The Relevance of a Person-Centered

Approach to Therapy with

Transgendered or Transsexual Clients

Tina Livingstone
Research Student, University of Strathclyde,
Glasgow, Scotland

Abstract. In line with contemporary debate on the demedicalization of distress, this paper advocates that
the person-centered approach to counseling and psychotherapy offers more relevance to transgendered
or transsexual clients than the present inclusion of Gender Identity Disorder/Transsexualism as a Disorder
of Personality and Behavior in American and international psychiatric diagnostic manuals. It explores the
feeling of shame experienced by such clients through social stigmatization, the relevance of a
phenomenological approach, and their particular need for empathy and affirmation.

Keywords: phenomenological approach, gender identity disorder, affirmation, relational depth, empathy

Die Bedeutung eines personzentrieiten Ansatzes zur Therapie von Transgender- oder transsexuellen
Klienten
Im Einklang mit der derzeitigen Debatte zur Entmedikalisierung von Leidenssituationen vertritt dieser
Artikel die Ansicht, dass der Personzentrierte Ansatz zu Beratung und Psychotherapie Transgender- oder
transsexuellen Klienten und Klientinnen Bedeutsameres zu bieten hat als die amerikanischen und
internationalen psychiatrischen Diagnosemanuale. Diese klassifizieren gegenwärtig die Störung der
Geschlechtsrollenidentität bzw. Transsexualismus als eine Störung der Persönlichkeit und des Verhaltens. Es
wird das Gefühl der Scham untersucht, das diese Klienten und Klientinnen durch soziale Stigmatisierung
erleben, die Wichtigkeit eines phänomenologischen Zugangs und ihr besonderes Bedürfnis nach Empathie
und Bestätigung.

La importancia del enfoque centrado en la persona para la terapia con dientes transexuales o transgénero
En consonancia con el debate contemporáneo sobre la de-medicalización de la angustia, este escrito
propugna que el enfoque centrado en la persona en counseling y psicoterapia, ofrece mayor relevancia a
los clientes transgénero o transexuales que la actual inclusión del Trastorno e Identidad de Género/
Transexualismo como un trastorno de la Personalidad y Gonducta en los manuales de diagnóstico
psiquiátrico Estadounidenses o internacionales. Explora el sentimiento de vergüenza padecido por muchos

Author Note. The author may be contacted at: <tina@tgiàct.co.uk>.

© Livingstone 1477-9757/08/02135-10
 PCA and Therapy with Transgendered or Transsexual Clients

clientes como consecuencia de la estigmatización social, la importancia del enfoque fenomenológico, y

su especial necesidad de empatia y afirmación?

La pertinence de la thérapie dans l'approche centrée sur la personne avec des clients transsexuels ou
trans-genre
En écho avec le débat actuel autour de la dé-médicalisation, cet article affirme que le counselling et la
psychothérapie dans l'approche centrée sur la personne sont plus pertinents pour les clients transsexuels
ou trans-genre alors qu'il est inclut dans les Manuels de diagnostic psychiatrique américains et
internationaux : trouble d'identité de genre/transsexualisme sous la rubrique "Trouble de la Personnalité et
du Gomportement." L'article explore l'expérience de la honte ressentie par ces clients à cause de la
stigmatisation sociale. Il explore aussi la pertinence d'une approche phénoménologique et le besoin
particulier d'empathie et d'affirmation de soi de ces mêmes clients.

A relevancia de uma abordagem centrada na pessoa com clientes transexuais ou que procedem a
mudança de género
Em consonancia com o debate actual acerca da "nao medicalizaçio" no sofrimento, este artigo défende
que, no counseling e na psicoterapia, uma abordagem centrada na pessoa, é mais relevante para clientes
transexuais ou que procedem a mudança de género, do que a actual inclusáo da Perturbaçâo da Identidade
de Género/Transexualismo nas Perturbaçôes da Personalidade e Gomportamento, como sucede nos
manuais de classificaçâo e diagnóstico psiquiátrico americanos e internaciones. É explorado o sentimento
de vergonha vivenciado por estes clientes em virtude da estigmatizaçâo social, a relevancia de uma
abordagem fenomenológica e a necessidade particular destes clientes de empatia e afirmaçâo.

