
8. Wisdom/ Ego Integrity vs. Despair ( Late Adulthood)
is now viewed in retrospect. One spends time reviewing their life and deciding
whether it has been one of productivity or despair. (as cited in Papalia &
Feldman, 2012)
As in all developmental stages and constructs, it is important to remember that moving back and forth between certain stages is a normative expression. Transgender emergence, unique developmental stages as explained by Lev (2004), includes various states.
The first state is awareness. This beginning stage is often where people are in greatest stress or distress. The therapeutic goal is to equalize, neutralize or normalize the felt experience of what it means to be transgender. This is not the stage to make decisions about transitioning, but rather a time to safely explore, in a stable setting, thoughts and ideas.
The second stage, seeking information/reaching out is when people seek to gain education and support about transgenderism. The therapeutic task is to facilitate networking and linkages. This is where the person moves from an internal process to an outward one by
transformative.
Stage three, disclosure to significant others involves telling spouses, partners, 56 family members and friends about their transgenderism. The therapeutic task involves
people, this stage represents the most painful and difficult passage of their lives.
Stage four is exploration: identity and self-labeling . This stage involves the exploration of the various identities and names used to identify ourselves most accurately. The therapeutic
Exploration: transition issues/possible body modification is the fifth stage and involves exploring options for transition regarding presentation, identity and body modifications. The therapeutic task is the resolution of the decisions and advocacy toward their desires. This is when their gender is made abundantly clear to others.
Integration: acceptance and post-transition issues is the sixth stage the gender variant person experiences. Here, they are able to integrate and synthesize their transgender identity.
The therapeutic goal is to support adaptation to transition-related issues and processes (p. 235).
These states of emergence involve a complex interaction of layered interpersonal, physical and psychological processes. Not everyone will go through them systematically or integrate them completely. They are offered here as a valuable guideline for clinical direction and clarity.
There are no physical interventions available for pre pubertal children, but they can transition socially, assuming a new name and their preferred gender identity full-time. Because
on early, the Standards of
Care, (SOC) does not take a stand on whether children should or should not be allowed to socially transition. This encourages the mental health professionals to work with families to 57 evaluate the pros and cons and communicate their decisions sensitively to their children
(Boedecker, 2011).
Guidelines for mental health professionals have been suggested by various authors who have worked in the field for over 20 years. These veteran clinicians focused on the distinctions between the and those of their families. Some suggestions by Ehrensaft
(2011), from Gender Born, Gender Made , are that children have to:
Become aware of the gender their parents think them to be.
Learn how that gender is related to their bodies as in boys have a penis, girls have
a vagina and so forth).
Take in what their culture says about what it means to be male or female and how
they act .
Measure that information against information in their own brain.
Put together thoughts, feelings and body into an authentic gender identity.
Find a way to fit into the world in which they live. (p. 59)
Ehrensaft (2011) suggested that in order for children to be able to do these tasks, parents need to reinforce certain aspects of their role as well. Some of her recommendations included:
Provide children with a consistent gender label, perhaps adopting more recently
coined terms such as ze or hir (just as Ms. was introduced to include both Mrs.
and Miss).
recognize their language when they say
.
. 58
Model expressions of gender.
Provide some open creative space where parents and children together or children
on their own can fantasize and play with all different possibilities of gender.
acceptance in the larger culture. (pp. 59-60)
It is difficult to stay focused on these gender tasks if anxiety or conflict is a constant source of pressure. However, it is helpful to remember that the focus needs to be on the livelihood and safety of child. Their best chance for a successful adaptation is when parents can be supportive, loving advocates and allies to their gender creative children while maintaining a healthy balance in their home and school environments.
The current SOC (WPATH, 2011) maintains that the goal of treatment for mental health treatment of transgender children should include the following:
Help families (and communities) develop and navigate an accepting and
.
Help families manage the emotional angst that often appears as anxiety and
important that the clinician NOT push their agenda or force a resolution regarding
gender.
Expand the binary template, and give the child or adolescent room and time to
explore variations of gender.
Support the child or adolescent and his/her family in making difficult decisions
in church
and/or the community. 59
Help families of younger children make decisions about the timing and nature of
social transitioning.
Help educate the wider community as necessary and advocate for the
Maintain a supportive therapeutic relationship with the child or adolescent and
family throughout their social changes and/or physical interventions.
Counselors are important advocates who may help clients gain access to creative, non- traditional options not otherwise available. In an article from Counseling Today,
Outs 2011), addresses the importance of infusing creativity to the counseling session and emphasizes that creativity is about clients and counselors identifying new ways, paths and approaches. Victoria Kress, professor and director of Community Counseling
Clinic at Youngstown State University said:
Creativity is about clients and counselors being more cognitively flexible, opening themselves to new ideas and experiences, tolerating ambiguity and garnering a sense of enthusiasm, energy and playfulness. This is the backbone of creativity in counseling.
Expressive art activities only serve as a vehicle for inspiring creativity.
Gladding, (2011 introduces practitioners to how music, dance, imagery, visual arts, literature, drama and humor can be used effectively in counseling. He illustrates how counselors can inspire clients through creative channels for positive change and growth (p. iv). 60
CHAPTER 3
An Overview of the Expressive Art Therapies
and the time came when the risk it took to remain in a tightly closed bud became infinitely
- Anais Nin
History and Alchemy
The expressive arts have been well established throughout history to shine a light on darkened or hidden places in the psyche when fear or discord threatened to obscure hope or possibility. They are viable healing tools that are helpful in reconciling emotional turmoil or conflict and have enhanced well being, self esteem and quality of life. Since ancient times, the arts have been used as both preventative and reparative forms of treatment.
Shamans or medicine people chanted poems, prayers and songs as part of their healing rituals. In ancient Greece, Apollo was known as the dual god of both medicine and poetry. This has often been referred to as a starting point for the historical foundation of poetry therapy. In fact, the ancient Greeks are credited with being one of the earliest people to instinctively conceive of the importance of words and feelings to both poetry and healing ( Mazza, 2003).
Blinderman (1973) traced the use of poetry to deal with emotional problems even further in history to preliterate times when ancient incantations were used. Often, the purpose of the chanted word or prayer was to bring about change in self, others, or the environment. In his
is not the herb administered to the sick which is considered the essential part of the cure, rather the 61
millennium B.C.C, when ancient chants were written on papyrus by the healer. These words were then dissolved into a solution that could be easily ingested. This process allowed the power and healing aspects of the words to be immediate (p. 10). We have a modern version of this ancient ritual called writing. This is when we allow ourselves to slow down, breathe in our words, digest their meaning, integrate thought, feeling and experience and allow the act of putting the pen to the page to create both immediate and lasting change (p. 11).
) gives a timeline history of poetry as a therapeutic modality. He reiterates that the healing act of using words probably began with shamanic incantations. Then, about 5,000 years ago, in what is today known as Iraq, a cuneiform picture language engraved on clay tablets was invented. This was called the basis of our alphabet. Meanwhile, on the other side of the world, Chinese ideograms were invented. These juxtaposed two or more images, creating a kind of alphabet that was visual
singing psalms while he accompanied himself on the harp (p. 119).
We are already familiar with Aristot release of emotion through theatrical portrayals of life. Modern day poets involved in poetry slams and spoken word events are accomplishing a similar goal. In the past 45 years, thanks to the success of confessional poets like Anne Sexton and popular balladeers like Leonard Cohen and Bob Dylan, poetry has returned to its lyrical roots and returned poetry back to the people.
New excitement among youth has been generated in regard to this poetry resurgence and blossoming of words for all people (Malchiodi, 2006, p. 118). 62
Bibliotherapy
According to Hynes and Hynes-Berry (1994, rev. 2012), the authors of the classic text
Biblio/Poetry Therapy, The Interactive Process , the steps in the bibliotherapeutic process are fourfold and continuous.
(recognition), he or she goes on to look at their personal response to them (examination). The process then moves to a deeper level of introspection as the person considers the first level of understanding of any new feelings or ideas that may surface. This is called juxtaposition.
Finally, the individual evaluates the impressions and insights and integrates them into his or her inner self (self-application). This new and deeply personal meaning will help guide the individual toward future attitudes and actions.
Hynes and Hynes-Berry (2012), further state that the bibliotherapist works with main goals to achieve:
Improved capacity to respond by stimulating and enriching mental images and
concepts and by helping feelings about these images to surface.
To increase self-understanding by helping individual value their own personhood
and become more knowledgeable and more accurate about self perceptions.
To increase awareness of interpersonal relationships.
To improve reality orientation. (p.15 )
In addition to creating insight and self understanding, bibliotherapy is also used with clients exhibiting significant emotional or behavioral problems. McCulliss (2012) stated that distinctions can be made between the way bibliotherapy occurs (reactive and interactive), the types of materials used (imaginative and didactic), and the purposes served by the practice (self- 63 actualization and problem-solving, social acceptance/attitude, psychotherapeutic and education).(p. 140).
Poetry Therapy
The expressive art therapies serve as guides to help navigate rough terrains of isolation, marginalization, depression and anxiety. An unfolding of inner processes coming into fruition and manifesting as creative, cathartic releases in the form of poems, songs, stories or art happens almost spontaneously.
Sometimes the sharing of a simple quote or a poem that demonstrates a universal theme is enough so that the individual or group sees that they are not alone with their feelings. A client may realize that someone has left a foot print here before and now they may follow it and know they will survive.
This specific method is called the isoprinciple which means a poem with a universal theme is paired to the corresponding or matching emotion that the patient or client is experiencing at that time. The isoprinciple, a term that is used in music therapy as well, is at the core of poetry therapy (Leedy, 1985). The poem becomes the understanding someone who speaks directly to them. The use of narrative and metaphor contributes to the development of psychological theory and practice as well.
Dr. Jack Leedy, considered to be the founding father of poetry therapy, utilized this process in the early 1960s when he was practicing psychiatry at Cumberland Hospital in
Brooklyn, New. He would regularly prescribe poems for his patients struggling with drug addiction, depression and pain and was known for asking his patients for poems in exchange for their methadone. He utilized the power of reading and writing poetry as a natural healing source available to everyone. In his book, Poetry the Healer (1969), Leedy spoke about how Aristotle 64 ranked the poet high, as physician to the psyche. Furthermore, he stated: characterized poetic drama as not only for the purgation of suppressed and undesirable feelings but as a valuable instrument for the development of insight (p. 8). Leedy was interested in restoring poetry to its time honored, not to be surrendered role that of poetry, the healer. He emphasized the importance of selecting poems that not only matched the mood or tone of the client, but further emphasized it should not have a simple or falsified happy ending. He felt that
-productive if the clients perceive the positive ending as
as cited in Mazza,
2003, p. 19). The authentic, purposeful and truthful.
From a clinical perspective, Lerner (1987) stated that in poetry therapy the focus is on the person, not the poem. Clients are not asked the true meaning of a poem, but rather the personal meaning and its various applications to their lives. Poetry gives a personal perspective to universal themes and bridges gaps we may not have seen through an ordinary lens. It has been said that we live the narrative of our lives, the story itself, in prose, yet we dream in poetry.
Poetry represents the emotional and symbolic representation of our conscious and subconscious selves. Freud s ( Malchiodi, 2007, p.
119).
The need to vent is called catharsis and its importance and relevance to the healing process can be traced back as far as Aristotle (Alschuler, 2006). Although the use of poetry and expressive writing as a healing modality is not new, latest research regarding the reading and writing of poetry, expressive writing or journaling, offers new hope and creative applications from different theoretical frameworks. (Mazza, 2003; Nicholls, 2009; Pennebaker, 1990). 65
The expressive art therapies offer a road to the unconscious process that allows for finding meaning in the present. Utilizing these tools helps to foster personal growth and flexibility as we grow, make mistakes, and assert ourselves again and again.
Resiliency is often reflected. Many may revisit the despair of depression, even briefly,
exert themselves due to apathy and anhedonia. Often, when a depressed person isolates socially, writing or reading poetry can help dissolve the darkness: ore and more I have come to
: finding the light newly blocked on one side, it
.
Louise deSalvo (1990) stated that when we are able to write about trauma, depression or crisis, this become observers an important component of developing resilience. We regard our lives with a certain detachment and distance when we view it as a subject to describe and interpret. We reframe the problems in our life as challenges as we ask ourselves how to articulate what is on our mind in a way that will make sense (p. 73).
Over the past 20 years, research has shown the psychological and health benefits associated with emotional disclosure (expressive writing) about traumatic life experiences
(Harrist, Carlozzi, McGovern, & Harrist, 2007, p. 923). Pennebaker (1990) discussed research he performed alone and with colleagues about the efficacy of using expressive writing in resolving
about emotional upheavals has been found to improve the physical and mental health of a variety of populations. (p. 40). He was primarily 66
mpt significant
eSalvo, 1999, p. 24).
number of quantitative research studies since 1986; qualitative studies are emerging (as cited in
Nicholls, 2009, pp. 171-172). Pennebaker (1990)
He wrote that: Writing about thoughts and feelings of particular traumas forces individuals to bring together the many facets of complicated events. Once people can distill complex experiences into more understandable packages, they can begin to move beyond the trauma.
