Cultural Competence and Relationship Minorities

A friend approached me last week in regards to this article about things I learned at Transcending Boundaries, a wonderful conference I had the honor to attend whose purpose is to educate and provide a haven for people who are part of gender, sexual, and relationship minorities.  While she told me she enjoyed the article, she expressed some concerns that she had about my "newness" to some of these issues.  "If you're writing that you just learned that BDSM isn't scary," she queried, "how can someone in the kink community feel comfortable coming to you for therapy?

I answered her with one of my favorite therapy stories.  (The details have been changed to protect client confidentiality.)

A woman came into my office looking very nervous.  She was coming to therapy to explore anxiety issues, and since starting therapy can be an anxiety-provoking experience, she was visibly shaking as she sat down on my couch.

I gave her my standard intake talk about office policies, confidentiality, late cancellations, and other routine matters, and then asked what had brought her to therapy.  She began to talk about debilitating anxiety and some of the things it prevented her from doing in her daily life - things like grocery shopping, socializing, and engaging in hobbies.  She told me about the support system she and her husband shared, and then paused nervously.

"I should tell you... yes, it's going to come out eventually so I should just tell you.  My husband and I are polyamorous."

I smiled.  "Thank you for sharing that with me.  I have a lot of friends who are poly."  And the most amazing thing happened - her body visibly relaxed, and she was able to complete the remainder of the session with a much calmer, more natural demeanor.

I learned a lot from that experience about the importance of an open mind and a willingness to learn from clients about the way they live their lives.  Just like I don't need to be a tax attorney to do therapy with a tax attorney, just like I don't need to have experienced terrible trauma to help someone who has, I also don't need to have the same types of relationships my clients do in order to help them with their other problems.

Seeking therapy is scary for a lot of people, but for people in the GSRM (gender, sexual, and relationship minority) community, there's another layer of difficulty.  Unless they find someone who has a basic understanding of the way they live their lives, they could find themselves face to face with a therapist who wants to spend the first few months of therapy exploring how their polyamory is really just indicative of a fear of commitment, or how their interest in BDSM demonstrates that they must be repressing or reenacting a trauma history.

Being culturally competent means having a basic understanding of a community and a willingness to learn more from an individual - striking a balance between educating oneself about the way people live while also maintaining an understanding that each individual experiences things differently.  Most people talking about cultural competence are referring to racial or ethnic groups, but there are a lot of different types of cultures outside of that definition.  For example, I just read an article about being culturally competent to work with individuals in the military.

I would assert that cultural competence is also important in working with relationship minorities.  I have a fundamental understanding that individuals who are polyamorous or kinky are not "broken" and I leave it to an individual to educate me about what their identity in that community means to them.  I recognize that my polyamorous 3:00 client might "do" polyamory in a very different way than my polyamorous 4:00 client.  I understand that if someone tells me they're exploring kink, they might mean bondage, they might mean role playing, or they might mean something I've never even heard of.  I may need people to clarify terms for me - to remind me that a "switch" is sometimes dominant and sometimes submissive, or to explain to me that a "metamour" is the romantic partner of your romantic partner.  But at the end of the day, I have enough understanding to acknowledge the way my clients live their lives and to help them with whatever led them to seek therapy.

All of this is compatible with my own personal way of looking at mental health: "If you're not hurting anyone else against their will and you don't feel emotionally bad, you're probably doing ok."

5 Common Mistakes Made by Well-Meaning Allies

In every minority community, allies are an instrumental part of the fight for equal rights.  Becoming an ally is a choice and a commitment, as well as an act of bravery.  Unlike members of minority communities, who advocate for equality to better their own lives, allies do so in order to raise awareness of what they perceive to be an injustice that does not directly affect them. 

I recently presented at Transcending Boundaries about common mistakes made by well-meaning allies of the GSRM (gender, sexual, and relationship minorities) community.  This community includes transgender, genderqueer, intersex, gay, lesbian, bisexual, asexual, pansexual, polyamorous, and kinky individuals.  This presentation stemmed from the premise that allies have the responsibility to educate themselves and to have the humility and willingness to learn from their mistakes.  Following is the information from that presentation. 

1. Making Assumptions

Heteronormativity is the belief that people fall into two distinct and complementary genders, and that male people and female people have defined “roles.”  Additionally, it is the assumption that heterosexuality is the “normal” sexual orientation and that anything else is deviant.  This is not usually a malicious mindset, but it is one that most heterosexual, cisgender people hold until they think to question it. 