Y y i^:^^y::^y^~~i¿X.TJ V y i^:^-^-^ iy^Tjvfi-:; y y(:x.

Words are the building blocks ofthe self and of society to the extent that "language is at the
root of all our thoughts, something that we cannot 'stand outside of, and something that is
intrinsic to our sense of who we are" (Mearns & Cooper, 2005, p. 5). The power of well-
placed words can in fact hold and heal; they can also batter and destroy. Unfortunately,
sometimes people's attempts to do the former have inadvertendy created pathways to the
latter; the medical model of mental illness being a prime example. Notions of abnormality,
disorder and deviance are so weighted with negative value judgments that human conditions
associated with such vocabulary quickly become socially stigmatized, compounding distress.
Whilst categorizing human distress in line with the medical model of illness "is a way of
thinking that is meant to be helpful" (Sanders, 2007, p. 36), I believe that categorizing
human diversity as such is defmitely unhelpful, however unintentional that may be.
136 Person-Centered and Experiential Psychotherapies, Volume 7, Number 2
 Livingstone

Well overfiftyyears ago Carl Rogers (1951) spoke out against the dehumanizing effect
of clinical diagnosis: "There is a degree of loss of personhood as the individual acquires the
belief that only the expert can accurately evaluate him" (p. 224). Rogers went on to warn that
"it would appear that the long-range social implications are in the direction of the social
control ofthe many by the few" (ibid.). Indeed, the inclusion of homosexuality in the Diagnostic
and Statistical Manual ofMental Disorders until 1973 accords with this observation. More
recently Pete Sanders (2007) notes that "disabled people, lesbian, gay and bisexual people,
men, women, transgendered people, may be diffèrent but they are not ill" (p. 36). Regrettably,
in the case ofthe trans-identified population, both the diagnostic manuals utilized in treatment
in the UK, the Diagnostic and Statistical Mamial of Mental Disorders, 4th edition (DSM-IV)
(American Psychiatric Association, 1994) and The ICD-10 Classification of Mental and
Behavioral Disorders (ICD-10) (World Health Organization, 1992), so far disagree with him.
They continue to pathologize gender diversity. As Riki Anne Wilchins (1997) points out:
"getting help shotild not require you to accept a psychiatric diagnosis, produce a dog-and-
pony show of your distress, and provide an identity to justify its realness. That is a debasing
and dehtimanizing procedure" (p. 192).
Throughout my writing I opt to use the term trans-identifiedm preference to the labels
transvestite, transgender, and transsexual, which are somedmes offensive to the clients' perceptions
of self. Whilst the term mzw-tóíonW hopefully offers respectful incltision to those who have
completed gender transition and no longer regard themselves as trans-identified.

DECOUPLING THERAPY FROM DIAGNOSIS

Carl Rogers noted:

[I]n my early professional years I was asking the question. How can I treat, or cure, or
change this person? Now I would phrase the question in this way: How can I provide
a relationship which this person may use for his own personal growth? (1961, p. 32)

Applying this wisdom unconditionally to the trans-identified population, whom society

has so long sought to cure from who they are, feels to me an appropriate way to begin to
mend the damage ofthe heterosexist dominion wrought upon them. Despite being clear
ÚV3X gender identity disorder "is not meant to describe a child's nonconformity to Stereotypie
sex-role behavior" (APA, 2000, p. 580) the diagnostic framework for trans-identified people
within the DSM TV-TR is still littered with stereotypes. Speaking of biologically male
children who identify as female-gendered, it reports that they "particularly enjoy playing
house, drawing pictures of beautiful girls and princesses, and watching television or videos
of their favorite female-type dolls, such as Barbie" (APA, 2000, pp. 576-577); whilst of
female-bodied children identifying as male-gendered it states "these girls prefer boys as
playmates, with whom they share interests in contact sports, rough-and-tumble play and
traditional boyhood games. They show litde interest in dolls or any form of feminine dress
up or role-play activity (ibid.). The preferred diagnostic in many parts ofthe UK-ICD-10