Writing then, organizes trauma (p. 185).
Talking and writing about stressors appears to provide some distance from the stressor and also provide some insight into the stressor. Poems are used purposefully in poetry therapy
(PT) and are carefully selected for a sense of hopefulness. Helping clients develop a sense of self-compassion, hopefulness, adaptive coping skills, movement through small acts of wellness
(such as activities of daily living), are some of the counseling goals inherent in working with individuals.
Appropriate literature selection is a key to successful use of poetry and bibliotherapy
(1994, 2012) addresses the importance of thematic dimensions of distinguishing good poetry as tools for therapeutic discussion and integration. The following table summarizes the spectrum of qualities in each dimension, with the most desirable ones on the left and the least desirable on the right. 67
Thematic Dimensions
Universal experience or emotion Personalized
Powerful Trite
Comprehensible Obscure
Positive (Ambiguous) Negative
(p. 52)
______
Stylistic Dimensions
Compelling rhythm Sing-song/discontinuous rhythm
Imagery Imagery
Striking hackneyed or absent
Concrete abstract
Language Language
Simple, precise vocabulary difficult or archaic vocabulary
Clear, simple diction convoluted diction
Complexity Complexity
Manageable length long
Succinct diffuse, rambling
(p. 53)
Client-developmental bibliotherapy provides for creative opportunities by developing a different, imaginative ending to a story, by discussing the effects of making specific changes in 68 the story line. In this type of therapy, the client writes as if he was one of the characters addressing a specific area of concern, common to both him and the character (McCulliss, 2012).
In an interview, poet David Whyte (as cited in Wylie, 2008), described the importance of
With the publication of The Use of Written Communication in Psychotherapy (Pearson,
1965), a number of applications of writing in clinical practice were explored. The most consistently cited advantage of using writing in psychotherapy was the provision of a vehicle to express and analyze emotion. The most consistent disadvantage cited was the provision of a vehicle to promote resistance through intellectualization and avoidance (p. 12).
Poetry therapy practice models are steeped in psychoanalytic literature and theory as well as the humanistic, symbolic and interpersonal theories. White and Epson (1990) presented a conceptual framework and practical applications of various writing techniques as they pertain to narrative therapy and poetry as a healing modality. Of particular emphasis is the practice of letter
-
.
Mazza, (2003) utilizes three basic components of practicing poetry as a therapeutic modality in order to provide a framework that accounts for differential use of poetic techniques for a wide range of clients. The three components are as follows:
1. The receptive/prescriptive component involving the introduction of literature into
therapy
2. The expressive/creative component involving the use of client writing in therapy 69
3. The symbolic/ceremonial component involving the use of metaphors, rituals and
storytelling (p. 17).
The process of facilitating story therapy begins from the moment a story is introduced and continues through a series of verbal and nonverbal interventions that encourage participants to interweave their own emotional reactions and narratives with the stories they read, discuss and write (Chavis, 2011, p. 150).
A common poetry and narrative therapy technique is to have a person retell the story of their life so they may view it from a different perspective and gain various insights. It helps individuals answer the difficult questions of who they are, why they are here and what they are supposed to do with their lives. 2006), offers a way to begin to tell that story:
d a new story
Of your
Or of your abandoned childhood
It is the story you have been writing
Where you can rise
From the bleak island of your old story
(Blumenthal 2006, p.83) 70
This is a forgiving poem that allows for choices and a way to automatically correct ways to tell or re-tell a life story. There is an opportunity to question the way the story has been told and whether it is congruent with the way that life is being lived.
Art Therapy
The expressive art therapies of poetry and narrative as well as art and music, are creative and accessible tools that can be used effectively in a counseling setting by a qualified professional. These expressive art therapies are invaluable guides for accessing the unconscious as well as conscious conflicts and bringing them to the surface to help guide patients from a place of confusion to the safe shores of clarity or understanding. Art helps express a complexity that the linearity of language often cannot, through its ability to be simultaneously objective and subjective, engaging both the inner and outer worlds (Wadeson, 2010).
All of the art therapies share a primary commitment of action that engages emotions in a direct and physical way; an ability to generate creative energy as a healing force for mind, body, and spirit; and a belief that the creative imagination can find its way through our most perplexing and complex problems and conflicts (McNiff, 2005). The experience of creating images is believed to be inherently healing and offers individuals a way to self-understanding, behavioral change, and emotional reparation. Vick (2003) observes that art therapy is actually a hybrid discipline that draws from the fields of art and psychology (Malchiodi, 2007).
The American Art Therapy Association provided this definition of what art therapy is and what it does:
Art therapy is the therapeutic use of art making, within a professional relationship, by people who experience illness, trauma, or challenges in living and by people who seek personal development. Through creating art and reflecting on the art products and processes, people can 71 increase awareness of self and others cope with symptoms, stress, and traumatic experiences; enhance cognitive abilities; and enjoy the life-affirming pleasures of making art (ATA
Newsletter, 2004, p.4).
Integrating Art Therapy and Sex Therapies
There are strengths inherent in utilizing art therapy, especially as it relates to sex therapy.
Research has shown that the tactile nature of art connects mind and body, increasing the possibility for self-discovery and lasting change. (Riley,2004). In addition to art helping to decrease defenses (Wadeson, 2010), it is a process of externalization, allowing clients to tangibly interact with his or her own thoughts and beliefs, providing the opportunity to physically change them, add to them, preserve or deconstruct them (Franklin, 2000). Research also suggests that art therapy has neurological benefits, allowing the use of more and different areas of the brain than verbal therapy, perhaps leading to deeper understanding and more permanent change (Lusebrink,
2004).
Art has been a conduit for the expression and communication of sexuality dating back to ancient civilizations such as China, India and Greece (Bhugara & de Silva, 1995). Early vignettes of art therapy and sexuality fnd that the depth of experience is clear for both therapist
Levick, 1973, p. 291). New definitions of sexual health include attitudes of sexual freedom, acceptance and openness, requiring shifts in clinical approaches (Meana & Jones, 2010). Sexual conflicts often develop based on deeply rooted cultural understandings such as gender, sexuality norms, relationship values and individual feelings about these understandings. Art therapy can help illuminate and dissect problematic understandings (Jones et al., 2011). This understanding 72 of self can provide an opportunity for individuals to deeply explore current personal and cultural shifts, and what these shifts may mean for their own value sets (Chilman, 1990). The externalization of art allows the client to project emotions through symbolic representations.
This use of metaphor can also decrease anxiety, allowing the client to talk more freely about ideas and thoughts so they may have an emotional handle on what had been previously troublesome. Art also introduces a kinesthetic application to help clients remain connected to their physical bodies (Hass-Cohen & Findlay, 2009). This is especially important when working with gender dysphoria where discord or disdain about the body is a typical manifestation.
Sensations have a chance to connect with emotions with the guidance of the therapist and new sexual and sensual meanings are discovered.
Sometimes, images reflect influencing factors that have inhibited sexual development or functioning arise. Often this is a result of being able to bypass the conscious process and express directly through the symbols created in the art. Themes like eating disorders, sexual abuse and self injurious behavior often come to the surface (Fink & Levick, 1993).
Typical traditional therapy relies heavily on words to convey meaning. Expressive art therap been hidden behind the disguise of words.
Benefits and Special Considerations: Why the Arts vs. Talk Therapies?
Personal growth is a difficult yet rewarding process. It is reliant on many factors and experiences. The poet e.e.cummings had a quote that exemplifies this point well. He said:
The arts provide an effective frame work for helping clients gather courage to express, develop and understand the self more intimately. 73
Every client is an individual that requires a different and effective approach in counseling. Some may be resistant to talking in general because they have not been allowed to speak honestly before or they feel too vulnerable to express so openly that which has been closeted for so long. Simply talking about life issues can also be used as an excuse or a way to intellectualize, generalize or rationalize certain feelings or circumstances. The expressive art therapies have a way of circumventing and bypassing logic, intellectualizations and judgments
(Malchiodi, 2005). They make the unconscious, conscious, help us break out of ruts that keep us from reaching our goals and give us a map by which we can navigate our next destination. In addition, the use of metaphors or symbols gives clients a visual image that allows for different possibilities and perspectives.
Music Therapy
The American Music Therapy Association (2004) defines music therapy as:
the psychological, physical, cognitive, or social functions of individuals with health or educational problems (p. 1). The purpose of music therapy is to use music for emotional and or mental benefit of a client. Some of those benefits will be clarified within the context of this study.
In a Counseling Today article, therapist Degges-White (2011) said,
Creative techniques may be especially helpful when working with clients who have limited verbal ability, who are working with issues/experiences that are difficult or traumatic to 74 nature, are creative beings. Children use the visual arts, drama, play, movement or music to express themselves in sessions quite naturally (p.27).
Music has been a common modality used to help clients revisit, restructure and reconcile both losses and victories in their lives. Music helps us to transcend the present and recollect times gone by or times we imagine or hope will happen. The use of music is especially helpful with adolescents who are struggling with identity issues, cognitive disorders, the decision making process and those experiencing stressful situations such as trauma, violence or bullying.
(Malchiodi, 2008).
Music Therapy Applications
The American Music Therapy Association (2004) promotes music therapy for multiple uses within a therapeutic environment. It can be used to access the function of an individual physically, cognitively, socially and psychologically by using music as a means of observation as well as assessment. In addition, music therapy can be defined as a systematic process of intervention wherein the therapist helps the client to promote health, using music experiences and the relationships that develop through them as dynamic forces to change (Brooke, 2006).
Clients find music to be an accessible tool they can use to represent their past, present and futures and to tell their own personal stories using either the music or the lyrics. Often this happens in the playing of the music via the use of an instrument such as drumming or by simply listening and interpreting personal meaning of the lyrics. Songs seem to resonate with individuals at a core level where they can deeply feel emotions that speak directly to life experiences
(p.176.) transgender youth. Some of the songs (in addition to music videos) that I have shared with 75 clients are songs they are already familiar with due to radio play or popular movies. The song
(2013) written by Bareilles and Jack Antanoff, (Sony/ATV Tunes) is a particular favorite due to its universal message of defining bravery and courage. Some of the lyrics are included here:
You can be amazing you can turn a phrase into a weapon or a drug,
love,
Refrain:
I wonder what would happen if you say what you want to say
The song, originally written to help a gay friend speak up about his truth, also shares aspects that appeal to transgender youth. Not only is there an important message about bravery and truth-telling, but there is also a distinct movement to the song. It has a cadence that is rhythmic and playful. The video is uplifting and shows people of various sizes, genders and cultures dancing in unusual places. It is a song that addresses universal themes of being hurt with words or phrases and the journey taken to get through those difficult times. At the very end of the music video, a bys ) must have taken the wrong pill because he has directed his dancer to let loose and dance with others in a shopping mall. Metaphorically speaking, it ultimately reflects the difficulty of being ourselves in any given moment without concerns of criticism, disdain or harm. 76
Questions and topics for discussion to utilize in a session after this song is shared might be drawn from the following:
What does the word brave mean to you?
Talk about the last time you were brave.
Do a 5-minute write on the word brave. What did you discover?
A symbol that best represents the word brave is...
In a session where music is utilized, the focus can be on the words, the movement or
the story such as why the song was written in the first place and for whom it was directed or intended. Poetry and music in therapy can motivate and activate clients. In group modalities, the promise of poetry relates specifically to cohesion, universalization and self-expression.
Additionally, poetry and popular music can be helpful in breaking resistance in the early stages of treatment (Mazza, 2003, p.72).
Another popular song artist is Pink (2012). H
Blackwood Music) can offer encouragement to transgender youth when they feel exhausted from efforts to metaphorically or literally get up the energy and make an effort toward a desired goal after being knocked down numerous times, the lyrics are:
just a couple times/ 77
(Chorus)
Ever worry that it might be ruined/ Does it make you wanna cry?
Are you just getting by, by, by?/ You gotta get up and try, try, try/
You gotta get up and try, try, try
The song has a mantra like tone to it as the refrain echoes try an affirmation for the client listening to the song and often culminates in the individual singing the refrain to themselves in times of need.
The casual tone invites the listener to hear the words differently and informally. The first line is a key to understanding reframing what has been hurtful into an opportunity for change:
Funny how the heart can be deceiving
more than just a couple times
Intrinsically, the listener knows there is nothing funny about love , yet
there is a sense of talking to a trusted friend who is singing some well thought out advice. The metaphors in the music engage ability to perceive connections made between something particular and a larger reality. Metaphors are intended to satisfy the head and the heart; they enable a sense of psychological and spiritual balance; they open communication between the known and unknown parts of self (Fox, 1997, p. 65)
Therapists utilize music therapy in various ways according to the needs of the client and purpose of the work. It can be used for purposes of assessment and treatment as well as evaluation. In some approaches, the music-making process is at the forefront and is considered the agent of change; in other words, it is the experience of music that creates change in the client. 78
In other approaches, it is the experience of the music itself that becomes a stepping stone to verbal discussion and insight (Forinash & McKnight, 1999).