This often reveals itself when asking about partners – for example, asking a male-presenting person if he has a girlfriend or wife.  While these questions are well-intended, they reinforce a non-heterosexual person’s idea that he or she is part of an outgroup, and it is usually safer to ask about a person’s “partner” or “significant other.”  A person also has the right to define his or her own identity, and it might not always be what it appears.  For example, a male-bodied human who is attracted to other males is not necessarily gay – he may be bisexual, pansexual, or a heterosexual MtF (male to female) transgender woman.  Similarly, a woman not attracted to men is not necessarily a lesbian – she might be any of the aforementioned, or perhaps asexual.

Additionally, making assumptions about gender and related pronouns can be hurtful, and when in doubt, it is polite to ask.  This can be tricky, because this isn’t always the right course of action to take.  For example, you’re unlikely to ask the checkout person at a grocery store what his or her preferred pronouns are.  On the other hand, if you meet someone in a social situation where many gender-variant people are present, or if someone presents somewhat ambiguously, the best thing to do is directly ask the person what he or she prefers.  While some people prefer male pronouns and others female, still others prefer gender-neutral pronouns, such as “they” or “hir” and “ze”.

Perhaps the most insidious kind of assumption is stereotypes.  Being an ally does not give you the right to perpetuate stereotypes; on the contrary, it gives you the obligation to keep others informed that these stereotypes are not always true.  One common stereotype about this community is that everyone – especially gay men and bisexual individuals – is promiscuous.  While many LGBT people may be polyamorous or have open relationships, many are also monogamous.  The converse assumption – that everyone wants to pair-bond, get married, and have children – is also not always accurate.

2. Outing People

Allies often have many GSRM friends and acquaintances, and because of this it is easy to become desensitized to the level of sensitivity involved in a person’s coming out process.  The world of an ally is often a safe place where people are open-minded and understanding of a wide variety of sexual, gender, and relationship orientations, but unfortunately there are still a lot of places where that does not hold true, and where outing someone could seriously compromise their safety. 

Furthermore, coming out is a lifelong process, and something that people have to make a decision about every time they meet a new person.  When a person does come out and is met with a positive response, this can be very empowering.  If you out someone, you take that power away from them. 

Words can be warped as rumors travel, and once something is said, it can’t be unsaid.   For these reasons, it’s important to seriously consider the ramifications of your words before telling a third party that your friend is gay, transgender, polyamorous, etc. 

3. Invasive Questions

Allies are sometimes given very personal information about a friend, including details about a person’s sexual activities or genitalia, but no one ever has the obligation to answer questions about these things.  When asking questions of a friend, or especially a stranger, it’s very important to be respectful.  It’s very disconcerting for a person to become a case study, and subjected to a barrage of questions about what lesbians do in bed, or what is in a transwoman’s pants.

If you do decide to ask some of these questions, there are a lot of things to consider.  The first is whether you have properly built a rapport with this person.  Next, think about what you would be comfortable disclosing in a similar situation.  For example, if a person asked you to describe the most intimate parts of your body, how would you feel?  Lastly, if you are going to ask a personal question, acknowledge that you don’t have the right to the information by saying something like, “look, you don’t have to answer this, and if I’m overstepping a boundary, please let me know.”  And if the other person says they’re not comfortable answering your question, respect that.

4. Us/Them Mentality

In some ways, being an ally is a huge responsibility, but in other ways, it can be very easy.  When you’re with your GSRM friends, you’re able to talk about fighting the good fight, but when you’re at work, you can be just another straight guy.  But the problem with this is that it ignores the parts of you that are not 100% heterosexual.  Sexuality and gender are a spectrum, and a lot of people fall in the 99% range of heterosexuality and cisgenderness.  However, most people can acknowledge that there are parts of them that do have same-sex attractions or that stray from their “traditional gender roles.”  Acknowledging these parts of oneself can increase empathy for people within the minority.

Conversely, it’s important to recognize where you are “privileged.”  What this means is that as part of the dominant culture (in other words, the part of you that allows you to be “that straight guy” at work), you are afforded certain advantages that the people to whom you are an ally lack.  Peggy McIntosh developed a theory of race called the Invisible Knapsack, in which she listed 27 “privileges” that are unknowingly held by Caucasian individuals.  Many of these are adaptable to be relevant to the GSRM community, such as:

