Ethics and Transgender Care

By Nancy Nangeroni

In preparation for this article, I interviewed several leading authorities in the area of psychotherapy and the “gender community.” Because some of the opinions expressed by these professionals might draw attack by those who disagree with their opinions or practices, I will not name names nor quote individuals here. Moreover, I have changed certain inconsequential specifics to further disguise the identity and practices of individuals whose experience I have drawn upon. My intention is to fuel conversation, consideration and re-evaluation, but not to instigate or in any way support attack upon individuals and/or their practices.
Recently, a transperson in San Diego shot to death both herself and her therapist. In the days following this horrifying incident, at least one person alleged that the therapist employed unconventional technique. This self-identified client reported that the therapist employed a strategy of heightening the stress upon her clients, reportedly as a test of whether they could handle post-surgical issues. Later reports did not contradict this, but defended the therapist as a friend of the community. Whatever the therapeutic technique being employed, the outcome was deadly.

In a Massachusetts prison, a transwoman wastes away, convicted of murder. Hir story: s/he had been intensely conflicted in hir gender issues, and had become addicted to alcohol and drugs at an early age. Finally, though, s/he began to get hir act together, getting sober and clean while seeing a therapist. When s/he confided hir gender issues to the therapist, s/he was told, “what you need is a good woman, and I’m that woman.” They became lovers, and s/he moved in with hir therapist, during which time the therapist’s temper surfaced on multiple occasions. During one temper outburst, she attacked her lover and former client, first with scalding water, later by threatening hir with a knife. S/he blacked out, coming back to consciousness two days later to find hirself charged with the murder of hir therapist. S/he now passes hir days in county jail trying to obtain some modicum of justice and the hormones s/he needed from the start.

These are just two cases of questionable treatment by presumably well-intentioned care providers apparently leading to disaster. There are more. The frequency of such tragedies, occurring much too often for a population as small as ours, demands some questioning of what is going on.

Many members of our community suffer from attention deficit disorder. Doctors think the problem is an inability to pay attention to one thing for any great length of time, but I think that it’s just the symptom of a serious lack of attention received. Individuals in our community often lead isolated lives, never sharing a part of ourselves with others. This leaves us without loving attention in the area of our gender difference, and vulnerable to all who would give us the positive reinforcement we so desperately need for our sense of wholeness. The good feeling that comes over us when a person from outside the community tells us we are beautiful is as irresistibly euphoric to many as crossdressing itself. We fall over each other declaring our appreciation for such persons, putting them on a pedestal of welcome. Too many of us suspend critical judgment of their practice, equating gratitude with trust. Too often we become easy prey for all who would take advantage, whether by design or by accident arising from bad practice.

On the other hand, our community has had to teach the medical and psychological professions about ourselves, laboring at great length to counteract the historically transphobic approach of both professions. Disillusionment with health care professionals runs strong, especially among transsexuals. Many transfolk wind up treating such caregivers as necessary obstacles who are either incapable of or unwilling to make the effort necessary to reach a true understanding and appreciation of our whole selves, but whose services nonetheless fulfill real needs. Though distrusting the caregiver, these trans clientele are nonetheless made particularly vulnerable by their lack of participation in a genuine process of self-inspection and true dialogue.

At the same time, some caregivers have developed loving and supportive relationships with the trans community, and seek to be of real service to our needs. These good people are helping educate their professions to greater understanding and more appropriate assistance for gender-diverse peoples. But in doing so, some of these people cross the line that their profession normally draws around appropriate relationship with their clientele. Therapists who socialize extensively with their client community are performing acts which their profession frowns upon. And yet, gender-variant people continue to line up for their services. What is going on here? Are transgenders mere lemmings, ignoring conventional wisdom in flocking to the promise of help without heed for actual results? Or are the services being given to our community necessarily outside of conventional ethics, a necessity brought about by our own outlaw status in this society?

I was attending a party at a convention when a therapist I knew only by name walked into the room. As this person entered the room, at least half the transwomen in the room – probably 20 in all, presumably all clients of this therapist – began applauding. I was surprised to see a therapist encouraging this sort of relationship with their clientele, one which seemed to engage clients in a state of mild hero worship, which could not help but distort their ability to critically judge the therapist’s advice.

Contrast this to another therapist I know who attends community events rarely, because s/he has a deep and abiding respect for maintaining boundaries which facilitate hir effectiveness as a therapist. While availing hirself of the best of the available literature on the subject, s/he scrupulously avoids situations which would place hir in a conflict of interest which might influence hir ability to objectively advocate on behalf of hir clientele, and argues strongly for such practice.

When I sought out a therapist for myself, I chose someone who was not too close to the community, because I was concerned that too much immersion in the trans community would prejudice their perspective. I also chose someone who was not a transperson themselves, for the same reason. In retrospect, I was certainly prejudiced by an earlier encounter with a therapist who was also a transperson, and another who was a community regular, both of whom had behaved quite inappropriately. However, there are some excellent therapists who are also transpeople, and there are also some excellent professionals who spend significant time at community events. On balance, the most important characteristic for a therapist is neither familiarity nor distance, but rather a healthy approach that acknowledges the difficulties in providing truly unbiased service. There are both good and bad therapists inside and outside the community, and there is also a chemistry that acts between therapist and client that can render a therapist who is enormously helpful for one person completely ineffective for another. Thus each individual client must exercise great care in finding the therapist who will be good for them.

