Group Work With Transgender Clients

lore m. dickey
University of North Dakota

Michael I. Loewy
Alliant International University
Drawing on the existing literature, the authors research and clinical experiences, and the first authors personal journey as a member and leader of the transgender community, this article offers a brief history of group work with transgender clients followed by suggestions for group work with transgender clients from a social justice perspective. The article includes specific information about the elements of groups, including types of groups, leader competencies, group members, location, and group format. Keywords: female-to-male; groups; male-to-female; social justice; transgender

The history of group work with the transgender community dates back to the 1970s (Althof & Keller, 1980; Green & Fuller, 1972; Keller, Althof, & Lothstein, 1982). Early groups were aimed at reconditioning boys who exhibited feminine behaviors. Today, these groups would be considered a form of reparative therapy for sissy boys or tomboy girls who were perceived as being in danger of becoming homosexual or transsexual (Rottnek, 1999). In the late 1970s a transsexual was considered to be a person who had a strong desire to change his or her physical body to match his or her felt gender. While still true today, there has been an emergence of people who do not embrace the gender binary, and who choose to not physically transition. These individuals are commonly referred to as being transgender or genderqueer (Vanderburgh, 2007). During the advent of group therapy for adult transsexuals, groups had a variety of therapeutic goals, including helping the person to become oneself, orienting the patient back to his original gender role and identity, and

Manuscript submitted June 22, 2009; final revision accepted March 31, 2010. lore m. dickey, M.A., is at the University of North Dakota. Michael I. Loewy, Ph.D., is an associate professor and Ph.D. Program Director of the California School of Professional Psychology at Alliant International University. Correspondence concerning this article should be addressed to lore m. dickey, 2752 Campus Walk Ave #29K, Durham, NC 27705. E-mail: dickeylm@gmail.com
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decreasing effeminate behavior (Lothstein, 1979, p. 67). Lothstein began a transsexual group therapy project in 1975. Lothsteins clinic provided a variety of support that, at the time, seemed impossible to accomplish in individual therapy as clients were seen as being highly resistant. Some of the clients in this group experience attended the group only because it was a requirement for treatment and transition. This group served both male-to-female (MTF) and female-to-male (FTM) clients. Althof and Keller (1980) discussed the advantages of group work with transsexual clients, whom they referred to as gender identity patients (p. 481). This terminology was reflective of the inclusion of gender identity disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSMIII; American Psychiatric Association [APA], 1980). Similar to Lothstein, Althof and Keller found the group to be more effective than individual therapy, in part because the therapist was able to obtain information that may never be revealed in individual psychotherapy (1980, p. 488). There are no published accounts of the difference in effectiveness of group and individual work with transgender clients. Early group practitioners believed group work would yield greater results than individual work (Althof & Keller, 1980; Lothstein, 1979). During the 1970s1980s, transsexuals began to offer peer-led support groups. Ingersoll Gender Center in Seattle, WA is perhaps the oldest organization founded for the purpose of reaching out to transsexual and transgender individuals. It was founded in 1977 and has been running a weekly group consecutively for over 35 years (M. Botzer, personal communication, August 12, 2009). Members of the transgender community began offering groups as a means of addressing ongoing needs from a trans-positive and strengths-based perspective. The early history of the psychological treatment of transsexual persons reveals an emphasis on psychopathology. This focus on curing children and adults who are gender nonconforming is another example of psychologys long history of being used as a tool of oppression and the standard bearer of the status quo (Fouad, Gerstein, & Toporek, 2006). Mirroring Western cultures xenophobia and sexism, psychology viewed a natural variation in the human condition as a sickness that required treatment (DSMIVTR; APA, 2000). Social justice, multicultural, and feminist approaches to understanding and treating transgender individuals have been introduced into the psychological community. From these perspectives, the needs of transgender people can be framed in terms of equity, access, participation, and harmony (Crethar, Torres Rivera, & Nash, 2008). The purpose of this article is to bring together feminist, social justice, and multicultural approaches to group work with transgender clients to form a basis for

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culturally-competent practice. We draw from the literature, our own research and clinical experiences, and the first authors personal journey as a member and leader in the transgender community.