• I can if I wish arrange to be in the company of people of my sexual orientation most of the time.
• If I should need to move, I can be pretty sure that my neighbors will be neutral or pleasant to me.
• I can go shopping alone most of the time (for clothing of my correct gender), pretty well assured that I will not be followed or harassed.
• I can turn on the television or open to the front page of the paper and see people of my sexual orientation or gender identity widely represented.
• When I am told about our national heritage or about “civilization,” I am shown that people of my sexual orientation and/or gender identity made it what it is.
• I can arrange to protect my children most of the time from people who might not like them.
• I can swear or not answer letters without having people attribute these choices to the bad morals of my sexual orientation or gender identity.
• I can do well in a challenging situation without being called a credit to my sexual or gender identity.
• I am never asked to speak for all the people of my sexual orientation or gender identity.
• I can criticize our government and talk about how much I fear its policies and behavior without being seen as a cultural outsider.
• If a traffic cop pulls me over, I can be sure I haven’t been singled out because of my sexual orientation or gender identity.
• I can easily buy posters, postcards, picture books, greeting cards, dolls, toys, and children’s magazine featuring people of my sexual orientation or gender identity.
• I can go home from most meetings of organizations I belong to feeling somewhat tied in, rather than isolated, out-of-place, outnumbered, unheard, held at a distance, or feared.
• I can take a job with an affirmative action employer without having co-workers on the job suspect that I got it because of sexual orientation.
• I can choose public accommodation without fearing that people of my gender identity cannot get in or will be mistreated in the places I have chosen.
• I can be sure that if I need legal or medical help, my sexual orientation or gender identity will not work against me.
• If my day, week, or year is going badly, I need not ask of each negative episode or situation whether it has discriminatory overtones.

Additionally, we developed a few that are specific to GSRM individuals:

• I can have a child without being judged.
• I can hold hands with a partner in public without fear of discriminatory remarks or violence.
• I never have trouble knowing which bathroom to use.
• I can post details about my relationship status on Facebook without worrying about who will see it.
• If my partner gets sick, I can visit them in the hospital without anyone intervening.  If they pass away, I can rest assured that our children will remain with me.
• I can get married without it being viewed as a “political” act.

Because of this unique position of holding privilege but also being aware of the challenges faced by GSRM people, allies are able to form a bridge between these communities and those who are less informed about issues related to them.

5. Social Loafing

If you have chosen to be an ally, you have chosen to be an advocate.

In the 1960s, a woman named KittyGenovese was brutally murdered outside her Queens apartment while many of her neighbors observed.  This event resulted in the development of a psychological theory called “social loafing” or “diffusion of responsibility.”  What this means is that the greater the number of people witnessing an event, the less likely any one person is to intervene.  It’s easy for allies to view themselves as “just an ally” and not become involved, but advocacy is one of the most important roles of allies.  It’s easy to stand in silence in response to the “white guy nudge” when an injustice has occurred or an insensitive joke has been made, but it is the role of every ally to stand up for equality, sensitivity, and what is right.

Being an ally does not just mean saying you have gay friends.  It means helping to further the rights of gender, sexual, and relationship minorities so that they can enjoy the same rights and privileges that we do.

There's no place like...

I lived in a house in California until I was 5.  Then I lived in another until I was 18.  Then I spent the summer with my long-distance boyfriend in Georgia before starting my freshman year of college in Ohio.  I remember, upon arriving in Ohio, sitting down in front of a computer to lament on my Livejournal (a blog before blogs were a thing) that nowhere felt like home.  California was left behind.  Many of my valued people were in Georgia.  And all my stuff was in Ohio.  I remember pontificating on what I probably believed at the time were very deep thoughts about the nature and meaning of home, and how it was all three places, but simultaneously none of them.

Fastforward ten years, and at least as many living spaces.  In my four years of college, I lived in ten different places - three dorm rooms (first in Ohio, then in Georgia) and seven apartments with my then-boyfriend who was from a military family and had therefore never learned the benefits of housing stability.  Then I moved back in with my parents during graduate school, went to a "starter apartment" in Boston, and a year later moved to a wonderful apartment in the quasi-suburbs. 

The last of these apartments was incredible, and I was certain I would live there until I was ready to buy a house.  But then my partner and I received an unwelcome visit from our until-that-moment-wonderful landlord, who informed us that he had sold the building where we lived, and we had one month to find another home.

Why am I recounting such a personal story on a blog that is supposed to be about therapy issues?  Because this entire incident has me thinking a great deal about displacement, moving, and the associated stressors.  The moment we were told we had to move, I immediately felt homeless and unstable.  I had been floating comfortably among the top three layers of Maslow's Hierarchy of Needs (image below, more of an explanation behind the link) and now I was knocked down to level 1, wondering where I would sleep!

Then I went through a grief process, akin to the stages developed by Elizabeth Kubler-Ross.  First I felt denial.  "Absolutely not!" I declared.  "We are staying right here.  We are not going anywhere.  I will magically stumble upon enough money to outbid the buyers and we will buy this house and we are going to keep living in this apartment!"  Then anger: "I hate the landlord!  I hate the buyers!  I hate the construction workers!  I will scream hateful words at them all!"  Next, bargaining: "I'd be willing to pack all our stuff, put it outside, then move it back in and set it up.  But I'm not moving to another place."  Then depression, where I became rather quiet and negative.  Finally, reluctant acceptance: "Ok, let's start looking for another place..."

(It's worth noting that grief can actually be much more complicated and individualized than the Kubler-Ross model, but in this case, it wasn't.)