Person-Centered and Experiential Psychotherapies, Volume 7, Number 2 137

 PCA and Therapy with Transgendered or Transsexual Clients

(World Health Organization, 1992) feels less sexist in its explanation: "F64.0 Transsexualism.
A desire to live and be accepted as a member of the opposite sex, usually accompanied by
a sense of discomfort with, or inappropriateness of, one's anatomic sex, and a wish to have
surgery and hormonal treatment to make one's body as congruent as possible with one's
preferred sex" (p. 365). It still, however, lists such cross-gender identification as a disorder
of adult personality and behavior. Moreover, whichever diagnostic manual is used, male-
to-female trans-identified people in particular are frequently expected to be asexual or
submissively heterosexual, failing which they may find themselves labeled transvestic
fetishists.
The notion of disorder in the case of trans-identified people is based on cultural norms
rather than any clinical abnormality. "There is no diagnostic test specific for Gender Identity
Disorder. In the presence of a normal physical examination, karyotyping for sex chromosomes
and sex hormone assays are usually not indicated. Psychological testing may reveal cross-
gender identification of behavior patterns" (APA, 2000, p. 578). The heteronormative society
in which, most of us live assumes that being gender congruent, that is, having gender in line
Wïuï physicality, is not only the norm, but also the natural way to be. This value renders those
born trans-identified into a socially stigmatized, medicalized minority deemed abnormal
and unnatural. It is small wonder then that "relationship difficulties are common and
fiinctioning at school or at work may be impaired" (APA, 2000, p. 577). Moreover " [s] uicide
attempts and Substance-Related Disorders are commonly associated" and individuals "may
manifest coexisting Separation Anxiety Disorder, Generalized Anxiety Disorder, and symptoms
of depression (APA, 2000, p. 578).
Beyond the descriptors of Z)5Ai-7yor ICD-10, a trans-identified lady explained the
isolation and distress of her existence and opened my eyes to the pain of her reality thus:
"It feels like I am trying to live life behind frosted glass; knowing that nobody in the world
can see me clearly nor know who I really am." To my mind such distressing alienation
from the world is best met with "the experience of being deeply respected" (Rogers, 1951,
p. 44) inherent in the person-centered approach. Whilst philosophy, psychology, sociology
and anthropology may fascinate us with their explorations and interpretations of trans-
identified minorities, it is actually, to paraphrase gender therapist Randi Ettner (1999),
"those who are humanistically or existentially orientated" who "will resonate with the
transsexual's movement toward self definition" having "advantage in that they are accustomed
to acknowledging and afiirming phenomenological and experiential states" (p. 111). In a
person-centered approach to therapy "the confiised, tentative and almost incoherent thinking
of an individual who knows he has been evaluated as abnormal is really respected by being
deemed well worth understanding" (Rogers, 1951, p. 44). It feels well past time that the
trans-identified population was deemed well worth understanding and met with the
genuineness, empathy and unconditional positive regard of a facilitative phenomenological
approach.

138 Person- Centered and Experiential Psychotherapies, Volume 7, Number 2

 Livingstone

BINARY FRAMES OF REFERENCE AND BEYOND

iVIajority rule in sex and gender is so embedded in our ctilture that it has a profound effect on
the development of the trans-identified individual. Constructing identity narratives helps
make sense of both self and society, with both factual and fictional narratives informing and
inspiring our own. One would be hard pushed to find children's books with a transgendered
hero or a princess who grew to be king; this then presents such children with a very bleak
future. Fairytales quickly become nightmares when the only visible adult version of you is the
pantomime dame. Recendy the Traditional Values Coalition warned parents against the
character Doris in the family films Shrek 2 and Shrek 3:
The chatactet has five o'clock shadow, weats a dtess and has female breasts. It is cleat
that he is a she-male ... During a dance scene at the end of the movie, this
transgendeted man expresses sexual desire fot Prince Charming, jtimps on him, and
both tumble to the floor. (Traditional Values Coalition, n.d.)