SOCIAL JUSTICE ISSUES IN GROUP WORK WITH TRANSGENDER CLIENTS The issue of equity affects transgender individuals in almost every area of life (Currah, Juang, & Minter, 2006; Lombardi, 2007). The social justice perspective informs us that it is not the transgender person who is sick. It is society and the mental health professions that need to become more accepting of difference and to let go of rigid definitions of gender and the gender binary that hurts everyone, to one degree or another. Transgender people continue to face discrimination and bias in many areas of life. Recent accounts of hate crimes show societys continued intolerance for transgender people (Baker, 2009). This intolerance is often internalized by transgender individuals, which may lead them to mental health providers for help in being normal. In turn, help seeking, along with the cultures rigid gender norms, forms a basis for the continued pathologizing of transgender people. This creates a cyclical process whereby pathologization leads to further internalized transphobia that can contribute to comorbid presentations in a trans persons life (Carroll, Gilroy, & Ryan, 2002; DAndrea & Daniels, 2001). Access to care is a significant issue for the transgender community. Often, care is biased, at best, and, at worst, the outcomes are iatrogenic. Social justice-oriented counselors understand that focusing on individual pathology and helping people fit in to society perpetuates the oppression of transgender people (Lombardi, 2007). It is our role and duty to help change the systems that oppress transgender people and thereby empower our clients to do the same. Participation in ones own treatment plan and care is a basic human right (Crethar et al., 2008). Like health care in general, the needs and desires of transgender individuals have for too long been pushed aside in favor of the expertise of medical and mental health professionals. Feminist perspectives in psychotherapy inform us that the client is the expert on his=her=hir (a gender-neutral pronoun; Feinberg, 1998) own experience (Brown, 1994). We must listen to and believe our clients experience. On the other hand, there is danger of the counselor relying on the client to educate the professional about transsexualism and transgenderism. Counselors working with the transgender community must be educated in transgender issues and culture. A group of professionals and trans activists recently developed guidelines for culturally competent care of the transgender community

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(Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling [ALGBTIC], 2009). These guidelines differ significantly from the Standards of Care (SOC; Meyer et al., 2005), which are used as a resource for all care providers to help develop a plan for transition. The SOC are often viewed as troublesome by the transgender community and trans activists (Lev, 2009). In a working group conducted to address the needs of transgender clients, participants identified the need for (a) increased self-awareness of transphobia, (b) inclusion of trans issues in training and coursework, and (c) a strengths-based approach to trans practice and research (dickey, Singh, & Chang, 2008). The development and publication of transgender competencies will help move the profession forward. The ALGBTIC guidelines clearly address these concerns and are a welcome addition to the professional literature. Given this historical picture of group work for transgender clients and the need for counselors to work from a holistic, social justice perspective, it is important for group workers to provide services that meet the needs of the community. In the following section we describe considerations for group workers to keep in mind when developing a group for transgender clients.

SUGGESTIONS FOR GROUP WORK WITH TRANSGENDER CLIENTS Published research on group effectiveness for the transgender community is nonexistent. One article (Denny & Boswell, 1992) and one book chapter (Israel & Tarver, 1997) describe how to start a support group for this community. There are a number of considerations group leaders should attend to before beginning a group for transgender clients, including: (a) types of groups, (b) group leader competencies, (c) group membership, (d) meeting locations, and (e) group format. Types of Groups Group workers may choose from among a variety of group types for transgender people, depending on the needs of the community. Groups may include general support or specific support based on diagnostic issues (e.g., depression, anxiety, social skills). Transgender people face a variety of stressors that may be mitigated through the use of a support group, including risk of job loss, familial discord, and difficulty accessing competent health care. In therapy or process groups, the focus could be on developing social skills as opposed to addressing

