Transgender Emergence

Therapeutic Guidelines for Working with Gender-Variant People and Their Families

By Arlene Istar Lev, CSW-R, CASAC

Haworth Clinical Practice Press ©2004

Reviewed by Dave Parker

Are you – or a family member – considering or beginning male-to-female or female-to-male transition? You should study this book.

Transgender Emergence was written to fill the huge hole in the theory and practice of care for all gender-variant people and their families. It is a superb resource. Originally intended for professionals in psychiatry, psychology, family therapy, and social work, Transgender Emergence is also an excellent guide for clients to use in evaluating and choosing members of their support network.

Arlene Lev is a family therapist with over 20 years of experience addressing the unique therapeutic needs of LGBT people. She is a member of the Harry Benjamin International Gender Dysphoria Association – and is at odds with those who would use the Standards of Care to act as gatekeepers rather than guidelines to serve the needs of transsexuals. She postulates that much of the pathology experienced by gender-variant people is due to their experience with our cultural and sociological demands, rather than their gender variance.

Ms. Lev stresses that the transgender’s/transsexual’s personal identity is real, and cannot be changed. All clinical efforts should be geared toward helping the client and their family accept and adjust to their gender variance. The goal of the therapeutic relationship must be empowerment of the client and their family to rewrite their lives in a meaningful way. She believes that transgender is nothing more (or less) than a normal, healthy variation of human expression.

There are three parts to the book. Part I discusses transgender/transsexual throughout history, outlining various attempts at understanding sex, gender, and their relationship to each other. The historical premise is that anything other than the polar opposites of male and female is deviant – and must be punished or fixed. As most transgendered people know, “fixing” often meant behavior modification by punishment.

Part II discusses diagnosis, evaluation, and treatment philosophy developed during the past century. Lev finds that “The diagnosis of Gender Identity Dysphoria is part of a long historical process of labeling and pathologizing sexual and gender differences.” She criticizes this diagnosis as a mixture of unscientific clinical assumptions that are inappropriate as the basis of treatment.

Part III examines potential treatment philosophies and recommends those treatments that honor diversity. The “disorder” or psychopathology found in transgender/transsexual clients is most often the result of gender suppression by family members and society rather than being the cause of their gender variance.

Unique to Lev’s recommendations is the idea of providing therapy to the entire family throughout – and even after – transition. No family can absorb the announcement that a member is not what they seem without disturbing the established family dynamics. One chapter is devoted to discussion of the stresses imposed on other family members and several solutions to alleviate those stresses.

In the past – and often still today – many clinicians have treated transgender/transsexual children and youth by assuming a dysfunctional family. These clinicians then attempt to “protect” the child to accomplish a cure. Lev outlines treatment or therapy that recognizes and respects the child’s reality.

Chapter 10 deals with care and treatment of intersex people. Lev examines the current medical practice of early surgery, and then advises accepting the recommendations of the Intersex Society of North America (ISNA): delay any and all irreversible procedures until the patient (child) matures sufficiently to make their own informed choices.

The basic premise of this book is that all gender variance represents natural and healthy expressions of human diversity. Lev’s therapeutic goals are all geared toward honoring that diversity and helping the client and their family to accept that diversity and build a healthy and happy life.