Clinicians will often ask if there was a particular line that stood out for clients in the song so the focus is on the impact of the message and is paired to a personal experience. This allows for the client to purge the emotions that may have been stuck or unable to reach through words alone. Music allows for movement in a visceral and active way.
In the Creative Arts Therapies Manual (Brooke, 2006), Bruscia (1998) focuses on defining music therapy as a systematic process of intervention wherein the therapist helped the client to promote health, using music experiences and the relationships that develop through them as dynamic forces of change (p. 176). He further relates that as part of a therapeutic
(177).
In addition to using pre-selected songs that focus on a universal theme, therapists may invite their clients to comment on particular songs that are either already in their play lists or are familiar with because it has a special message just for them. Common session starters geared around music might be introducing a song with a theme t state and asking some general questions like: Was there a particular line that stood out for you?
What was the general message you received from this song? How did it make you feel? Did it give you any insight to what you are currently going through or did it shift your mood in any particular way? Overall, what stood out for you the most?
Another current approach in music therapy is songwriting. Songwriting is recognized by researchers, according to LaVerdiere ( 2006)
as being a valued intervention in therapy. Gallant and others 79
(1997) present clinical interventions related to their cumulative experience in the field of music therapy of more than 40 years. Gallant and colleagues (1997) stress that music interventions that integrate the use of poetry and songwriting can be beneficial to clients with addictions as well as
(p. 179).
Clients seem to benefit from exercises that ask them to draw from personal experience so
they actively participate in the creative aspect of expression. A favorite is the Sound track of
Your Life assignment. Here, clients are asked to list transitions in their lives that might correspond to particular songs of either that time or songs that have helped to carry them through that time of difficulty or change. This could also be called their personal story, narrative or life theme. It is easier to break it down into 5-10 year increments to help them focus more acutely on moments that may also serve as snapshots of their lives. Usually, 10-12 songs are sufficient to
story most authentically. Clients are encouraged to bring in photographs as well that may be a visual stimulus for this project.
Many choose to write their own songs or anthems. Examples to help this process flow more easily might be garnered by asking - feeling sad, isolated or detached. Do they have a theme song for their life? It is usually easiest to start with their birth year and then talk about things they remember as being important in their life. What were some milestones for the individual? Any achievements they would like to set to music?
How have losses played a role? Geographical moves? Coming out process? Are there important relationships that have life lessons to teach?
Some examples from life to show thematic universalities might be Elton J
(John & Taupin, 1983) to show clients perseverance or a feeling of accomplishment. Part of the refrain is: 80
Looking like a true surviv The feeling evoked is one of surviving a kind of punishment or fate and coming out on top as a victorious winner.
The song may trigger experiences symbolic of accomplishing the impossible. Other themes for exploration might be pride, fear, determination, birth and death.
This assignment is similar to a musical scrapbook in that it helps clients to connect with feelings, thoughts and memories experienced during various transitional times of their lives. Not only is it powerful, it is enjoyable to see the broad appeal of music as well as poetry (lyrics) to evoke a response. Music speaks of our world and communicates our unique mix of cultural and personal experiences (Duffy & Haberstroh, 2011, p. 34). Songs can be reality checks, bargaining chips or they can help us dismantle denial or even build hope.
Other songs of perseverance that can be used successfully in session are: Bruno Mars,
Carey and Whitney Houston,
triumph over tragedy.
It is also empowering and recommended to ask the client to bring in some of their favorite music to session and ask them directly how the words or the rhythm have impacted them. Other clients may elect to write their own songs and bring in a CD of their original music or play it in session. The music is often eclectic in nature and runs the gamut from folk or rock to punk, heavy metal or rap. Music allows the authentic voice of the client to be spoken, sung and heard. Some clients gravitate to heavy metal music where screaming the lyrics are the chosen 81
members because it either fit in with family ideals. The song by the group Crown the Empire (2011), The Fallout (Rise Records), expresses the frustration an individual might feel by being part of a world that is apathetic to their needs:
Relient K, an American rock band formed in 1998 and is associated with contemporary
Christian music as well as mainstream pop punk and alternative rock. The song Be my Escape
(Gotee Capitol, 2004) terms:
outta here,
The bottom line for evaluating universality is the decision to match the appropriate song to done carefully and purposefully, can elicit profound results.
Counseling as an Artful Science
Counseling is an art form in and of itself. Many of us work behind closed doors in a kind of microcosm so we are usually at a loss to know all of the nuances of this mysterious and complex process. tioners work this delicate balance of science as art and art as science. 82
Counselors also differ on the key ingredients necessary to make for great counseling and a difference to their clients, but according to an article in Counseling Today, (December, 2012) some basic tenants seem to be the following:
A willingness to listen carefully
Unconditional respect, authenticity, empathy and compassion
A passion for helping others
Those who make positive social justice changes in their communities
Those who ask for, receive and integrate systematic feedback from clients
Someone who is creative and cares about empowering others
Truly exceptional counselors are those that live what they teach to others
They incorporate flexibility, multi-cultural competence and courage
They are self-aware, maintain humility and honor the power of silence
They use multisensory modalities such as art, music and mindfulness
They have unrelenting patience, curiosity and a sense of humor
Great counselors are always open to learning and stretching themselves as people
(pp.26-33).
In general, a great counselor will develop innovative ideas and applications in order to continuously grow in their field. They will be willing to learn from every experience and fine tune the scope of their practice according to the issues that are uncovered with the populations they serve.
Some of the issues that we can expect to find in a therapeutic alliance include: the exploration and eventual expression of identity; sexual development; social development; self- 83 esteem; and the emotional aspects that often accompany these discoveries. The expression of anxiety, depression, uncertainty, sorrow and bereavement as well as insight, celebration and victory that may accompany transition of both the individual as well as the family is often cathartically released through the use of the creative art therapies of music, art, poetry and narrative. 84
CHAPTER 4
Counseling Issues for Transgender Youth
Strength does not come from physical capacity.
It comes from an indomitable will.
-Mahatma Gandhi
Overview of Needs
There has been an increased interest in the physical and emotional well being of transgender or trans variant youth, especially in the past decade. This shift in professional understanding occurred parallel to high profile media attention to show a growing public willingness to acknowledge, tolerate and accept gender non-conformity, especially as it occurs in children.
Well-known publications such as The New York Times , and television programs like
20/20 specials, and shows featuring Oprah Winfrey, Dr. Drew Pinsky, and
have been instrumental in exposing the world to the various experiences of gender non-conforming youth. However, visibility in and of itself does not necessarily equal automatic acceptance or even tolerance. The life of a gender non-conforming (GNC) child or adolescent is still difficult and sometimes dangerous as well.
Researchers have uncovered disturbing facts that need immediate attention so that the well being and safety of transgender youth everywhere may be optimized. In 2013, the
American Psychiatric Association changed the diagnostic label of gender identity disorder (GID) 85 to gender dysphoria. Yet this does not make transgender youth or their families exempt from the constant surge of emotions felt when faced with continued legal, medical and educational battles.
Sixteen states and the District of Columbia have transgender rights laws that protect transgender or gender non conforming children against discrimination. In California, these protections have been in place for some time and include full and equal access to programs and facilities such as gender neutral bathrooms and if need be, private changing areas for gym and sports (Transgender Legal Defense, 2012).
According to The National Gay and Lesbian Task Force and The National Center for
Transgender Equality, a 2011 survey of 6,450 transgender individuals live in the United States.
This survey included all 50 states, the District of Columbia, Puerto Rico, Guam and the U.S.
Virgin Islands. The survey results revealed some startling statistics: 57% were rejected by their families; 41% were not allowed to change their gender on their IDs; 19% have experienced homelessness; 19% were refused medical care; and 47% have attempted suicide. Suicide is the third leading cause of death for adolescents (aged 15-24) in the United States, accounting for
20% of all deaths annually among that age group. (The National Center for Transgender
Equality, 2011).
Bullying and Harrassment
Transgender youth in particular do experience a disproportionate amount of harassment and statistics which indicate that transgender youth do account for a disproportionate amount of suicides. Children and adolescents who express their identity as a trans-male or trans-female in schools are often victims of physical and sexual violence. Schools are a great source of anxiety for many trans variant youth, because being different is often reason enough to be judged, harmed or even killed. 86
In a 2011 study of transgender students, almost half said they had been punched, kicked or injured with a weapon at least once in the last year (Gray, 2011). Christy Lee Pollis, a trans- girl, said she was spat on and kicked while in the restroom by two young teenage girls. The teenage girls dragged her by her hair and ripped the earrings out of her ears as a crowd watched
(as cited in Gray).
Unfortunately, stories like this are not uncommon. The Transgender Discrimination
Survey showed that 35% had been physically assaulted and 12% experienced sexual violence while attending school (Grant, Mottet, Tanis, Harrison, Herman & Keisling, 2011). This same report further stated that six percent of these students were expelled and 15 % left school because of mistreatment. Teachers and school officials alike were often as negligent as school-aged peers when it came to disrespect for or non-tolerance of transgender youths. The study showed that the transgender adolescents who were harassed by their teachers, were more likely to quit school and end up with lower income. In addition, the average GPA for transgender students who were frequently physically harassed was at least half a grade lower than students experiencing less harassment (Boedecker, 2011).
Suicide
It is not surprising to find that transgender people isolate themselves in order to protect themselves or avoid the possibility of ridicule, rejection, physical or emotional harm. For instance, though data suggests that though 6.9 % of adolescents have attempted suicide, nearly one third (32.2%) of transgender youth have done so (Clements-Nolle, Marx, & Katz, 2006).
The therapeutic capacity of the language arts for adolescents has received significant attention in the literature (e.g., Abell, 1998; Bowman, 1992; Mazza, 1991). The ego-enhancing 87 qualities of decision making can improve self-esteem, contribute to healthy identity formation, and restore an element of control to the adolescent during a tumultuous transitional period
(Mazza, 2003, p.75).
The adolescent period is one of high creativity but it is often mired by feelings of loss and conflict.
Depression
Depression is a common ailment in the psychotherapy and medical fields, and is often what motivates an individual to seek professional help. Part of our job as counselors is to encourage resilience through creative expression during these times of duress or stress.
confinement of your aloneness
to learn
anything or anyone
that does not bring you alive
Some clients may minimize the devastating effects of depression on their daily activities of daily living, functionality at work or school, interpersonal relationships and sense of self- worth. For the transgender youth, who experiences anxiety and depression on a regular basis due to the pressures of trying to mask their true identities, this can be exhausting.
Rejection and Homelessness
When transgender youth are abandoned by their families of origin, they are often forced to fend for themselves and this can mean a life on the street. Unfortunately, some youth 88 experience parental rejection and abandonment rather than acceptance. Children may be kicked out of the house after disclosing their transgender identity. For example, one hotline caller stated she had been ew this was only temporary. She was 16, anxious, and scared. This individual developed multiple coping mechanisms to create a place of safety and calm, not matter how temporary it may have been.
False Gender Self
Often, a false gender self is created; a put on face or persona so that the child may safely navigate the difficult terrain of intolerance for differences. They may try to squelch or deny their true gender selves to keep the peace, so to speak and replace it with a false one. This may be an attempt to stay safe in an often hostile environment.
Any child can develop a false gender self. This may show up as the gender creative child who dresses as their true gender at home but hides these clothes in shared company like at school or social settings. This might be the child who was born biologically as a boy who prefers sequined dresses and boas but hides them under the bed for when he returns home from school
e for bed. He may then elect to sleep in his princess pajamas and dream of the day when he will become a true princess with long, golden hair,
-
When gender non-conforming children have to adopt false gender self strategies, it may
African-
American child who has to endure or confront racism, or children in gay or lesbian families who confront homophobia at a young age. 89
Parental Concerns
There is a growing need for health professionals who can help families address their own
identities. Andrew Solomon (2012), author of Far From the Tree , a book about parenting for families of individuals affected by spectrums of cognitive, physical or psychological differences emphasizes that parenting takes imagination and a different kind of unconditional love.
Solomon (2012) noted times when he witnessed a shimmering humanity from these families who have experienced humbleness and compassion for loving their children not as they could have been, but for who they are, in spite of biology, culture or circumstances. He saw human differences as a unifying and reinforcing event and stated,
anguish our children they put us th (New York
Times.com) Parents are beginning to gain guidance from a growing faction of medical and mental health experts who no longer see the issue of being transgender as something that needs to be fixed but rather negotiated.
The following excerpts are taken from actual calls received asking for help from a gender specialist: A mother is crying into the phone and quickly asks, Is it possible for my daughter to really be my son? Sh She wants us to call her by a male name, get rid of her girl clothes and treat her like a boy.
A father is alternately crying and pausing as he speaks into the phone at 8 p.m. He says,
M She says we will handle this matter privately or with our pastor. Our 13 year old son has always been different. We thought that was because of his 90
us to enroll him in another school so he can attend as the girl he feels he has always been. this.