Whilst some may take their warnings of sexual subversion to heart, and others dismiss both
character and incident as comic humor, the trans-identified child may surmise from this
character that their adtilt fixture lies somewhere between threat and ridicule, and is definitely
ugly in the eyes of everyone. Mearns and Thorne (2007) observe that "to be judged by
another on the basis of the self we are presenting is one thing, but to be judged for what we
believe is our essence is partictilarly dangerous" (pp. 39-40). Such is the judgment passed on
trans-identified people fi-om a very early age. Hence their inclination toward fiagile process
which, as Margaret Warner (1998) explains, "tends to develop when early childhood experiences
have not been received empathically" (p. 380). Trans-identified clients are in many ways the
epitome of persons in fragile process — fiequendy overwhelmed and feeling out of control.
In a certain sense they "are asking if their way of experiencing themselves at that moment has
a right to exist in the world" (Warner, 1998, p. 381) and "any misnaming of the experience
or suggestion that they look at the experience in a diffèrent way is experienced as an answer
of no to the question" (ibid.).
Social expectations may begin in childhood but certainly do not end there. The pressure
to conform to majority rule is immense and cumulative. Unsurprisingly the majority of
trans-identified people who undertake counseling arrive emotionally and psychologically
bent under the weight of objectifying conditions of worth, received implicidy and explicidy
fiom both immediate family and society as a whole. I cannot overemphasize the importance
of affirmadon (Davies, 1996; Mearns & Cooper, 2005) and prizing (Rogers, 1957) in working
with this diverse population. These are people whose very existence is embedded in social
stigma and taboo and they feel it most keenly. Simply "refraining fi-om judgment, or holding
an atdtude of'however you are is alright by me'" (Mearns & Cooper, 2005, p. 43) is insufficient.
Due to the social isolation and consequent anxieties of being trans-identified these people
need our proactive affirmation. Bihliotherapy, that is, "using literature for self-help and personal
grovrth" (Kus, 1995, p. 79), can provide such affirmation and help facilitate informed choice.
Ettner (1999) speaks of the "need for acceptance, coupled with a desire to appear normal"

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 PCA and Therapy with Transgendered or Transsexual Clients

that "stunt identity development" (p. 102) in trans-identified clients. Here the feminist
perspective of the therapist as teacher and the value of the educative function in counseling
are particularly significant in order to:
1. provide reassurance that the client is going through a normative experience;
2. help make sense of some of their feelings, and inspire hope in resolution.
(Davies, 1996, p. 35)

"One of the cardinal principles in client-centered therapy is that the individual must be
helped to work out his own value system vwth minimal imposition of the value system of the
therapist" (Rogers, 1951, p. 292). Here trans-identified clients offer particular challenges to
many therapists in that their very existence tests one of the primary assumptions of our
culture — that gender is an immutable binary and, moreover, that it is always congruent
with physicality. Such cultural tenets being implicidy and explicidy embedded in consciousness,
we must be prepared to step outside that cultural frame of reference, wherever it ends for us,
and genuinely engage with that of the client. Like Ettner (1999) my experience is that having
"two categories — transsexuals and transvestites — based on whether there is accompanying
fetishistic behavior, is overly simplistic and therapeutically unproductive" (p. 70), hence my
use of the terms trans-identified ssià trans-historied in striving to respea all identities, including
those who have completed gender reassignment.
It is aligning ourselves with the client's perceptions that enables us to grasp the root of
fragile process as ego-syntonic (congruent with self) rather than ego-dystonic (at odds with
self). Recendy, for example, a client of mine punched a mirror and sent a photo of the bloody
result to her family. One interpretation of her action would be that such behavior was ego-
dystonic, however, in holding the client's perception of her world I understood her process as
egosyntonic. My response in hearing what lay underneath this for the client, in the context of
a history of trauma, abuse and neglect, was to ofFer an understanding "You wanted your
parents to loveyou"— an accuracy that conneaed with the client, bringing hurt but understood
eyes into contact with my own. Trans-identified clients often present the full range of ego-
syntonic process associated with survivors of abuse; from "confused and scared" through
"controlling" to "detached" znA even self-destructive (Mearns & Thorne, 2007, p. 27). Such
difficult process may initially be a way of achieving a localized sense of safety; for example
detachment fiom people may be considered a reasonable response to being hurt by those
people. However when such self-protective process becomes a universal principle, applied to
all relationships, life becomes really difficult.
From the person-centered perspective then ego-syntonic process is about being truly
open to working on the client's terms, however fragile; holding the client's perspective rather
than regarding them as disordered. To ignore the client's perspective in this regard, in effect
says "your worldview is wrong; change it and get on." Where such fragile process exists the
therapist who truly values the client's experience is often thefirstperson to ofïèr them "a deep
valuing of how they are in the world" (Mearns & Cooper, 2005, p. 43).
Trans-identified clients ofi:en come to counseling v^^th very traditional, even stereotypical
perceptions of gender. Even those who feel themselves beyond the gender binary feel