So we found another apartment, and it's big, and it's quirky, and it has most of what we were looking for, and it's within our budget.  So that was good - we packed and moved all of our belongings, and we've been here for about a week.  But I still drive on autopilot to the old place.  When I'm at work, picturing myself relaxing at the end of the day, I picture my old living room or kitchen.  I'm sure it will feel like I live here eventually, but in the meantime, I'm just trying to navigate the psychology of moving and the instability and upheaval it brings, and to figure out how long it will take for it to feel like I live here.

I'm curious about other people's experiences... if you don't mind, I'd love to hear your stories about moving to a new apartment and how long it took for them to feel like home.  Please leave them in comments below.

8 Things I Learned at Transcending Boundaries

This past weekend, I attended an event called Transcending Boundaries whose stated purpose is to “serve our ever-evolving communities, including bisexual, pansexual, fluid, queer, transgender, transsexual, genderqueer, asexual, intersex, polyamorous, and kinky persons, as well as allies, those who prefer not to use labels, and those who are questioning their identities.”  There were academic and informational panels, social activities, and an endless supply of interesting, lovely, and genuine people to talk to.  As an ally to all of these communities and a therapist hoping to increase my competence to work with them, I attended the conference not knowing quite what to expect, and was overwhelmed by the consideration and acceptance I experienced over the course of the weekend.  I learned a lot about many different things, and I’d like to share some of these nuggets with you.

1. There are as many ways to live as there are people living, and all of them – as long as they respect the rights of others – are equally valid.  My general rule has always been that if you are not hurting anyone physically or emotionally, and you feel good inside, the way you’re living your life falls within the spectrum of “you’re doing fine.”  This point was driven home this weekend when I met a lot of different people who live their lives in a lot of different ways.  I encountered very little that I hadn’t seen before in some respect, but being surrounded by so many wonderful people who defied convention really solidified this conviction that I already had. 

 

2. GSRM is a thing.  First there was GLB (gay, lesbian, bisexual).  Then transgender people were recognized and there was GLBT.  And then the acronym grew from there and we had GLBTQQIA (to account for queer, questioning, intersex, and asexual people) and it got overwhelming and everyone had different versions of the acronym that considered other populations and some people just started calling it “Alphabet Soup.”  So to solve that problem, the proper term became “queer.”  I, for one, have never been completely comfortable using the term “queer.”  I do, because many people who are very near and dear to me fall under this umbrella, but in less savvy populations, it still holds a very negative connotation.  It’s also worth mentioning that none of these acronyms or terms account for polyamory, kink, or other alternative relationship and family styles.  And thus developed GSRM, which stands for Gender, Sexual, and Relationship Minorities, which I think is a wonderful, broad, and encompassing term to discuss all of these groups and experiences, and which I had never heard before this weekend.

3. The proper use of “they” as a gender-neutral pronoun.  The following is something I already knew: Gender is not binary.  What this means is that our society tends to conceptualize a male/female dichotomy, which says that people who have male genitals are male and people who have female genitals are female.  Ok, then there are transgender people, and if a person can take a small leap of comprehension, it’s easy to understand that there are biological males who feel female and vice versa. 

But what a lot of people don’t know is that just like sexuality, gender is a spectrum.  Some people don’t feel completely male or completely female.  I remember how baffled I was the first time I encountered this several years ago.  Trying to be sensitive, I asked a then new friend what pronouns were preferred, and that person shrugged and said “either.”  At the time, I didn’t get it.  I thought that maybe he (I chose male pronouns, following the example of this person’s partner) felt male but didn’t feel comfortable asking people to validate that.  It wasn’t until sometime later that I encountered the terms “genderqueer,” “genderfluid,” "gender variant," and "gender nonconforming," which helped me to conceptualize that this person felt somewhere between male and female, or maybe completely neutral and not even on that spectrum at all.  But our language doesn’t provide pronouns for people like that.  Some people have tried inventing them and use words like “zie” and “hir” but if you use those words, many people have no idea what you’re talking about.  Others just prefer the use of the word “they,” as in “oh, that’s Alex.  I met them a few hours ago.  Let me introduce you to them.”  The first few times I tried it, the word “they” as a singular pronoun felt weird in my mouth and really awkward to say.  But after this conference, I feel confident saying that I feel pretty competent using these pronouns.  

4. BDSM is not scary.  BDSM has always been the part of the GSRM community that I have distanced myself from.  I haven’t gone to panels that cover related issues or talked to people in “the scene” about it because frankly, it has always made me uncomfortable.  But talking to people at this conference, I’m amazed at the level of respect and communication necessary to negotiate a BDSM scene.  It involves setting boundaries and parameters, being open about levels of comfort, and learning how to communicate if things have gone too far.  There are still a lot of ways that people “play” that I can’t imagine ever trying myself… but I think that when laypeople talk about Bondage, Dominance, Sadism, and Masochism, the words that come to mind are often things like “perverted” or “depraved.”  But if you take as a given that everything that occurs is consensual and set boundaries are respected, non-practitioners of BDSM could actually learn a whole lot about sexual communication from this community.