These are some of the many voices heard by concerned parents desperate for answers and immediate guidance. Many transgender youth have a wealth of information at their fingertips on this topic because their access to the internet and social media is more readily exercised. Their parents, however, may not have as much experience with surfing the net or feel comfortable about the information they may find there.
Letters
Often, a counselor is the first person to direct or redirect the seemingly unanswerable questions, offer comfort, assurance or education. Some individuals are just interested in carry letters we can write for them as a professional so their child will have a kind of prescription to carry with them in case they need to explain why they need to leave class early, use a particular bathroom, not be hassled by strangers or use it as a precursor to receiving hormone treatment.
These letters can be extremely powerful when they validate that the person is not seeking special treatment per se, but rather, the kind of respect and treatment a transgender person needs without the usual condescending or uninformed response. They contain basic information to give the individual a sense of comfort as well as security. They can be anywhere from a paragraph to a page long so it is easy to read and states just the necessary facts. Here is an example of a carry letter I have used for transgender youth clients: 91
To Whom It May Concern,
I am writing this letter in regards to , who has been under my care since
______. I am a clinical sexologist and gender specialist working with (name) and their family for the purpose of helping them through gender identity issues and concerns.
______was assigned a (male/female) gender at birth but has shown signs of gender fluidity from early life. Under my care, they are now transitioning as the affirmed
(male/female) they feel they have always been. With the support of their parents, this client is now living fully in their congruent gender. In order to promote and continue with their general well being, it is imperative that (name of client) be seen and treated as (male/female) by their parents, educational settings and community. In school settings, and the community, this would include congruency in such matters as bathroom use, participation in sports activities, or any other programs that might maintain the dignity, safety and respect for this individual.
If I may be of further assistance, please do not hesitate to call me on the direct line listed on my letterhead.
Thank you for your continued support and understanding.
Respectfully,
(Practitioner name and credentials)
In addition to the carry letters, counselors are sometimes asked to help in the writing of a letter to inform other family members about the changes that are taking place in the family. This is often along the lines of a yearly review or Christmas letter that encapsulates the highlights of 92 for transgender youth and their families. Inherent in this process is the fear of rejection, criticism or fear of causing unmanageable distress for older members of the family. (Krieger, 2011).
An example of this letter to announce these transformative changes within the family might sound something like this:
Dear Friends and Family,
This has been a year of many changes, triumphs and struggles. Fortunately, we have come to a place of realization and finally celebration and we wanted to share this with all of you.
Some of you know that we have had some school issues with our daughter Chris. At first, we thought it was due to just being a teenager and going through the usual pressures of teen life; socialization and trying to fit in with friends, school events, scholarly expectations and a general development of self as an individual. Chris has always been shy but she excelled in all of her classes so we thought everything was okay. Suddenly she began to withdraw even more, refused to go to school and eventually her grades began to plummet. She struggled to tell us what
anyway!) and that she would understand what was going on and asked the teachers and guidance personnel if they had any information regarding all of this.
Apparently, a lot more had been going on for a long time. Chris had been isolating herself in every classroom and kept busy by writing or drawing. She rarely spoke in class and the teachers noticed that her mode of dress had become extremely casual and layered, even when it was hot outside. She was not disruptive in class, so no measures were taken until she started to ask to leave 5 minutes early from every class. The teachers suspected bullying and thought she 93 might be going through a coming out process regarding being a lesbian. When they confronted her about this, she
To make a long story short, our daughter is not a lesbian, is not mentally ill and is not going through a particular phase. Our daughter is transgender. Some of you may already know that this means that her gender is not congruent with her assigned sex. You have seen the stories
our child. Her brain and body do not match like it does for most of us and a gradual transition is now taking place. She (Chris) is making her transition to Mark. This means we are helping him to live his life congruently as the boy he felt he has always been. We realize that you may need time to understand all of this so we have enclosed a list of resources and web sites to help explain this even further.
We have been learning about this process along with our child and he (please be sure to use male pronouns from here on in) has been a fabulous teacher. We wish he could have found the courage to tell us earlier, but at least it is now finally out in the open and things are beginning to turn around for the better.
His friends and teachers have been extremely helpful and are all on board to help through this transition. His grades have already shown marked improvement and he is generally a much
first, but we were losing her to the deep depths of depression. A parent of another transgender child reminded us that we can at least celebrate the birth of our son instead of mourning the loss of a depressed or possibly dead (statistically speaking) daughter. That was a humble reminder of how important this transition was (is) to our child. 94
We hope you will make the change to calling Chris by his chosen (and soon to be legal) name, Mark. We have been in close contact with a network of other transgender kids and their parents and this has been extremely helpful and supportive. We invite you to be a part of this continued support as we navigate through these exciting changes. We are counting on love to get us through these times and are hopeful that you will be the loving, supportive family and friends you have always been.
With gratitude and love,
Your family
Other examples of letters for family members, health professionals and schools are listed in the various books and resources listed in the back of this study.
Some of the introductory and basic necessities counselors will need to activate the process of utilizing the expressive art therapies will now be discussed.
Counselor Preparations- Basic Tools
A licensed professional will be sure not to work outside their area of expertise or comfort level. A background and interest in the arts is helpful and recommended, although it is not mandatory. However, having a creative or expressive arts specialist within the allied network of helping professionals to consult with will be a significant contribution to the overall treatment of the individual.
Creating a safe, clear space to experience the expressive arts is invaluable. An area that is designated for private expression for the various arts will include a work station that is easy to clean and plenty of basic supplies such as: a good variety of pens, pencils, paper, paints, glue 95 sticks, crayons, stamps, scissors, sculpting clay, puppets, plastic figures of people and animals, a multi-media station for the use of playing/viewing music, crystal bowls (wonderful for meditating and tuning in to more spiritual aspects of sound), musical instruments (homemade or store bought), poetry anthologies, files of poems by themes or topics, or musical compilations that can be easily accessed, collage and simple arts and crafts materials are some basic requirements.
In addition, a willingness on the part of the clinician to be open to the creative process is a major part of successful treatment. Maintaining a child like curiosity and wonder about the unfolding of a process will allow for maximum discovery and freedom for the client. The emphasis is always on the process, not the product and it is never about competition or measuring to someone else
What matters most an outward expression without the fear of ridicule or rejection. An attitude of receptivity and welcoming is the best way to invite this creative and authentic expression. Thompson and
Rudolph (1992) used two dimensions to examine techniques appropriate for use in counseling
Fighting, cruelty, complaining and resistant behavior are among the external problems for children. Among the internal conflicts (otherwise known as conflicts with self) are poor self- concept, underachievement, inattention, shyness, anxiety, dependency, perfectionistic behavior and school phobia (p. 62). Once these conflicts have been brought to light, it is easier to navigate the next step or course of action as it provides a template from which we can work. 96
Invitations to Uncover and Discover
The use of creative writing (poems, stories, diaries) is a useful technique for both assessment and treatment. It provides a vehicle for the client to express emotion and gain a sense of order and concreteness (Mazza, 2003).
Writing Prompts
Writing prompts or warm up exercises are brief techniques that are used to free associate in order to access unconscious process. One example of a prompt might be to complete an open ended sentence, experience a timed write on a specific topic, free writing, word cluster techniques, journal writing or therapeutic letter writing.
Sentence Stems
Sentence stems allow for the exploration of universal themes in an informal format.
Through the journal device of sentence stems, individuals can explore various aspects of self by being spontaneous, honest and specific. It is immediate feedback for individuals to see and hear the unexpected perspectives of their lives. Many poems are derived from sentence stems as it serves as a launching pad to ignite ideas.
Fox (1995) recommends answering some of the open ended questions of sentence stems to include multiple
I am wary of
Frothy ads that promise me the earth and the sky
Big barking dogs and fast-talking politicians 97
I am awed by
Young children who expertly flip and tumble in gymnastics
Two lions fighting in the African sun (p.149-150).
Participants free write without editing or re-reading what was written so they can empty out their emotions and see them more objectively on the page. Commonly used sentence stems are listed below:
If you really
This is a moderately structured format that gives the client both permission and a comfortable boundary to express with relative ease.
Word Clusters/Cluster Poems
Word clusters or cluster poems allow participants to start with a powerful or emotionally laden word that they write and then circle in the center of the page. 98
This is followed by then listing a series of words around that one cluster word that gives further meaning and provides more depth.
Example: the word transition.
Authenticity
Change Stage Regenerate
Fear Congruence Switch
Freedom Mutation Opportunity
TRANSITION
Bridge Converge Trust
Angst Passage Process
Uncertainty Movement Question
Opportunity Doubt Unveil
The word transition illustrated within a circle takes on new shape and meaning and becomes a kind of mirror, telescope or deflector where various expressions can be safely viewed.
Once all of the words are on the page, participants may elect to take the one word that best describe where they are in that moment and free write for five to fifteen minutes. This will 99 enable them to thoroughly process emotions in the present and positively purge what may have been blocking conscious thought.
Acrostics
Acrostics are vertical and horizontal representations of a key word. Sometimes the
list their qualities, make a statement or tell a story. An example might be: HUMAN
History has sometimes been
Unkind in
Making or manifesting
Assumptions about my
Name, nature or nationality to navigate the truth
This simple technique allows the client to see a different view of a common word, emotion or representation in a fresh light.
List Poems
List poems are some of the easiest to write because they do not require lengthy instructions regarding format or rules about rhythm or rhyme. Children are especially drawn to this technique because it is fun and liberating. There are some basic outlines that one may follow so that the list is more than just a grocery list under the guise of being a poem. Lansky (1996), a 100 c basics about writing a good list poem. Three requirements:
1) The writer is telling you something
2)
3) Each item in the list is written the same way
Here is how the list poem might look:
People who are mean to me,
People who are dumb.
People who say they are friends of mine,
People who are bullies.
People who call me names behind my back,
People who ask about things that frustrate me,
People who frustrate me.
This technique works best when the client is asked to simply make a list of certain things that may be blocking them in some way. Most people are used to making lists as reminders for the day, homework assignments or other mental notes. List poems allow clients to be systematic 101 about accomplishing tasks. In addition, it gives them the ability to express difficult emotions in an organized fashion. It is a way to safely and thoroughly purge excess emotional baggage.
Unsent Letters
Correspondence therapy or letter writing as a therapeutic tool can be traced back to
Freud. Letter writing can be used as a way to deal with physical distance, break resistance and capitalize on client strengths (Burnell & Motelet, 1973). The client is instructed to write a letter to a person, place or thing so they can have a feeling of closure or productivity. This letter could be to a person they are unable to confront for various reasons such as death, illness, fear, incarceration, not feeling capable of articulating feelings, or physical limitations. The letter could also be symbolic and not to anyone in particula
.) be included in this process for a very distinct reason. I have found that the post script has often been the part of the letter that can stand alone. It is what the writer truly wanted to say to begin with, but they needed the process of the letter itself to work their way up to those final, perceptive words. In other words, the post script is not just a reminder. It is the main gist of the letter and carries most of the weight of its meaning. Watching this process unfold in a counseling session is quite astounding because the client is able to express without interruption or pretense. They are able to receive their own message directly and often from a salvaged part of self.
Another part of this exercise is to ask the client to also write the response they would have liked to have received from this person, place or thing and to include a post script in that 102 letter as well. This enables them to come full circle in association with that event or person. It is an extremely empowering exercise.
Art Prompts
by the mask I wear.
For I wear a thousand masks, masks that I am afraid to take off.
And none of them are me.
I fight against the very thing I cry out for
But I am am told that love is stronger than walls, and in this lies my hope.
Who am I? I am someone you know very well for I am every man you meet and I am every woman you meet.
-Anonymous
Masks
After an introduction to this poem, clients may choose to make a visual representation of the face they show the world versus the face they only show to themselves. This can be done with a simple drawing or a more detailed representation like in mask making. In session, the basic outline for the mask is made and clients may elect to finish this project at home. There, they may include more personal items, including photographs, pieces of jewelry, buttons, fabric, old ticket stubs and other meaningful items. Masks can be made easily with paper plates, 103 construction paper, paper bags and other creative art materials. They can be mono or multi- dimensional and include mixed media materials as well. Some clients like to use more concrete materials like ceramics, clay or stone. The main intention is to get the client engaged in the process of making a cohesive start so they might begin to see various possibilities to expressing their authenticity.
Seena Frost (2010), creator of SoulCollage, an Intuitive Collage Process for Self
Discovery and Community, demonstrates methods to self discovery through creative collage work based on archetypes and metaphors. The work blends art, photography and poetry into a hybrid process of discovering self and appreciating and accepting the transformations that are possible.
Collage Work
An expressive tool to see how individuals might view themselves in the past, present and future, SoulCollage works through creating individual card decks. Participants choose a small, medium and large image from collage materials provided. On a 5X7 index card, they may glue the large image first to the card as the background and then the other two images are placed on the same card. The images can be placed directly on the card or may take on a three dimensional form where they are folded or extend beyond the card itself. There are no restrictions and this often adds to the joy in creating the representation of self. Many cards can be made to represent self, community and the world. Examples in SoulCollage Evolving (2010) include the shadow cards, community cards, transpersonal cards, or a new category or creation that the individual designs. Statements that accompany the card may be in the form of 104
for you (p. 86)
The cards allow individuals to see a process that may have otherwise lay dormant or had been inaccessible to the conscious self.