While it is theoretically possible for a therapist completely unfamiliar with transgenderism to render appropriate, non-prejudicial service to a person of non-conforming gender, it is unlikely that they will be able to do so. Likewise, while the therapist who is transgender or personally involved with the transgender community may have the best possible intentions, it is also unlikely that they will be completely free of prejudice about what is the “right” approach to transgenderism. For some trans clients, doing the opposite of what most others would advise is the healthiest possible course, and it remains the therapeutic challenge to recognize such diverse truths. The therapist must walk a fine line between making good use of their extensive experience with trans issues, while still allowing themselves to put their prejudices on hold and be educated by their client to new solutions that might not have been previously advisable or even possible.

A conscientious therapist must find a balance between educating themselves on existing and emerging schools of thought, and allowing for the emergence of new forms of diversity for which there is no precedent, or with which precedent the therapist is simply unfamiliar. This begs the question, how does the therapist walk that line between ignorance and prejudice, and how does the trans client judge the therapist’s effectiveness in doing so?

A good starting point for the client in making a judgment of their therapist’s bias is to discuss it. Prejudice is the distillate of experience, and all people hold some amount of prejudice. Anyone who denies that they harbor prejudice is being unrealistic and simply harboring their prejudices under a veil of denial. Such people might be dangerous as therapists and should probably be avoided. Prejudice which is openly discussed, however, can be allowed for and counteracted consciously, hence robbing it of much of its power. Thus, an open and ongoing discussion of prejudice in the therapy setting is not just a good idea, but essential to a therapeutic relationship that is to be truly healing.

All of the respected professionals I interviewed spoke of standard ethics practices which would limit contact between therapist and client outside of the therapeutic setting. By all accounts, standard practice is that the therapist should give notice to the client if the therapist will be appearing at a social function at which the client is present. The issue is vulnerability, and the client’s need to enjoy their private space without word or action from that space influencing their therapeutic relationship. And yet, even while all of the professionals I spoke with follow this same rule, there is considerable latitude in their interpretation. Some will go to great lengths to avoid contact with their clientele on the grounds that any contact is potentially injurious, especially if their client is closeted with respect to crossdressing. Other professionals feel that a show of friendliness is important in creating an atmosphere of acceptance and trust, and that to obviously avoid such is damaging in itself.

Mental health professionals are bound to keep confidential the identities of their clientele. Standard practice holds that the therapist must not, upon a chance meeting, acknowledge the therapeutic relationship. This protects the client, whose reputation or other relationship might be damaged by the knowledge that they are in therapy. While the National Association of Social Workers (NASW) Code of Ethics allows therapists to identify clientele given their permission, some professionals regard the publishing of real names in written works as bad practice.

There are some limits for all mental health professionals that are firm and easy to identify. They may not engage in a sexual relationship with any client past, present, or future. This means that they may not accept a client who is a former lover, or become lovers with any former client. Any sexual advance by a therapist towards a client is a serious ethical violation, and should never be tolerated. Therapists also cannot violate any confidence, except when a person is dangerous to themselves or others, in which case they are required to report it to authorities.

I asked what kinds of guidelines we might provide to members of our community, for how they can determine when a therapist’s behavior is out of bounds. The answer is unfortunately not simple. Clearly, sexual contact is completely unacceptable. Any touching that makes the client uncomfortable is also inappropriate. If something your therapist says or does makes you uncomfortable with that person, the first thing to do is to discuss the matter with the therapist. IN most cases, this will resolve the issue. If it does not, get the opinion of another helping professional. It is an unfortunate fact that there are practicing therapists who have serious emotional problems, and each of us needs to maintain some alertness against such people. As one therapist said, “Just because you’re a therapist, doesn’t mean you’re healthy.” Make sure your therapist has, at a minimum, either a therapist of their own, or a consultation group that provides some oversight to their practice.

Finally, there is the issue of marketing. It has long been the practice of surgeons to attend conventions and conduct sessions describing the surgeries they perform. While such sessions are of great interest to individuals, they are also great marketing opportunities for the surgeons, who drum up considerable business with such appearances. The same holds true for mental health professionals. Standards of practice frown on all but the most conservative self-promotional practices.

One therapist stated that too often, therapists who are not experienced in gender issues insist on holding onto clients rather than referring them to more qualified individuals. While there are still too many geographical areas where there is no such qualified help, fortunately this is changing. While we need to keep developing knowledgeable practitioners, these days there is no reason why they cannot get their education by attending conventions and training sessions. Clients should not have to educate their therapist.

There is clearly a spectrum of behavior on the part of our community’s therapists which crosses the line beyond which individuals can and do get hurt, sometimes tragically. Were it not for our culture’s devaluing of transpeople that leads to less serious interest in our hurts, we would probably be hearing far greater outcry, and might have more help in policing exploitive behavior. However, this is the society we live in, and nobody’s going to fix it for us. We’re doing a good job of educating caregivers about the healthy and beautiful aspects of gender diversity. Perhaps now it’s time to take a critical look at the care we are receiving — and paying for — and to insist on certain standards of performance and ethics.

  • How can we determine when a caregiver’s behavior is detrimental to one or more members of our community, and what should we do about it?
  • What can we teach individuals to empower them to identify when their therapist’s behavior is out of bounds, and how best to handle such situations?
  • To what extent should we welcome therapists at social events, and what, if any, guidelines should be maintained for their behavior in such a setting?
  • How can we assure that professional participation at events is educational rather than business-oriented?

These are questions that neither I nor any other individual can answer for everyone. The answers are many and varied, and depend upon individuals and situations. Perhaps what we need to do is teach not the answers, but the questions.

Originally published September 1998 in Transgender Tapestry magazine