5. Coming out is hard.  I knew this in my head, obviously.  And I’ve been, alternately, a shoulder to cry on and a bulldog protecting perceived threats to my friends for years and years.  But here – try an experiment.  Write down on a piece of paper the ten most important things in your life… the things that get you out of bed and make your life worth living.  It can be anything, from people to activities to your career to a cup of coffee.  No seriously, give this a try – it’s meaningful and important.  Come back to this article when you’ve completed that task.

Ok, done?  Now cross off three things from that list.  Did you do that?  Think about how you’re feeling, having crossed those things out of your life.  Alright, now cross off three more.  Did you do it?  Was it harder?  Check in with yourself – how are you feeling right now?  Ok, now cross off three more so that there’s only one thing left.  How do you feel?

We did this experiment in one of the workshops this weekend, and I’ll tell you – it was hard.  I crossed off my first three without too much trouble.  Then my next three were harder – I found myself crossing off most of the things that make me who I am – interests like musical theatre and scrapbooking that are an enormous part of how I define myself and how others define me.  I looked at my list, and all I had left were my partner, my parents, my friends, and singing, the last of which feels like my very core.  And when the activity leader told me to cross off three more, I stuck my pen in my ponytail and crossed my arms.  I absolutely refused.  But when I thought about it later, I thought to myself that I probably would have kept singing, because it’s such a part of how I express myself that I would need it to genuinely process the loss of everything else.  And that’s a tame reaction – other people in the room were sobbing at the thought of these losses.

Here’s the parallel: A person who is thinking about coming out has a perceived loss of all of the important things in their life.  They won’t necessarily lose these things, but they feel that they may.  And so every time they are open about who they are, there is a fear that other important pieces of their life will be lost. 

6. There is still a lot of fighting ahead.  Advocating for the rights of minority or marginalized groups is such an important thing to do.  Massachusetts recently designated transgender individuals as a protected group when it comes to housing and employment, but there’s still a lot left to fight for.  In the transgender community, for example, public accommodations are still a big issue.  Gender-neutral bathrooms are not widely available, and a transgender person can be asked to leave any establishment where management is not comfortable with a person’s non-conforming gender presentation.  I even met a woman who told me she was fired from her job because she came out as polyamorous.  I’m confident that with people like Gunner Scott, Ignacio Rivera, and Lorelei Erisis advocating for these causes, changes will be made, but there’s still a long way to go.

7. A family is not always two people plus children.  At this conference, I really came to appreciate the notion that polyamory is more than just a desire to be “promiscuous.”  It means a mindset in which you are open to being in a relationship – be it romantic or purely sexual – with more than one person.  I met some incredibly family-minded individuals at the conference who defined family differently than how most people think of it.  Four people who love each other all raising children together, or two committed individuals in a primary relationship who both have partners on the side to fill needs – whether those needs are sexual, social, or something else.  It’s a mindset wherein people don’t depend on one person to fill every single need they may have.  Some people talked about being an introvert with an extroverted partner who likes to go out a lot, and the value of that person having other partners to go to some of those events so that the introvert can have “alone time” and sit on the couch and read without their partner feeling neglected.  I still think monogamy is for me (and I’m pretty sure most poly people wouldn’t hold that against me) but I’ve definitely broadened my perspective of what makes a family or a relationship.

8. Community and supporting one another are key.  The theme of this year’s conference was “bringing us all together.”  This reflects the importance of community not only among transpeople and among poly people and among kinky people and among gay people and among asexual people and so on, so forth, but also the importance of being supportive of other communities.  I learned a lot by venturing outside my normal “comfort zone” and was pleasantly surprised at how welcomed I was.  It’s so important to question biases, educate yourself, and be there for other groups.  I also learned that an ally isn’t just someone who’s privileged in every area and supportive of marginalized groups, but also someone who is part of some of those marginalized groups but advocates for the rights of other groups where they themselves are privileged.

Emotionally Focused Therapy: a modality for couples

Last weekend, I posted about all of the wonderful people I met and all of the exciting things I learned, and I included a few teasers about two subjects which were broad enough that they required posts of their own.  One of those was Emotionally-Focused Therapy.

Emotionally-Focused Therapy is the latest "craze" in couples counseling.  I've been curious about it for awhile, because it's one of those buzz words that keeps popping up in therapist circles, and I finally had the opportunity to learn a little bit about it at a networking event through The Massachusetts Association of Marriage and Family Therapy.  A woman named Suzanne Marcus spoke about the subject for half an hour and I finally learned a little bit about this wonderful modality!