Artistic Dialogues
Poet and artist J. Ruth Gendler, author of The Book of Qualities (1998), is an insightful book that gives human characteristics to emotions. Each page showcases a particular emotion like courage, fear, whimsy, anxiety, excitement, pain and many more to explore the diversity of emotion through narrative stories. Gendler switches pronouns every other page to give equal voice to the qualities and avoid stereotypical labeling. Some excerpts include:
the middle
He does not trust anyone, not even his friends, Worry, Terror,
useful to juxtapose two different emotions such as fear and courage and have them engage in a 105 dialogue with one another. This is a technique that is both enlightening and empowering because
to alien emotions. It is suggested that the client uses the non-dominant hand to respond in order to weaken or soften the power that the emotion once had over the client. For example, when trying to eradicate fear and bolter courage, the dialogue that courage would speak would be written with the dominant hand and fear would respond with the non-dominant hand. This would then involve the mind-body process whereby the emotional shifts can be seen, felt and known.
Picturing the Invisible
- photographing representations of emotions. I may suggest they take pictures of what represents
the insights gained.
Cell phones can be used as accessible tools to capture instant images that can be expanded upon later. This technique also enables the client to have the elusive or unseen dreams, ideas or actions readily within their reach. In addition, photographs are transporting and allow clients to live within a frame of safety, beauty or possibility.
Photography Prompts
*What does the picture of your life look like to other people and how does it look to you now?
* Photograph the rough edges of your day versus the places of ease
*Focus on your favorite color and take a day to photograph everything you see in that color around you
*If you were to make a documentary of yourself, what might that look like? 106
*Bring in a favorite picture of yourself (or take a new one) and discuss what is happening right outside the frame. What happens next?
*Choose 10 favorite pictures from your files and write about why they are your favorites. What do they represent?
*If you were marooned to outer space and only allowed to take one picture with you, which one would you take and why?
Bridges, Fences, Paths and Walls
Most of us construct walls and fences at given moments in our lives to protect ourselves from forces of relationships or circumstances. They allow us distance from things that might be threatening or harmful or serve as coping mechanisms or constructs of familiarity as we negotiate change. A powerful exercise is to ask clients to draw representations of their bridges, fences, paths or walls. Clinicians may ask when were these built (walls/bridges/fences) or when was this path paved? Are they still under construction? Where do they lead? Who is on the other side? What materials were used to create your bridge, fence, path or wall?
Writing and Illustrating Your Autobiography
has been a mainstay in the expressive arts field for various reasons. It is applicable to various populations because it addresses fallibilities inherent in all people. It is a poem about renewal, hope and life lessons as well as the need for taking responsibility for our actions and being accountable for
Sidewalk, 1993). The poem addresses the habit of doing the same thing over and over again but 107 expecting a different result. It is about repeated mistakes and trying to put the blame elsewhere.
As the reader progresses through the poem, they see different alternatives they can make to stop themselves from falling into the same hole. The poem provides a viable way to formulate a different plan of action. Here are a few transitional parts of the poem:
1
I walk down the street,
II
III
IV
I walk around it.
V
I walk down a different street. 108
and their life choices. It can also be used as an autobiography where clients are asked to write their own autobiography in five short chapters and then to also create the cover for their book.
story or to make the outside cover? How are they different and how are they the same? Are they congruent? 109
CHAPTER 5
Transgender Youth and the Arts as Expression: Mirrors, Masks, and Other Magic
To be nobody but yourself in a world which is doing its best
Day and night to make you like everybody else
Means to fight the hardest battle which any human being can fight
And never stop fighting.
-e.e.cummings
Gender non-conforming children may learn prematurely that the world is a gender unfair place that may strike out against them (Ehrensaft, 2011). The child may attempt to fit in based on what the world might expect to be appropriate or gender adaptive behavior. They may begin to see that life is full of real dangers, but if all goes well, more comes with the realization: sophistication and wisdom, skill building, fighting back, becoming passionate, and rising above adversity.
Client Expressions through Poetry, Narratives, and Art
Be who you are and say what you feel
And those who matter, 110
-Dr. Seuss
experiences that include general research questions best answered through verbal reports, or in this study; art work, poetry and narratives. This qualitative series of case studies will add to the personal as well as existential understanding of living life as a transgendered youth.
Case Study: Jess
Jess was a nine year old biological boy who had started to socially transition as a girl six months before our initial visit. Her mother Kellie had been divorced for three years and was now in a committed relationship with a woman for the past year. Her partner was the only support person either had at the time and that support was beginning to wear thin.
She would scream and cry in jags and then sulk in her bedroom for the rest of the day. Kellie met with me first and stated that Jess was exhibiting unusually aggressive behavior, and was being extremely oppositional. She was having nightmares and panic attacks and had begun to lie and fabricate stories. Was this a reaction to recent losses in the family, the recent move to another state, or just a need for attention? Could this also be a phase or resistance to the looming onset and eventual development of puberty?
Jess had difficulty making friends back in Chicago but seemed to align herself with one girl that had been in her same grade. This had been her only friend. She feared that she would never have a true friend again and that her life was doomed. 111
This was a compounded case because of all the variables: The family had just relocated to a new state and the adjustment from the move was particularly challenging. Very little support was available in their new surroundings, they were away from life -long family and friends, and Jess was afraid of going to a new school, and not making friends. Also, she was concerned about how the school would accept her as a girl, and whether they would allow
Kellie was concerned that now tha transition as a girl would be more complicated. She related how Jess had always been a hyper child and was almost too eager when it came to socializing and this would turn the other kids off sometimes to the point of bullying. Jess was awkward and never seemed to fit into a particular group.
problem about my being trans (self identified) because my father has a big problem with it. But there are certain other things I like about her being in our family. For one thing, she loves when
I write her poems and stories. I write her
I watched as Jess aggressively played with crayons, markers and hand puppets. She had great difficulty sitting still and being socially interactive. She whispered certain questions into
stead of speaking to me directly. She wanted to know why I had only two baby dolls, a male and a female in my office. Where was my other doll? When I told her
ju 112
Jess loved to play with words and had a vivid imagination. She asked if she could write me a story/poem for our next session, but warned me that it may be only partly true. I let her know that with our imaginations as the steering current of our stories, it was okay to bend
The Girl Behind the Glass
A little girl is looking at herself in the bathroom mirror and imagining herself with long, curly hair, held in place by a beautiful barrette with a big, white bow. Her hair is short right now and very stringy. She is not pretty or delicate. In fact, she does not look like anyone she has ever seen. She wants friends who will stay long enough to share a bowl of ice cream or watch a video. She can feel herself start to cry and her reflection gets blurry in the mirror.
Then she remembers that this is a magical glass like her favorite fairy tale, Snow White. She knows that she needs to talk to the mirror and believe in the answers to her questions. Her eyes sparkle with hope as she sings a song to herself in the privacy of the moment.
With this song that I sing/I can be anything,
A boy, a girl, a hybrid too/I am magically perfect t you?
What others say
Make a wish/I will grant it today.
Are you afraid to be for real? Think your heart is for others to steal?
Just be yourself in a beautiful dress 113
When Jess came in for her next session she was excited to share her realizations in what she called her stoem, her invented word for both story and poem. She realized that she
that kept changing in the mirror. She also began to realize that some people would be more
a good person and I need to be a friend to
Fox (1997) reminds us that parents imagination, insight and distinct uniqueness through poetic language. He states,
surprise about who that child is. Surprise is a gateway through which parents remind themselves - or learn for the first time that their children are on a unique adventure, with
(p.97)
Case Study: Conrad
Our lives begin to end the day we become silent about things that matter.
-Dr. Martin Luther King, Jr.
Conrad was 14 when he was first referred to my office for issues regarding anxiety and gender dysphoria. He was slender, shy and almost seemed to want to disappear into the background. His appearance was ambiguous, and when he spoke at all, it was in a soft tone. He 114 was dressed in jeans and a baggy tee shirt, a binder as well as a white undershirt and he wore thick eye glasses. He kept his head down toward the floor and would wring his hands nervously..
He complained of constant stomach pains and would throw up often right before school.
He never felt he was either one gender or the other, nor did he feel any bond of trust of friendship from these students so his answer would vary from saying nothing at all and ignoring
the cruelties and personal threats of students eager to harass him and aligned himself with teachers he could talk to or at least be with during the lunch hour. A couple of times he was groped in a class and was too shocked to say anything to the teacher in the classroom.
Sometimes the kids would call him degrading names, like thing one or thing two , weirdo or psycho . Some days, he was a human target for thrown pencils, paper airplanes or spit balls.
He feared being jumped in the hallways. Often, the abusive behaviors were unintentionally from the teachers, whether it was because they did nothing to stop the taunting from the other students or instead, punished Conrad even though he was the person being victimized.
Teachers are woefully undereducated about transgender issues and as a result, transgender youth are often misdiagnosed as being difficult in the classroom, having learning disabilities or deep psychological problems (Glavinic, 2010). Meanwhile, their transgender issue, the true cause of their school maladjustments and difficulties, remains unaddressed. 115
Kim Pearson (2009), the executive director of the national advocacy organization
TransYouth Family Allies (TYFA) states that the intolerance at school is incredibly tough on
horrors for Conrad, especially if there was a substitute teacher that called out the birth name while taking attendance. It is one thing when a person tries to be stealth in school and still another when someone calls out a name that is gender specific, made even worse when it
public.
In a survey of approximately 3,500 people who identify on the transgender spectrum, younger participants reported markedly higher levels of harassment because of their gender expression within the previous year. This could be due to the greater visibility of transgender youth which may have increased their exposure to mistreatment in some respects.
Many of the participants regardless of their level of being out to immediate family members or friends--reported that they feared for their physical safety because of their gender identity/expression. A majority (55-58%) of those who were out to several, most, or all of their family and friends, indicated feeling sometimes or often unsafe (Beemyn & Rankin, 2011).
Conrad battled with his anxiety and social awkwardness by drawing pictures of creatures from his imagination. He started drawing when he was about seven or eight. Many of his drawings were hybrids like a wolf and a tiger, a bat and a cougar or a German Sheppard and a fox. He found company and solace in drawing and it seemed to ease the anxiety and social phobia he was experiencing at the time. An only child, he felt a great kinship to his creations and developed complex narratives that accompanied his work. 116
He admitted to always thinking outside of the box when it came to art. One of his first drawings was of an alien abducting a whale, when other kids were drawing stick figures or flowers. He stated: My themes were always animals, especially the hybrids. I had to develop
took a
ones you give yourself. You choose the rules about how you want to express and in what form.
- something I have never had. You are only limited by your own imagination.
Conrad, like most transgender teens, dreaded his first puberty. For him, it happened in the fifth or sixth grade. He states he felt he was more fearful of becoming a woman than anything else that had already happened in his life. He felt the ultimate betrayal of his body
who always played the role of the father, the brother, even the family dog anything but the dreaded girl.
In Troubling the Line: Trans and Genderqueer Poetry and Poetics (Tolbert &
Peterson, 2013), Shipley talked about the way a poem transforms language as well as identity.
Shipley ask How do we begin to write about a body that has been historically illegible? I find that poetic language can allow us to pursue (through its visceral, bodily qualities) sensations that are, perhaps paradoxically, actually beyond language. A definite and precise
197). 117
online relationship with a girl. This was also around the same time he started on male hormones. The testosterone injections, over a period of time, lowered his voice significantly, helped him fill out in the chest and enabled him to grow both a beard and a moustache. He was building sexual confidence as a result of being able to talk somewhat freely without the usual judgments or rituals often assigned to gender.
He felt better equipped to practice the art of conversation without experiencing the fear of social ridicule or backlash. He was eventually able to cope better with crowds and felt confident and congruent in his role as a young man. His drawings developed from being singular characters that were lamenting about being lonely or uncertain about love or relationships to expressions of sexual confidence or dominance. In other words, he and his art developed simultaneously.
The first drawing shown below (Fig. 4, Appendix A) is representative of his desire for answers. Conrad sees himself as a lone wolf /human hybrid humbling himself on his knees.
The character is dressed in a long-sleeved shirt and pants. The accompanying words read:
to do
And lost my destiny
I sit beneath the sun 118
My hands held to the sky
I cannot ask a question
But still I wonder why.
Even the format of the poem is a drawing in and of itself. It is bent almost in a prayer pose to accompany the drawing as a complete structure to represent inner and outer expression.
I asked Conrad to think about the face he used to show the world and the face he used to show himself. As an art therapy technique, this is about reflecting on our inner and outer worlds as well as exemplifying the balance between the two. What did that face look like? How does it differ from the face he shows to the world now? He said the face he showed the world before was stoic and blank and the attitude reflected was stand offish, uncaring, aloof and desensitized. He realized that the face he used to show would be the one that would protect him the most. In a way it was his mask as well as his armor.