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stressors. For example, MTF clients may desire help understanding language patterns and other gendered social customs. Similarly, FTMs may need help understanding how to negotiate male space and speech patterns. Process groups allow individual FTMs or MTFs to learn and share the myriad of subtle gendered expressions and communications that define gender in a culture. Psychoeducational groups have also been used in the transgender community for the purpose of viewing films or reading books that address transgender issues. Group bibliotherapy can be particularly helpful in small or newly forming groups with few or no experienced group members. Topic-limited groups are usually closed, time-limited groups (e.g., eight weeks). Topics might include: (a) early transition, (b) relationships and sex in transition, (c) grief and loss in transition, (d) surgical options and other medical treatment, (e) employment issues, and (f) gender presentation. Group Leader Competencies The Competencies for Counseling with Transgender Clients (ALGBTIC, 2009) include 16 competencies for group work. Themes across these guidelines include: (a) group member autonomy and involvement in treatment planning, (b) recognition of power, privilege, and oppression within the group (p. 11) as it affects transgender people, and (c) awareness of how the leaders own identities (e.g., gender and other sociodemographic factors) may affect group process. Readers are encouraged to seek out these guidelines as they will be useful for developing a practice that serves transgender clients. The guidelines alone do not qualify a person to work with this marginalized community; however they are an important and groundbreaking starting point for competent practice. Group leaders may need to be particularly adept at such skills as cutting off and linking (Jacobs, Masson, & Harvill, 2006). Some transgender group members may have experienced significant delays and missteps in learning appropriate social skills due to being expected to perform a gender that was not their own throughout childhood and beyond. For example, in a transgender support group led by the first author, a member had difficulty relating to other group members and was known for talking at length about topics that were not germane to the group theme. This members behavior had an impact on other members willingness to attend meetings. The challenge was to keep hir on topic so the broader needs of the group might be met. It was important for the leader to both work with the challenging individual and address the concerns of other group members.

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Group members may expect leaders to be knowledgeable about transition related issues. For example, a leader may need information about local resources such as trans-affirmative therapists, physicians, and surgeons. Additionally, it would be helpful to know the processes regarding name changes, updates to state identification (e.g., drivers license), and birth certificates. The processes vary from one jurisdiction to another. Group Membership An important issue that a group leader needs to consider is who the group will serve. Some groups serve both MTF and FTM clients together in one group, and other groups do not. There are different reasons for having mixed or separate gender groups. If the group is located in a large city there may be a large enough community of transgender people to have separate groups for FTM clients and MTF clients. However, for people living in more rural environments or smaller cities, this may not be feasible. In a recent study (dickey, 2007), FTMs indicated they stopped attending support group meetings because they felt the meeting rarely focused on issues specific to FTMs. Lack of attention to FTM issues happens for different reasons. One reason is that in a mixed-gender meeting there will be more MTF-identified clients than there will be FTM-identified clients. Although there are no published group attendance data, the first authors experience indicates that there are ten or more MTF clients for every one FTM client at a group meeting. The reason for this difference in numbers is not entirely clear. Prevalence data about transgenderism is controversial although most would agree that MTF transgender individuals are more common than FTMs (APA, 2000; Conway, 2002). Given the sheer number imbalance in the meeting, it is often difficult for the FTM to find time to talk about the issues pertinent to his=hir life. Another reason to offer separate groups for FTM and MTF clients is to provide time for clients to work on and address the needs that are more specific to their respective situation. The main similarities that MTF and FTM clients share are that both may consider taking hormones to affect secondary sex characteristics and both may face similar legal and bureaucratic barriers. While FTMs and MTFs also deal with physical changes, the challenges of coming out, and issues on the workplace, the realities of these processes can be very different. For these reasons, it makes sense that an FTM would not get his=hir needs met in a meeting that is dominated by MTF clients. That does not mean that the MTF needs are not important; they are. They simply do not always apply to the life of an FTM.