Basically, EFT is about patterns and ways of interacting.  Consider an argument between two people in a couple.  One person says something, the other does not respond, the first person gets angry at the lack of response and escalates, the second person flees.

This dynamic is called pursuer/withdrawer, and is the most common dichotomy in troubled relationships.  The pursuer (the first person) is seeking attention because he or she feels invisible, disconnected, and abandoned, and the message behind words and actions is, "I can't count on you!"  The withdrawer (second person) feels rejected, inadequate, numb, and overwhelmed, and his or her underlying sentiment is, "I can't do anything right, and if I'm wrong you might leave me."  The pursuer pursues because s/he is seeking a reaction, validation, and connection, and the withdrawer withdraws for fear of doing or saying the wrong thing.  This leads a couple to feel trapped and have spontaneous arguments.

The result of all of this is really negative circular feedback loops.  In other words, someone says something, which causes the other person to respond, which causes the first person to react, and so on.  So what happens is that person 1 is seeking validation, person 2 reacts from a fearful place, person 1 then tries to maintain contact, person 2 becomes even less certain of how to respond "correctly," and it escalates from there.  What both people have in common is that they are being driven by their emotions, and when they can hone in on and identify their emotions, they can become softer (if a pursuer) or more communicative (if a withdrawer).

This is just the very beginning of this theory and modality, which I learned from a half-hour lecture.  I plan to pursue more information, eventually by taking workshops, but my next step is to read Hold Me Tight by Sue Johnson.  If you're interested in learning more about these patterns, I recommend the same for you.

Professional Organizations, Couples Therapy, and the DSM-5

Wow, what a three days I have had!  This weekend and today, I have immersed myself in a different professional activity each day, and each has been completely invigorating in its own way.  I've learned so much, and am so enthusiastic for the future of my career and my profession, and I want to share these experiences with you.

I started my weekend with the Massachusetts Mental Health Counselors Association's annual planning meeting.  I've been wanting to get involved in MAMHCA for quite some time, so when I was invited to attend this meeting, I leaped at the opportunity!  What I learned is that the people who are involved in MAMHCA are an eclectic mix of enthusiastic, young clinicians and more experienced, seasoned, older professionals.  I was very impressed by the strengths each of these groups brought to the table, and how everyone worked together so well.

The meeting focused on a lot of different subjects, including membership, networking, scholarships and awards, and advocacy, as well as administrative matters like solidifying an annual budget for the organization.  I was nervous when I got there, wondering if I had anything to offer these experienced people who are so actively involved, but I quickly felt embraced and comfortable enough to bring up some thoughts I have about the importance of networking among counselors and mental health professionals on a whole.  I was asked to be the secretary on their Board of Directors, and may also be taking charge of an additional project with other members.

Sunday evening, I attended a networking event through the Massachusetts Association of Marriage and Family Therapy (MAMFT).  I felt like a bit of an interloper, since I'm not a Marriage and Family Therapist - I'm a Mental Health Counselor (though my educational background is as an MFT since that's the license that is most regularly granted in California where I went to grad school)... but I was readily accepted by them and met a number of wonderful people.  The group was very emphatic that they are the Massachusetts Association of Marriage and Family Therapy, not Marriage and Family Therapists, and that having an interest in a systemic perspective and in working with couples is sufficient to partake in the event and the organization.  I met a number of people with shared professional and personal interests, and had the privilege to sit in on a member's introductory overview of Emotionally Focused Therapy for Couples - a topic that is so rich and fascinating that I will be posting a separate blog entry about it in the next few days.

And today I went to a workshop about the DSM-5.  For those of you who are not familiar with the DSM, it stands for Diagnostic and Statistical Manual, it's a publication of the American Psychiatric Association, and it is the Big Book of Diagnosis for mental health professionals of all disciplines.  Currently, we are using the DSM-IV-TR, but the next edition is coming out in May 2013 and everyone is anxious to know how the way we do diagnosis will change. 

I have some very mixed feelings about the upcoming changes.  I'll post more fully about this later, because I think it's an important subject that therapy clients as well as therapists would benefit from learning about.  (After all, if someone is diagnosing you with something, don't you want to know what it means?)  But as a teaser, I'm pleased with some of the changes made in areas of addiction, mood disorders, and transgender issues.  I'm very upset at the elimination of Asperger's Disorder.  And I can't quite wrap my head around the new diagnosis guidelines for Personality Disorders.  Ok, now I'm disintegrating into genuine psychobabble, and I think I need to save the rest of this issue for its own post at some later date. 

But the point is that I don't think I've had such a great professional development weekend since my last 3-day annual conference a few years ago... and I hope for many more to follow.