Boyles, (2006) in her chapter, Individual Art Therapy with Resistant Adolescents
(Brooks, 2006) said that art is used to externalize and formalize a story, fear or experience and that it takes a weight off to put the image outside of oneself. Art has a narrative component as well and provides a record of where a person comes from, where they are in the moment and where they are going in the future (p. 40).
In the second drawing (see Fig.5, Appendix A), we see the character Conrad has drawn of himself engaged in an intimate embrace. The characters allowing them to both see and be seen. This was also a time that represents freedom 119 to express emotion fearlessly and to allow and accept love love for himself as well as his newfound ability to express love for another. In this drawing, one of the characters is partially clothed in shorts.
an erect penis that is dripping with ejaculate (Fig. 6 Appendix A). He is in the dominate position and they are both d related that his art work reflects his attitude as well. When asked about this drawing he stated:
Now 18, enrolled in college and enjoying his new found manhood, Conrad says he smiles at strangers and shows the face he wants the world to see. He is in a happy, committed relationship with his girlfriend of two years and looks forward to every day. He credits the expressive art therapies for helping him develop his personal identity and truth by expressing
working on because he enjoys seeing its evolutionary process.
Case Study: Adam
Adam was referred to my office when he was 14 years old. He wore his hair in a spiked blue Mohawk that was covered by an oversized hooded sweatshirt, baggy shirt and pants. He experienced anxiety and depression. He often experienced difficulty breathing, sometimes because of the double binders he had to wear to flatten his ample chest. Although he was in advanced classes and excelled academically, he had difficulty relating on a social level. He had a couple of close friends, but discovered over time that many were detrimental to his well being because they were instigating rumors behind his back. Others drifted away due to their 120 involvement in drugs or alcohol Adam had already endured three hospitalizations as a result of his self-injurious behaviors of cutting, his history of depression, social anxiety and suicidal ideation. He made his full transition as a male between the ages of 13-14 and was able to over ride difficult transitions with the help of music, art and writing. He stated that he would relax the most whenever he would draw. He started with cartoon characters and then branched out into realism around the age of 11 or 12, the same time as puberty.
The Levick Emotional and Cognitive Art Therapy Assessment (LECATA) reviewed in
Brooke (2004) encourages processing that is nonrestrictive and unstructured. Open-ended questions are asked and the participant answers in whatever he or she
-
Adam preferred working with larger pieces of art on a 36x24 canvas because he felt trapped doing smaller pieces. He was most challenged by realism and found that the arts offered the only positive way to express. He has noticed over time how his work has changed as he has transitioned. He related that there was an automatic response when he would pick up a pencil to draw. It was easy to go into a trance-like state and whatever was muddled or confusing would become clearer as he would draw. He noticed that when he was particularly angry, he would push himself harder and the lines would be darker. His drawings used to be angular, sharp and intense, now curves are the standard for his work. He also enjoyed working with oils because they provided a new challenge. Oils took a week to dry, allowing him to continue to work on blending qualities and playing with the textures and the dimensions. 121
The ability to bring words to the art that has been created is an invaluable skill. It is helpful that the novice should focus on some questions inspired by the field. Some examples include: What does the art say about how the client thinks and feels about himself? What does the art say about his or her body? What does the art say about how the client thinks and feels about others, particularly significant relationships? What does the art say
about his or her goals? What does the art say about his or her coping mechanisms, values or philosophy of life? (Mills, 2006), (p.37).
In that same chapter, Watkins (1981) offers further questions regarding understanding the relationship between the client and their work. Some of those deepening questions include the following: How can the images accurately be reflected upon so that they are not simply doodle marks on a page but rather closer analyses may lead to specific awareness of patterns and similar
work?
Have the many details of the picture been seen not only as something that can be rated, but also as a necessary part of this particular image as a whole? How can the image be deepened or extended? In what way is the image working out its own solutions to the problems at hand?
(p.37).
Fig. 7, Appendix A, is a drawing by Adam at age 12. It depicts a skeletal being carrying a shield. There are many symbols embedded in the drawing and various textures as well. He enjoyed doing this piece because it was one of the first big ones on canvas that allowed him to think past the obvious outside presentation and look deeper. He recalled how easy it was for people to see the negative side of the picture first and ask questions later. They assumed the picture was about death and destruction because of the skeleton, the dark background and all of 122 the sharp edges. When asked about this piece he simply said that he was interested in building a being from the bones up and felt that at the core level it would be easy to see this was a beast of peace or a guardian of the garden. Note the plant life at the bottom of the page and the light that emanates from them.
Adam stated that it was easier for him to be friends with people older than him because he felt so misunderstood by people his own age. He was not interested in socializing with other transgender youth either because he wanted to be stealth overall and not make gender the main issue. He had overcome much adversity and wanted to focus on future events and leave the past behind so he could cultivate more of his strengths. Resiliency is a term frequently heard in relation to the strengths perspective and positive psychology. It can be defined as a way to bounce back from events that may produce stress, emotional trauma, or transition. Resiliency
challenges and overcoming obstacles in their lives (Kirst-Ashman, 2011).
looking off to the direction of the future and is androgynous in form, as was Adam at the time of his transitioning. (See Fig. 8, Appendix A)
Adam continued to draw through the varied emotional landscapes he would experience.
He would draw anyone or anything that brought out a clear message regarding identity or attitude. He drew figures like Brody Dale, a singer/song writer he admired, Kurt Cobain who formed the group, Nirvana and musician Sid Vicious, a famous member of the punk group, The
Sex Pistols. Adam recognized his own evolutional, developmental process as he worked from the more esoteric drawings to the more clearly defined portraits. 123
The last drawing to include in this study is a sketch of a nude woman that Adam drew at age 15. (See Fig. 9, Appendix A). This was drawn to represent comfort with self, no matter the gender. It also represents the continuity of maturation and growth of an individual on all levels.
closed their book with some poems and thoughts by transgender clients that capture the essence of what it means to move through resistance, fear and isolation and finally arrive at a place of joy, growth and acceptance. Some are included here:
w like a fungus in the
The spiritual, emotional and physical aspects of self are revealed through these stories, songs and drawings. In essence, this study can be seen as a collective representation of a human struggle for authenticity through the expressive art therapies. This is an inclusive framework that highlights the strengths and creative aspects of individuals so we may accurately know their relationship to themselves and the world. This is in sharp contrast to a reductionist, minimalistic model that tends to focus on what is wrong with an individual or what can go wrong. We can be further enlightened by breadth, scope and vision through their unique expressions through poetry and narrative, art and music. This study values a holistic, hopeful and humanistic approach. I will close with some poignant words and latest drawing by 13-year old
Jazz: 124
Look into my eyes and you will find me. Look into my heart and you will find you. 125
CHAPTER 6
Conclusion
This has been an exploratory study in a burgeoning field and is meant to be an introduction to counseling transgender youth utilizing the expressive art therapies as an adjunctive modality. It is hoped that a curiosity has been piqued as to how counselors may creatively engage with transgender youth and their families to foster healthy adaption. Small scale studies have been done on transgender issues yet research in this particular area has been scant, at best. This study is the first to look at the specifics of the needs of transgender youth and their families through the expressive art modalities as a viable tool for mental health and allied health care professionals.
Particular areas of attention were given to gender transitioning, becoming a gender sensitive professional and finding support for these clients. Benefits and special consideration of the expressive art therapies were explored with a focus on counseling issues of bullying, suicide, depression, anxiety, rejection and parental concerns. Client expressions through poetry, narratives and art were utilized in three case studies so readers could better visualize the arts in practice. Writing, art and music prompts were offered as invitations to help uncover and discover
This conclusion is just a beginning to what I hope will be further explorations into a unique and much needed field of study. New possibilities for transgender youth and their families are coming to fruition from medical innovations to laws being changed across the states and in the world to ensure best practices and treatments. Perhaps by the time this study is published, more research and advances in the expressive arts therapies as well as the mental 126 health and medical fields will have been made to assist transgender youth and their families so we may all continue to grow in synchronistic, creative and healthful ways.
Assumptions and Limitations
One assumption of this study is that transgender youth in other geographic areas or other countries would have access to trained helping professionals who are equally comfortable working with transgender youth and incorporating creative art therapies. This study included three cases seen in private practice in the Southeastern United States, in a middle class suburb of a major city. A problem remains regarding how to deliver services to transgender youth in need of care or providing access to care through existing systems.
Another assumption may be that of consistent and congruent training and expertise among health care professionals in the multi-faceted areas of sexuality with an emphasis on sexuality and gender as well as the expressive art therapies.
The use of the expressive arts as an adjunctive tool may be difficult to employ or evaluate given the variations of the arts in general. Music, art, poetry and narrative have different assessment measures and thus different outcomes. Relevance of the work to this particular group studied also needs further research. Additionally, poetry and the related arts as a medium for qualitative study may not be accepted within the scientific community without appropriate proof of its significance.
As this was an exploratory study, it has inherent limitations. The limitations include age, race, culture, socio economic status, literacy and comprehension, and willingness to access and 127 incorporate expressive art modalities. Because it is a relatively new field, there are no studies to address longitudinal implications or concerns. In addition, there was personal bias-use of pre- existing cases already engaged in the creative art process in private practice.
Significance of the Study
This exploratory study has contributed to the literature on working with transgender youth and their families by showing how the expressive art therapies are modalities which many transgender youth already utilize on their own. Their innate creativity can be harnessed in a therapeutic way in order to navigate their emotional, physical and spiritual transitions. Recent, cutting edge research and their findings have been showcased in this study. Many of the studies show significant improvements in the areas of emotional and physical health, but we do not yet know the far reaching effects of the expressive art therapies as they relate to transgender youth as they begin to transition and beyond into adulthood. Also, it would be beneficial to know more about the intersection of expressive art therapies with neuroscience, medicine and other emerging research trends.
Counselors who plan to work with this population can benefit from the elucidations of salient theoretical frameworks and practical considerations such as: creating a safe space; helping transgender youth and their families access various resources; and linking them to trained professionals. An overview of how the expressive art therapies are utilized within a counseling setting was provided. Helping professionals may further benefit from the suggested writing prompts, art prompts and letters described herein. 128
Implications for Future Research
We have a small glimpse into the lives of transgender youth and their families. Still, there are no large-scale, complete long-term studies of life-long cross-sex hormone use in transgender people in the United States. Additionally, there are few if any long-term studies regarding most transgender related issues. This is partly because the topic is so new to the masses, partly because a large number of transgender people willing to participate in studies may be difficult to find and partly because the topic is so controversial. This also makes funding in general difficult. Much of the existing research has been done for the LGBT community and although this is helpful, the transgender community has issues separate from theirs and those alone need to be specifically addressed and researched (Teich, 2012).
Further studies of transgender youth, in the areas of discovering and implementing efficient assessment tools, fostering better treatment strategies and utilizing state of the art medical and alternative interventions are desperately needed.
Poetry and the related expressive art therapies and transgender youth have much in common. Both have been a natural and historical part of our world since the beginning, both have often been misunderstood and marginalized and both are works in progress. To preserve history and nurture a productive present and a promising future, respect for differences as well as an understanding of cultural and familial expectations will be helpful. The expressive arts are a natural and necessary part of our world, and vicissitudes and variations are common. The same can be said of humans. Perhaps being transgender will soon be seen as a healthy and natural variation of human expression and experience. I believe we are all witnessing a major civil rights movement that continues to evolve and unfold it is a gender evolution. 129
My hope is that the brave narratives expressed in this study will eventually culminate in compassionate and professional treatment and acceptance of human diversity, authenticity and a shift in forward thinking and research for our future generations. As the poet May Sarton so eloquently stated, We have to dare to be ourselves, however frightening or strange that self may prove to be is a difficult process, yet we strive to be unique and real at the same time. The gift of being real
Margery Williams, originally published in 1922:
Does it mean having things that buzz inside you and a stick-
When a child loves you for a long, long, time, not just to play with, but REALLY loves you, then
takes a long time.
to be carefully kept. Generally, by the time you are Real, most of your hair has been loved off, and your eyes drop out and you get loose in your joints and very shabby. But t matter at all understand. But once you are Real, 130
REFERENCES
Alschuler, M. (2006). Poetry, the healing pen. In S. Brooke (Ed.), Creative arts therapies
manual. (pp. 253-262). Springfield, IL: Charles C. Thomas.
Psychiatric American Medical Association (2008). Position Statement.
th American Association. (2002). Diagnostic and statistical manual , 4 Ed. Rev. (DSM-IV-TR).
Washington, DC: Author.
th American Psychiatric Association. (2013). Diagnostic and statistical manual , 5 ed. (DSM 5).
Washington, DC: Author.
American Psychological Association. (2011). Answers to your questions about transgender
people, gender identity and gender expression. Washington, DC: Author.
Angello, M. (2013 ). On the couch. A guide to raising and supporting transgender youth.
Philadelphia: Vanity Press.
Beck, K. (2013). Do transgender little girls have a fascination with mermaids?
http://www.mommyish.com/2011/06/03.
Beemyn, G., & Rankin, S. (2011). The lives of transgender people. New York: Columbia
University Press.
