Therapeutic Guidelines

We are aware that Gender Identity Disorder (GID) is recognized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). However, we understand that some persons are unhappy with their assigned sex and wish to explore therapeutic, hormonal, and medical options to transition into their self-perceived authentic gender. Sexual reassignment surgery may be the solution for some, while others may explore hormonal treatments or pursue other options to express their gender identity. We will explore with clients the best path for them to pursue that makes them feel the most comfortable.

While the International Healing Foundation believes and supports the client's right of self-determination in making medical and psychological decisions for their own treatment, it is also our ethical responsibility to warn clients of the risks of sexual reassignment surgery. Dr. Paul R. McHugh, former psychiatrist-in-chief for Johns Hopkins Hospital and current Distinguished Service Professor of Psychiatry, has recently remarked that that research indicates that the suicide rate among transgendered people who had reassignment surgery is 20 times higher than the suicide rate among non-transgender people and that studies from Vanderbilt University and London’s Portman Clinic of children indicate that among those who had expressed transgender feelings, 70%-80% “spontaneously lost those feelings” over time. Click here to read more.

While this may not be the experience of all transgendered individuals, we recommend that clients considering medical and hormonal options explore multiple different therapeutic approaches and treatments for GID and Gender Dysphoria before making their decision.

The following five-stage model, taken from the American Counseling Association’s Journal of Counseling and Development encompasses what many transgender people experience in the process of transitioning from their biological gender to their self-perceived authentic gender. We summarize these stages below to provide a brief summary of what transgendered individuals may experience (Note: this model was written primarily for males transitioning to females.).

  1. Awareness
    Transgender persons may realize that they do not conform to societal expectations for their biological gender role. This lack of congruence with mainstream gender roles goes deeper than their behaviors; at their core, they may feel fundamentally different from their biological gender. Therapists work to normalize the individual client's sense of himself/herself and explore the situational causes of distress as it has stemmed from society's reactions.

  2. Seeking Information
    Clients begin to research and understand the interpersonal, financial, and potentially legal consequences of transitioning into a new gender and the effect it will have on their social context. Therapists work with clients to understand and anticipate the potentially negative reactions they will face from society at large and often from specific individuals in their social sphere.

  3. Exploration
    The exploration stage involves the exploration of the meaning their transgenderism has in their life. Exploration usually involves an increasing comfort with themselves as an individual. At the end of this stage, people may understand that they are transgendered, are comfortable with it, and have begun to reshape their life in recognition of it. Therapists assist clients in developing their new gender identity, incorporate their new identity into their lives, and help clients explore options to transition into their new gender identity via hormonal and medical procedures, as well as assist them in their understanding of the overall impact of making a potential permanent gender transition. 

  4. Disclosure
    Disclosure is the process of informing others as to one's transgender identity, be it family, friends, or society at large. Transgender persons must work through the fear of losing family, friends, vocational opportunities, and other social communities due to their new gender identity. Therapists extend the therapeutic environment to include relationships with significant others, which may be a difficult process because of the pain often felt by the families processing the impact of the disclosure. 

  5. Integration
    In this final stage, the client chooses how far they want to take this integration. Options include surgery, medical intervention, or merely behavioral changes. For some individuals, living as their new gender without biological alterations may be sufficient. Other individuals may choose hormones or medical procedures. Therapists take measures to ensure that the client is comfortable with his/her choices, is cognizant of the consequences, and has taken steps to fully integrate those choices into a coherent whole. Before receiving permanent medical procedures to alter their gender, therapists encourage clients to undergo the process of a real life experience, that is, to live their entire lives as their new intended gender in order to demonstrate their ability to live this new identity. The preferred period of time for this phase is at least one year.

For more information, see:

Wester, S.R. et al. (2010). Using Gender Role Conflict Theory in Counseling Male-to-Female Transgender .Individuals,Journal of Counseling and Development, 88, 214-219

Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) Competencies for Counseling with Transgender Clients

The Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling has authored a thorough list of standards for counseling transgendered individuals, detailing appropriate therapeutic guidelines that consider human growth and development; social and cultural foundations; helping relationships; group work; professional orientation; career and lifestyle development competencies; appraisal; and research. Transgender-identified clients should expect to be counseled according to these standards, which may be viewed in its entirety at: http://www.counseling.org/Resources/Competencies/ALGBTIC_Competencies.pdf

The Harry Benjamin International Gender Dysphoria Association's Standards Of Care For Gender Identity Disorders, Sixth Version (February, 2001)

See page 11 for psychotherapy for adults (Note: IHF does not endorse the treatment for adolescent clients): http://www.wpath.org/documents2/socv6.pdf