Transgender Issues 101

Happy Independence Day!  Today, we celebrate the independence of our country from Britain, which includes, among other things, the assertion that all people are created equal!  Well, ok, the Constitution says it’s all men, which was definitely the initial intention of the Founding Fathers at the time, but thanks to suffragists, the Supreme Court, and the passage of time, women are considered (in theory, if often not in practice) to be equal as well.  

But what about transgendered people?  As of two days ago, Governor Deval Patrick signed a legislative act declaring that in Massachusetts, transgendered people are subject to all of the same rights and protections as cisgender (the opposite of transgender) people when it comes to employment, housing, education, and lending.  It also takes transgender status into consideration when deciding whether to rule an attack as a hate crime.  For more information on the ruling, see this article.

In celebration of this ruling - of Massachusetts recognizing all men, women, and transgender people as being equal - I think it’s time to write about what all of this gender stuff means.

Sex v Gender

The first thing you need to know in order to understand transgender issues is that there is a difference between sex and gender.  Sex is the biological component of being male or female, and gender is the sociological component of defining oneself as male or female.  What this means is that if you are cisgender (you were born with male parts and chromosomes and you now identify readily with a male identity, or you were born with female parts and chromosomes and you now identify readily with a female identity), your sex and gender are the same.  Conversely, if you are transgender (you were born with male parts and chromosomes and you now identify with a female identity, or vice versa), your sex is different from your gender.

Because gender is sociological, it is also a construct, which means that it is cultural.  Other cultures view the notion of femininity and masculinity very differently than we do here in the United States.  Some cultures have three or four genders, rather than just two, or assign a position of prestige to people who are transgendered.  For this reason, it is important to question ideas about what is “girly,” or telling a person to “man up.”  All of these things are relative to the environment in which they exist.

People often use the words sex and gender interchangeably, but this is inaccurate.  Often, this happens because people are afraid to use the word “sex,” since it’s a “dirty word.”  Whenever a pregnant woman tells me she is going to find out the gender of her baby, I want to ask her how technology has advanced so far as to be able to know such a thing!  The more accurate statement for her to make would be that she is going to find out the sex of her baby, and that if she fosters a positive, open, and nonjudgmental relationship with her child and maintains a healthy attachment with him or her, she may be fortunate enough to know the baby’s gender in anywhere from five to forty years.

The Definition of Transgender

Once upon a time, there were transsexual people and transvestites.  The former were people whose sex and gender did not match (male sex, female gender, or vice versa) and who therefore sought out surgeries to correct the situation.  Transvestites were people who simply enjoyed wearing the clothing of the opposite sex.  

While the latter term is still used (most famously by comedian Eddie Izzard.), it was decided that these terms are limited and do not adequately sum up everyone’s experience.  There are people whose sex and gender differ, but who do not have any interest in undergoing a surgical procedure to have their bodies match their gender.  Those who do choose to have corrective surgery may not completely physically transition.  For example, many female to male (FtM or transmen) people get “top surgery,” which involves a double mastectomy, but do not undergo a surgery to obtain male genitals.  Furthermore, some people are “third gender”, and do not feel their gender fits into either the male or female categories.  

Transgender is an umbrella term that was coined to resolve this, and to simply mean anyone whose gender differs from their sex. 

The Definition of Intersex

Transgender is often confused by laypeople as being the same thing as intersex.  Someone who is intersex is a person whose biological sex is more complicated than being simply male or female.  There are many ways in which this can occur, the most well-known of which is ambiguous genitalia, which used to be called hermaphroditism.  However, there are many other ways in which a person can be intersex.  These include over a dozen conditions, including Klinefelter Syndrome, where a person has an XXY chromosomal makeup, guevedoces, a condition common in the Dominican Republic in which a person appears to be female until puberty, at which point he develops a masculine appearance, and androgen insensitivity syndrome, in which a person’s body does not respond to testosterone, which in males creates a feminine appearance.

Often, it is not readily apparent that someone is intersex because their external genitalia appears male or female, but when a baby is born with obviously ambiguous genitals, the parents are often tasked with the decision of which gender they want their child to be and “corrective” surgery is done on the infant.  This is very controversial, and a lot of intersex people, as well as the Intersex Society of North America, are staunchly against it.    

Some, but not all, intersex people identify as transgendered.  As with any sexual or gender minority, it is important to ask individuals how they identify themselves, rather than relegating them into a category to which they may or may not relate.  It is equally important to understand that being intersex has to do with biological sex, whereas being transgendered has to do with gender identity.