Benjamin, H. (1966). The transsexual phenomenon. New York: The Julian Press, Inc.
International Review of Psychiatry , 7(2) pp. 159-167.
Life Against Romance: Poems . New York: Pleasure Boat Studio: A Literary Press.
Bockting, W.O., Knudson, G., & Goldberg, J.M.(2007). Counseling and mental health care for
transgender adults and loved ones. International Journal of Transgenderism , 9(3/4), 131
36-82.
Boedecker, A. (2011). The transgender guidebook: Keys to a successful transition. Self-
published.
Bornstein, K. (2013). My new gender workbook . NY: Routledge.
---. (1994). Gender outlaw : On men, women and the rest of us. New York: Routledge.
Boyes, S. (2006). Individual art therapy with resistant adolescents. Creative arts therapies
Manual . Illinois: Charles C Thomas Publisher, Ltd..
Brill,S., Pepper, R. (2008). The transgender child: A handbook for families and professionals.
San Francisco: Cleis Press Inc.
Brooke, S.L. (2006). Creative Arts Therapies Manual. Illinois: Charles C Thomas.
Brown, M.L., Rounsley, C.A. (1996). True selves: Understanding transsexualism . San
Francisco:Jossey-Bass.
Brownstein, M. (2010), Plastic, Reconstructive and Gender Related Surgery.
www.brownsteinmd.com . Accessed March 26, 2010.
Boedecker, A.L, (2011). The transgender guidebook: Keys to a successful transition. Self
published.
Burnell, G.M. and Motelet, K.P. (1973). Correspondence therapy, Archives of General
Psychiatry, 28, 728-731.
Colapinto, J. (2000). As Nature Made Him: The boy who was raised as a girl. New York: Harper
Collins.
Chavis, G.G. (2011). Poetry and Story Therapy. The healing power of creative expression.
Philadelphia: Jessica Kingsley Publishers.
Chavis, G.G., & Weisberger, L.L., (Eds.). (2003). 132
journey. St. Cloud, MN: North Star Press.,
Healthy Adolescent S Family relations, 39(2) pp.
123-131.
Cray, A., & Baker, C. (2013, May 30). The Affordable Care Act: Progress toward eliminating
insurance discrimination against transgender people . Center for P. Retrieved from
http://americanprogress.orgrogress
Delemarre-van de Waal, H.A., Cohen-Kettenis. (2006). Clinical management of gender identity
disorder in adolescents: a protocol on psychological and pediatric endocrinology aspects.
Eur J Endocrinol 2006; 155 (suppl 1) S131-S137).
DeSalvo, L. (1999). Writing as a way of healing: How telling our stories transform our lives.
Boston: Beacon Press.
DeVries, A. Cohen-Kettenis. (2007). Clinical management of gender dysphoria in adolescents.
Int J Transgenderism 2007; 9 (3) 83-94.
Duffy, T. & Haberstroh, S. (2011). A musical chronology and the emerging life song.
Counseling today. February 2011, p. 32-35.
Ehrensaft, D. (2011). Gender born, gender made: Raising healthy gender non-conforming
children. New York: The Experiment, LLC.
Ellis, M.L. Sexualities: Language and Embodiment in Art T
International journal of art therapy, 12(2) pp.60-68
Fausto-Sterling, A. (2012). Sex/Gender: Biology in a social world. New York: Routledge.
Fink, P.J. & Levick, M.F. (1973). Sexual problems revealed through art therapy. Art
Psychotherapy. 1, 277-291.
Forinash, M., & McKnight, S. (1999). Rose. In J. Hibben (Ed.), Inside music therapy: Client 133
experiences (pp. 191-198). Gilsum, NH: Barcelona.
Fox, J. (1995). -
Making . New York: Jeremy P. Tarcher.
---. (1997). Poetic medicine: The healing art of poem-making. New York: Jeremy P. Tarcher.
Practice/Psychotherapy Practice/Contemplative Practice: Sitting on the
Guidance and Counseling, 15(3) pp.18-23.
Frost, S. (2010). SoulCollage: An intuitive collage process for self-discovery and
community. California: Hanford Mead Publishers, Inc.
Futterweit, W. (1998). Endocrine therapy of transsexualism and potential complications of long-
term treatment. Arch Sex Behav 1998; 27 (2) 209-226. Pubmed.
Gallant, W., Holosko, M, & Siegel, S.(1997). The use of music in counseling with addictive
clients. Journal of Alcohol & Drug Information, 42(2), 42-52.
Gendler, J. (1988). The book of qualities. New York: Harper Perennial.
Gladding, S., (2011). The creative arts in counseling. Virginia: American Counseling
Association.
---. (1997). Poetic medicine: The healing art of poem-making. New York: Jeremy P. Tarcher.
Glavinic, T. (2010). Research shows lack of support for transgender and gender-nonconforming
youth in U.S. school systems. Student Pulse, 2 (01). Retrieved from
http://www.studentpulse.com/a?id=135.
Glicksman, E. (2013) Transgender today. American Psychological Association, 44 (4), p.36.
Goldberg, C.M., (2007). The power of words. New Hampshire: Transformative Language Arts
Press
Grant, J.M., Mottet, L.A., Tanis, J., Harrison, J., Herman, J.L. & Keisling, M. (2011). Injustice 134
at every turn: A report of the national transgender discrimination survey. National
Center for Transgender Equality and National Gay and Lesbian Task Force. Washington,
DC: The National Gay and Lesbian Task Force & The National Center for Transgender
Equality.
Gray, E. (2011). Transitions: What will it take for America to accept people for who they really
are? New Republic, 242( 10), 10-18.
Grayson, D., (2013). True colors: The use of the expressive arts therapies for transgender youth.
Annual AASSECT conference and presentation.June, 2013. Miami, Florida.
Grayson, D.E. & White, A. (1987). Parents and other strangers: A creative guide to better
relationships. NY: Ashley Books.
Green, J. (2004) Becoming a visible man . Nashville, TN: Vanderbilt University Press.
Green, R. (1974). Sexuality identity conflict in children and adults. New York: Basic Books.
Hass-
The Arts in Psychotherapy, 36
pp. 175-184.
Hirshfield, J. (2001). Optimism. Given Sugar, Given Salt (p. 71). NY: Harper Collins.
Heller, P.O. (2009). Word arts collage . Columbus, OH: Pudding House Press.
Hynes, A and Hynes- Berry, M. (1994, rev. 2012 ). Biblio/Poetry therapy: The interactive
Process: A Handbook. Boulder, CO: Westview Press.
Hubbard, E. A., & Whitley, C. T.(2012). Trans-Kin: A guide for family & friends of transgender
people. Boulder, CO: Bolder Press.
Jamison, K.R. (1993). Touched with fire: Manic-depressive illness and the artitstic temperament . 135
NY: Macmillan.
Kirst-Ashman, K.K.(2011). Human behavior in the macro social environment: An empowerment
rd approach to understanding communities, organizations, and groups (3 ed). Belmont,
CA: Brooks/Cole, Cengage Learning.
Krieger, I. (2011). Helping your transgender teen : A guide for parents . New Haven:
Genderwise Press.
Leedy, J.J. (Ed.). (1985). Poetry as healer: Mending the troubled mind . New York: Vanguard
Press.
nd Lerner, A. (Ed.) (1994 ). Poetry in the therapeutic experience. (2 ed.). St. Louis: MMB Music,
Inc.
Lev, A.I. (2004). Transgender emergence. Therapeutic guidelines for working with gender-
variant people and their families. NY: Haworth Press Inc.
Malchiodi, C., (Ed.). (2008). Creative interventions with traumatized children. New York:
Guilford Publications.
--- (Ed.). (2005). Expressive therapies . NY: Guilford Press.
Mazza, N. (2003 ). Poetry therapy: Interface of the arts and psychology. (Rev. ed.) NY:
Routledge.
McCullis, D. (2012). Bibliotherapy: Historical and research perspectives. Journal of poetry
therapy: The Interdisciplinary Journal of Practice, Theory, Research and Education, 25
(1), 23-38.
Meana, M. & Jones, S. (2011). Developments and Trends in Sex Therapy. In R. Balon (ed),
Sexual Dysfunction: Beyond the brain-body connection (57-71). Switzerland: Karger.
Mills, A. (2006). The assessment attitude. The creative arts therapies manual. Illinois: Charles 136
C. Thomas Publishers
Money, J. and A.A. Ehrhardt ( 1972). Man and woman, boy and girl. Baltimore: John Hopkins
University Press.
Money, J. (1988). Gay, straight and in-between: The sexology of erotic orientation. New York:
Oxford University Press.
Nelson, P. (2012). -discovery. New York:
Atria Books.
Nicholls, S. (2009). Beyond expressive writing: Evolving models of developmental creative
writing. Journal of Health Psychology, 14(2), 171-180.
Papalia, D., & Feldman, R. (2012). Experience human development. NY: McGraw-Hill.
Pearson, K. (2009, Feb. 23) Online interview.
Olson, J, Forbes, C., Belzer, M. (2011).Management of the transgender adolescent. JAMA
Pediatrics . Feb.7, 2011, Vol.165 No 2.
Pearson, L., Ed. (1965) The use of written communications in psychotherapy. Springfield, Il.:
Charles C Thomas.
Pennebaker, J. W. (1990) Opening Up: The healing power of expressing emotions. NY:
Guilford.
--- (2004) . Writing to heal: A guided journal for recovering from trauma and emotional
upheaval. Oakland, CA: New Harbinger Publications.
Pepper, R. (2012) Transitions of the heart: Stories of love, struggle and acceptance by mothers
of transgender and gender variant children. Berkeley, CA: Cleis Press.
Preidt, R. (2013, June 20) Sex Change Hormonal Therapy Deemed Safe . (M. Plus, Producer).
Retrieved from U.S. National Library of Medicine, National Institutes of Health at 137
http://www.nim.hih.gov/medlineplus/news/fullstory_html
Reiter, S. (2009) Writing away the demons: Stories of creative coping through transformative
writing. St. Cloud, MN: North Star Press.
American Journal of Art Therapy, 28 (3) pp. 71-79.
Schaeffer, L.C., Wheeler, C.C. (1995).
(1938-1953). Archives of Sexual Behavior, 24. pg. 73-93.
Schaeffer, L.C., Wheeler, C.C., & Futterweit, W. (1995). Gender identity disorders
(transsexualism). In G.O. Gabbard, (Ed.)
Shallcross, L. (2011). Working outside the box. Counseling today. February, 2011, pg.26-31.
--- (2012). The recipe for truly great counseling. Counseling today. December, 2012, pg. 26-33.
Slivinske, J. & Slivinske L. (2014). Therapeutic storytelling for adolescents and young adults.
Ohio: Oxford University Press
Solomon, A. (2012). Far from the tree: Parents, children and the search for identity . NY:
Simon & Schuster.
Teich, N. (2012). Transgender 101: A simple guide to a complex issue . NY: Columbia
University Press.
Tolbert, T.C. & Peterson, T (Eds.) (2013) Troubling the line: Trans and genderqueer poetry and
poetic s. NY: Nightboat Books.
rd Thompson, C. L. and Rudolph, L.B. (1992). Counseling Children, 3 ed., Pacific Grove, CA:
Brooks/Cole.
White, M and Epston, D. (1990) Narrative means to therapeutic ends. New York: Norton 138
Whyte, D. (1998) Sweet darkness. The house of belonging. (p.36) Langley, WA: Many Rivers
Press.
Williams, M. (1922). The velveteen rabbit . New York: Doubleday.
Wylie, M.S. (2008, Nov/Dec.) Breaking through: Interview with David Whyte. Psychotherapy
Networker, 32 (6), 56-61.
Winters, K. (2008). Gender madness in American psychiatry: Essays from the struggle for
dignity . Charleston: BookSurge Publishing.
--- . (2013). Mindful practices: Dignified and effective medical care for trans people.
rd Presentation for Broward County 3 Annual Transgender Medical Symposium. Fort
Lauderdale, FL. April, 2013
th Yarber, L.W. & Sayad, B.W. (2013). Human sexuality: Diversity in contemporary America . (8
ed.) NY: McGraw-Hill.
YES Institute. (2008, Feb.-Mar.). School counselors ask for help. Re-Vision, 4. 139
APPENDIX A
ART WORK
Figure 1- Jazz drawing, age 5 140
Figure 2-Jazz drawing, age 6 141
Figure 3- Jazz drawing, age 10 142
Figure 4- Conrad drawing, age 15 143
Figure 5, Conrad drawing, age 16 144
Figure 6, Conrad drawing, age 17 145
Figure 7, Adam drawing, age 12 146
Figure 8- Adam drawing, age 14 147
Figure 9- Adam drawing, age 16 148
APPENDIX B
Release of Expressive Therapies Work for Educational or Therapeutic Purposes
This is a letter of consent and agreement between Deborah Eve Babyatsky-Grayson, LMHC,
PTR, ABD and ______to use some of the above captioned patient sessions. These works may be presented either at professional conferences in a clinical or educational format or for demonstration purposes as a teaching aid. It may also be included as part of a Doctoral dissertation on the expressive arts therapies to be completed by 2014.