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Meeting Location The location chosen for a group meeting should be safe, convenient, accessible, and private. Finding such a meeting space can be challenging. It is important to discuss the group venue with the members, as there are many hidden meanings and associations for public spaces. One possible concern, for example, would be the cost associated with using a meeting space that meets those criteria. It is possible to find relatively inexpensive meeting space at public hospitals. However, conducting a meeting at a hospital could convey support of the medical model to members of the transgender community. Similarly, some transgender clients have been persecuted by their church or religious group and would not feel comfortable attending a meeting in a church or other religious facility. It is unlikely that a politically or socially conservative church, temple, or synagogue would offer space for a transgender support group meeting. However an open and affirming or reconciled church, temple, or synagogue might make space available. Although the religious facility or hospital may be welcoming, individuals who have suffered discrimination and persecution from religion or the medical profession may not feel welcomed or comfortable there. Group Format One of the challenges often faced by group leaders is developing a meeting format that meets the needs of both newcomers and old timers. In Milwaukee, WI, group leaders have developed a format that addresses the needs of both groups of people (m. munson, personal communication, 2007). The meeting begins with 30 minutes devoted to newcomers. This time is used to answer basic questions such as: Who are the trans-positive therapists in the community? How are prescriptions for hormones accessed? Who is doing chest surgery in the area? How does one change her=hir=his name? These are all important topics, but a person who already has completed these steps will quickly tire of a group meeting that never gets beyond these basics. The remainder of the meeting is then devoted to a predetermined topic. By providing this meeting format, leaders in Milwaukee have created an environment where the needs of trans individuals across the lifespan (not just transition) can be addressed. Topics might include alternatives to suicide, trans on the streets, and therapist meet and greet (For Ourselves: Reworking Gender Expression, 2009). Israel and Tarver (1997) stated that the purpose of transgender support groups varies, though most groups are open to anyone on the gender spectrum. Some groups provide social support, others

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provide technical assistance for those in early transition, and some focus on the political needs of the community. Israel and Tarver included pointers for beginning a group for transgender clients including: (a) start-up, (b) confidentiality, (c) speaking from ones own experience, (d) facilitation, (e) general courtesy, and (f) informationage resources. These pointers for group leaders provide a basic outline for group development. Similar to other group leadership ideas provided in this article, these topics are basic group organization concepts that have critical significance for transgender group members.

CONCLUSION Groups for the transgender community have moved away from the early model of reparative therapy and now are community-based and trans-positive. Social justice work focuses on helping ensure that opportunities and resources are distributed fairly [by] . . . working to change social institutions . . . that perpetuate unfair practices, structures, and policies in terms of accessibility, resource distribution, and human rights (Fouad et al., 2006, p. 1). Crethar et al. (2008) further stated counseling professionals have demonstrated a commitment to foster positive changes among the individuals with whom they work as well as the social-environmental contexts in which their clients are situated (p. 269). Reaching out to transgender individuals through group work is but one method of accomplishing this goal. Groups for transgender clients offer a crucial service that may not be available through individual counseling. We encourage group workers to access the ongoing education and experience necessary for competence in working with this often misunderstood and highly stigmatized group (Baker, 2009). The field of transgender studies is rapidly evolving. Leaders need to continue to develop their understanding of this community if they want to stay on the cutting edge of service delivery.

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Meyer, W. J., III, Bockting, W. O., Cohen-Kettenis, P., Coleman, E., DiCeglie, D., Devor, H., . . . Wheeler, C. C. (2005). The standards of care for gender identity disorders (6th ver.). Minneapolis, MN: Harry Benjamin International Gender Dysphoria Association. Rottnek, M. (Ed.). (1999). Sissies & tomboys: Gender nonconformity & homosexual childhood. New York, NY: New York University. Vanderburgh, R. (2007). Transition and beyond: Observations on gender identity. Portland, OR: Q Press.

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