Transgender People and Sexual Orientation

As much as being transgender is independent from being intersex, it is also independent from one’s sexual orientation.  Some transmen and transwomen are attracted to men, others to women, and others are bisexual, asexual, or pansexual.  The biggest similarity between someone who is “transgendered” and someone who is “gay” is that they are part of a minority.  However, the former is part of a gender minority, and the latter is part of a sexual minority.  Many people in the GLBTQQIAA (gay, lesbian, bisexual, transgendered, questioning, queer, intersex, asexual, ally - or as I call it, "gay alphabet soup") community choose to simplify the question of identity by identifying as “queer,” which is an all-encompassing term for a person in a gender or sexual minority.

“Gender Identity Disorder” in Mental Health

The Diagnostic and Statistical Manual, 4th edition Revised (DSM-IV-TR) is the current bible of the mental health world.  That means that anything a person is diagnosed with is in that book.  The third edition of the DSM eliminated the diagnosis of homosexuality as a mental disorder in 1980.  However, transgender people are still seeking recognition that their gender identity is not a “disorder.”

Currently, in the DSM-IV-TR, Gender Identity Disorder is a diagnosable mental health condition.  This name is very offensive to many people because it implies that someone who is transgendered is mentally ill.  In the 5th edition of the DSM (DSM-V), which is due to come out next year, there is a proposed revision to the diagnosis, and it has been renamed “Gender Dysphoria,” which is a much less offensive term.  However, many advocates want the diagnosis removed from the manual completely so that it the stigma and the idea of “pathology” are separated from the idea of being transgendered.

It should also be noted that gender identity is often considered differently in children than in adults, and is a different diagnosis (GID or Gender Dysphoria in Children).  This is because there is a much higher incidence of gender dysphoria in children than in adults, and some prepubescent children “grow out of it.”  However, although transgendered children do not always grow up to be transgendered adults, there is a strong correlation between childhood gender dysphoria and adult homosexuality.

Transitioning

The process of transitioning can be difficult for everyone involved.  For the friends and family of the person “coming out,” it can mirror a grief process.  If Billy tells his friends and family that he is transgendered and would like people to call her Suzy, Suzy’s friends and family are grieving Billy while they are learning to understand Suzy.  At best, this is done compassionately, and at worst, the transitioning individual can lose some important people in his or her life.

Transitioning can also be difficult for the individual, whether or not he or she chooses to have surgical procedures.  Reactions to the news that a person is transgendered can range from well-meaning but ignorant questions to outright cruelty, transphobia, and hatefulness.  As a person begins to live as his or her true gender, there is peacefulness to that, but society responds differently to men than to women.  My friend Tom wrote a beautiful article about how he was treated differently after transitioning.

If you know someone who is transitioning, or who has just come out as transgendered, the best thing you can do is take a learning stance.  Ask the person about his or her own individual experience, and how he or she identifies.  Don’t assume you know what it means when a person tells you he or she is transgendered - it is a very personal event that each person experiences differently - and don’t make assumptions about the person’s sexual identity or intersex status.  Additionally, don’t “out” people.  Before discussing a transgender’s person transition with a third party, ask who he or she is “out” to.  Be respectful of a person’s right to go through this process at his or her own pace.

Talking to Transgendered People

I’m now going to seemingly contradict what I just said: Think before asking questions.  Allow me to clarify.  If a question would be rude to ask someone cisgendered, assume it is rude to ask someone who is transgendered.  Someone who is transgendered is also a human being, and deserves the same respect, consideration, and right of privacy you would give to other human beings.

When faced with an anomaly, we have normal human curiosity and we want to know everything… but some questions are invasive and very personal, and some are invalidating of an individual’s gender identity.  An FtM transgender friend of mine is often asked whether he has a penis, and he usually responds by asking the questioner to describe his or her own genitalia in detail.  If a question is rude to ask someone who is cisgendered, it is probably also rude to ask someone who is transgendered.  Another offensive question people get asked is what their “real” name is.  This is negative not only because it invalidates their current identity, but also because it may be something they are trying to move beyond.  One person told me, “I don’t usually tell people my birth name, because then the person I’ve told tries to see me as that person.”  Honor the person’s identity by accepting the name and gender identity they have been introduced as.

Lastly, the question of pronouns can be tricky.  When unsure about a person’s gender, “it” and “he-she” are very offensive unless a person has told you that they are his or her preference.  The former objectifies the person, and the latter implies something “freakish.”  The best thing to do is ask a person what his or her preferred pronoun is and to honor this to the best of your ability.  For a primer about gender-neutral pronouns, here is a great article, put out by Transcending Boundaries, an annual gender and sexuality convention.

In Conclusion

For anyone interested in learning more about all of this, there are many great resources.  The collected works of Kate Bornstein is a great place to start.

It is also worth noting that I identify as a cisgendered ally.  If you are reading this and find that you disagree with anything I’ve written, or that something is factually inaccurate, I’d love for you to leave that feedback.  You can put it in the comments, or send me an email.