It is our understanding that only the first name or initials will be used to uphold confidentiality and anonymity. At no time will these works be used for profit or for sale. Full artistic rights revert to the artist.
Our signatures below state our understanding and agreement of these terms and for the release of liability as a result of utilizing works for educational or therapeutic purposes.
Name: (print) Deborah Eve Babyatsky-Grayson, L.M.H.C., PTR, ABD
Title: Clinical Sexologist; Professor Signature: ______
Name: (print) ______Signature: ______
Artist Date: ______149
APPENDIX C
Glossary
Affirmed Female: A person with a male body who considers herself to be female.
Affirmed Male: A person with a female body who considers himself to be a male.
Affirmed Gender Identity: The gender identity the person has declared to others.
Androgyny, androgynous: Expressing both masculine and feminine characteristics, either in obvious contrast or as part of an integrated whole.
Androgyne: A person who presents and identifies as neither man nor woman, masculine or feminine. This can be done with a gender neutral presentation, or by combining elements of both.
Androgyny: Flexibility in gender roles and the unique combination of instrumental and expressive traits as influenced by individual differences, situations and stages in life cycle The
Andros meaning man and gyne meaning woman.
Assigned sex/gender: The gender someone is considered to be at birth, generally based on genitalia. This is also referred to as biological sex.
Bigendered: Those who feel they have both a male and a female side to their personalities.
They may have two modes of gender expression, with different personas, or they may present androgynously. May also identify as Two Spirit.
Bind, binding: 150
Butch: Masculine appearing person. Often used to refer to masculine-appearing women who identify as lesbian.
Cisgendered or Cissexual: Someone whose biological sex/assigned gender is consistent with their gender identity. Cisgender has its origin in the Latin-
-derived prefix, trans- the other side of. The word cisgender has been used on the internet liberally since at least 1994.
In academic and literary use, the German sexologist, Volkmar Sigusch may have been the first to use it in a peer reviewed publication in 1995. The terms cisgender and cissexual have more recently been used in publications and have gained acceptance by many activists and scholars.
Coming out: identity, gender affirmation or sexual orientation. Being outed is the unauthorized disclosure by
Cross-dresser (CD) People who wear clothing, jewelery and or make-up not traditionally associated with their anatomical sex. Someone who enjoys dressing part of the time as other than their assigned gender. This can be associated with transitioning, sexual fetish or simply to
Drag King : An anatomical female who cross dresses as male primarily for performance or a show. They generally identify as females and do not wish to change their anatomical sex. The term is sometimes used as an insult toward a transman.
Drag Queen: An anatomical male who cross dresses for entertainment. They generally do not wish to change their anatomical sex. The term is sometimes used as an insult toward a transwoman. 151
FTM: Female to male transition. A person whose assigned gender at birth is female yet who identifies as a boy or a man and wishes to change their external appearance to match their identity.
Gay: A common term for homosexual
Gay Male: Refers to men who love and are sexually attracted to men.
Gender: Refers to the biological differences between people who are male or female or intersexed. It is also the designation of the role of a man or a woman.
Gender Bender, Bi-Gender, Beyond Binary, Gender fluid, Gender outlaw, Pan gender,
Polygender: Similar to genderqueer and androgyne, these terms refer to gender variations other than the traditional, dichotomous view of male and female. People who self-refer with these terms may identify and present themselves as both or alternatively male and female, as no gender, or as a gender outside the male/female binary.
Gender dysphoria:
secondary sex characteristics.
Gender expression or gender presentation: The external identity, expressed through movement, dress, grooming, hairstyle, jewelery, speech, and chosen name.
Gender Fluid Children: Children who defy the norms of binary gender and either slide along a gender spectrum or weave their own intricate individual patterns along the gender web. 152
Gender identity: else that may or m
Gender Identity Disorder (GID): According to the DSM-IV-TR (APA, 2002), gender identity disorder is the diagnosis used when a person has (1) a strong and persistent cross gender identification and (2) persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex, and the disturbance (3) is not congruent with physical intersex condition and (4) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning . According to DSM-IV-TR, gender identity disorder not otherwise specified can be used for persons who have a gender identity problem with a concurrent congenital intersex condition. Ma
In 2013, the fifth edition of the
DSM changed the diagnostic label to gender dysphoria (APA, 2013).
Gender roles and norms: Culturally determined behaviors, interests, relationship patterns and other characteristics typically associated with being male or female. This is also known as sex- role stereotypes. Gender variant or gender non conforming (GNC) refers to not fitting these assumed norms.
Gender queer or gender-nonconforming: People who think of themselves as falling outside of the gender binary.
Heteronormative: heterosexual and cisgendered.
Heterosexual: individuals who feel love and sexual attraction toward members of the opposite sex. 153
Homosexual: individuals who feel love and sexual attraction toward members of the same sex.
Hermaphrodite: Previously used to describe intersex; now considered pejorative and outdated.
Hormone therapy: Hormones taken to change ones secondary sex characteristics. This includes feminizing hormones (estrogen and androgen blockers) for MTF, and masculinizing hormones
(testosterone) for FTM .
Intersex: A spectrum of conditions involving anomalies of the sex chromosomes, gonads, reproductive ducts, and/or genitalia. A person may have elements of both male and female
LGBT: Acronym for Lesbian, Gay, Bisexual, and Transgender. Sometimes written as GLBT.
LGBTIQQAA: There are numerous variations of the basic LGBT acronym used by some
or Ally.
Lesbian: refers to women who love and are sexually attracted to women.
MTF or Male to Female: who was identified as a male at birth and now identifies as a woman and wishes to change her physical characteristics to match her gender identity.
Packing: Wearing or using a penile substitute such as a sock, a synthetic prosthesis (or a creative version of one,) called a packer. Some packers are quite elaborate as well as functional and can be used to urinate while standing. 154
Passing: not being perceived as the gender they are presenting. An example of this might be a stranger
Real life experience (RLE): Generally accepted guideline, from the Standards of Care for
Gender Identity Disorders (see WPATH.org), that requires clients to live outwardly in the gender that matches their gender identity for a specified period of time (typically one year) prior to being eligible for genital surgery.
Secondary sex characteristics: Biological differences between males and females that begin to develop at puberty. These include breasts, facial hair, voice changes, and body mass distribution and redistribution.
Sex: Some make the classification as the designation of a person at birth as either male or female based on their anatomy. Sometimes sex and gender are used interchangeably but it is best to clarify and distinguish sex from gender identity, and gender expression.
Sexual Orientation: The gender one finds emotionally and erotically attractive: opposite
(heterosexual or straight), same (homosexual/gay/lesbian), both (bisexual), all/any (pansexual, omnisexual) or neither (asexual).
SRS or GRS- Sex or Gender Reassignment Surgery: This is the preferred term for what was used previousl limited to: vaginoplasty, hysterectomy, tracheal shave, facial feminization and phalloplasty.
Stealth: person has gone
may be very distressing to a person who is living stealth. 155
Transgender or TG: This term was originally used for pre-postoperative individuals who did not desire SRS. Now it is used as the umbrella term for people whose gender identity and/or gender expression differs from their assigned sex at birth. A pre-op transsexual is someone who has not had surgery. This covers people who have just begun to identify as transsexual to those who are very close to the actual surgery. The post-operative transsexual is someone who has had gender re-assignment surgery. A non-op transsexual is a person who has had all the hormonal/surgical treatments except the genital surgery, and who either has no desire to proceed with surgery, or who cannot proceed due to financial or other constraints. Also used as identification for anyone who is gender-variant. The term is also common. It is best to ask the client their preference regarding terms as they may not identify with the transgender
Transgenderism: is the body of knowledge on the subject of being transgender.
Transition: identity different from the one assigned at birth. Some people find the term offensive and prefer terms such as or
Transfeminine: A person whose femininity or female identity is not universally considered valid. It covers a broader spectrum of transwomen as well as genderqueers and people with non- binary genders. Some people will prefer the term
Transmasculine: Generally refers to someone who was identified female at birth but who identifies or portrays his gender as male. Some people prefer to be referred to as men rather than transmen or transgender men. Alternate terms are: affirmed male, FTM, gender-affirmed male or man. 156
Transphobia: Dislike of, or discomfort with, people whose gender identity and/or gender expression do not conform to traditional or stereotypic gender roles.
Transsexual (TS): Person whose gender identity differs from their assigned sex at birth. These are people who often live full time as a member of their opposite sex or birth-designated sex.
They may or may not (1) take hormones or have surgery or (2) be gender dysphoric. Some people suggest that y people who are in the process of changing, or who have changed, their anatomical sex to align with their gender identity. In general, the term
For some, disfavored. When in doubt, the clinician should ask clients which terms they prefer.
Two-Spirit, Two-Spirited: People who display characteristics of both male and female genders.
This is sometimes referred to as a third gender. This term is derived from the traditions of some
Native North American cultures. The term also represents the self- identity description used by many Native American gay men who do not identify as cross-gender or transgender. 157
APPENDIX D
Resource List
American Medical Association, GLBT Advisory Committee:
http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/glbt-
advisory-committee.shtml
American Psychological Association, LGBT Concerns: http://www.apa.org/pi/lgbt/index.aspx
Family Acceptance Project: http://familyproject.sfsu.edu
Families Like Mine: FamiliesLikeMine.com
Freedom Rings: Gay-Rehab.com/blog
Gay, Lesbian and Straight Education Network (GLSEN), (212) 727-0135: http:// www.glsen.org
Genderfork: GenderFork.com
Gender Odyssey Family: GenderOdysseyFamily.org
Gender Spectrum Education and Training, (510) 567-3977: http://www.Genderspectrum.org
GSA Network: http://gsanetwork.org/
Human Rights Campaign, Transgender Issues, (800) 777-4723:
http://www.hrc.org/issues/transgender.asp
International Federation for Gender Education (IFGE): ifge.org
: http://www.Lauras-playground.com
Mermaids: http://www. mermaidsuk.org.uk
My Princess Boy website: http://www.myprincessboy.com
National Center for Lesbian Rights: nclrights.org
National Center for Transgender Equality: Transequality.org 158
National Transgender Law Institute: TransGenderLaw.org
Parents, Families and Friends of Families and Gays (PFLAG), (202) 467-8180:
http://www. Pflag.org
Safe School Coalition: http://www.safeschoolscoalition.org
SunServe: sunserve.org
SunServe Youth: sunserveyouth.tumblr.com
T-House Online: T-Houseonline.com
TransActive: TransActiveOnline.org
Transcend: TranscendSupport.com.au
TransFamily of Cleveland: Transfamily.org
Transforming Family: http://www.Transforming family.org/about-us
Transgender Law Center: http:// www.transgenderlawcenter.org
Transgender Law and Policy Institute: http://www.Transgenderlaw.org
Transgender Legal Defense and Education Fund, (646) 862-9396:
http:// www.transgenderlegal.org
Trans Student Equality Resources: http://www.transstudent.org
Transgender Psychology Alliance: http://www.Transgenderpsychologyalliance.org
TransFamily, (216) 691-4357 (Emergency Resource Hotline): http://www.transfamily,org
Trans Kids Purple Rainbow: http://www.Transkidspurplerainbow.org
TransProud: http://www.transproud.com
TransYouth Family Allies (TYFA), (888) 462-8932: http:// www.Imatyfa.org
Trevor Project (suicide hotline), (310) 271-8845 (office), (866) 488-7386:
http:// www.thetrevorproject.org 159
True Colours: TrueColours.org.au
World Professional Association for Transgender Health (WPATH): http:// www.wpath.org ( You
can obtain a copy of the Standards of Care at this Web site)
YES Institute, (305) 663- 7195: http://www.yesinstitute.org
Youth-Specific Organizations, (617) 467-5830: http:// www.camparanutiq.org
Expressive Arts Therapies Resources
Overview of Expressive Arts
International Expressive Arts Therapy Association: iecata.org
National Coalition of Creative Arts Therapies Associations: nccata.org
Art Therapy
American Art Therapy Association: artherapy.org
Art and Healing: artashealing.org
International Art Therapy Organization: internationalartherapy.org
Art Therapy Credentials Board: atcb.org
Art Therapy Alliance: artherapyalliance.org
Art Therapy Without Borders: atwb.org
Art Therapy Blog: artherapyblog.com 160
Biblio/Poetry, Narrative and Journal Therapy:
The National Association for Poetry Therapy: poetrytherapy.org
The National Federation for Biblio/Poetry Therapy: nfbpt.com
The Institute of Poetic Medicine: poeticmedicine.org
The Institute of Narrative Therapy: theinstituteofnarrativetherapy.com
The Journal of Poetry Therapy: Interdisciplinary Journal of Practice, Theory, Research and
Education: tandfonline.com/TJPT
Narrative Therapy: dulwichcentre.com.au/narrative
Center for Journal Therapy: journaltherapy.com
Transformative Language Arts: goddard.edu
Music Therapy
American Music Therapy Association: musictherapy.org
The Certification Board for Music Therapists: cbmt.org