140 Person-Centered and Experiential Psychotherapies, Volume 7, Number 2

 Livingstone

tremendous social pressure to fit within it. Through engaging with a phenomenological
approach, rather than being expected to fit clinical criteria, sometimes what emerges
comfortably transcends the binaryfi-amework.I am thinking in particular of a trans-historied
lady friend w^ho said to me smilingly, "I think, giving no particular value to the ntimbers
used, if Male was one and Female was ten, I am around eight or nine." Sharing this
phenomenological approach, plus my respect for inter-gendered and androgynous identities,
as well as male and female, has been visibly liberating to many clients. Respecting all diversity
as equally valid to the binary can restore the individual's basic human right of self-governance.
Being gender variant is not about flouting the rules or making alternative lifestyle choices; it
is simply about having developed differently from the majority.

RELATING AT DEPTH

Linguistically, the people who experience themselves as outside the gender binary have only
binary terms with which to express this. My perception of this as akin to having only black
and white paint to describe a yellow brick road resonated deeply with a recent client. Working
vñth issues of sexual and gender variance therefore necessitates not only the ability to "hear
what is underneath" but also offering one's understanding of meanings in diverse and creative
ways in order that its accuracy may be constantly checked. When one meets gender variant
clients with genuine respect and regard, laying aside heteronormative gender assumptions,
and authentically exercising a "dedication to going with the client's direction, at the client's
pace, and with the client's unique way of being" (Bozarth, 1990, p. 59), then one can engage
in the privileged relationship of relating to these people "not as they seem to outsiders, but as
they seem to themselves" (Combs & Snygg, 1939, p. 11). As Mearns and Cooper (2005)
note: "A superficial empathy understands what the client is saying and feeling but it is a
deeper empathy and congruence that communicates 'she understood how it feels to be me'"
(p. 45).
The majority of trans-identified and trans-historied clients have learned that they are
fundamentally "improper" or "wrong" in the eyes of society, simply by existing. We are then
meeting people who are both afraid of themselves and scared of us, because they live in a
world that has misunderstood and rejected them for a very long time. Mearns and Cooper
(2005) refer to a demand "upon the therapist to 'earn the right' to encounter" which is
particularly significant when working with "those clients whose systems of self-protection
offer sophisticated and stoic resistance to an encounter that carries a danger of exposing them
to the judgement of others and, indeed, to the judgement of themselves" (p. 45). The
development of my work with this minority population resonates with that notion; initially
the population regarded me with defensive suspicion but over time I have earned some trust.
Working with people suffering from the emotional fatigue of living on the cultural fringe
demands the willingness to go that extra mile and be trtdy adaptable in time and space. One
of the greatest anxieties for trans-identified clients is that they feel they may be an
embarrassment to others. Therefore being open to relating outside ofthe closed doors of a

Person-Centered and Experiential Psychotherapies, Volume 7, Number 2 141

 PCA and Therapy with Transgendered or Transsexual Clients

therapy room can be powerful in itself. In relating with trans-identified clients there are also
obvious parallels to Margaret Warner's (2000) work with clients who haveß-agileprocess (pp.
147-171): emphasis on consistency and flexibility is incredibly significant.

MOVING FORWARD

Whilst we may think of aversion therapy as something from the distant past it actually
remains in the history of many middle-aged/older trans-historied clients. Recently one of my
clients recounted how, in the late 1960s, she underwent electric shock treatment virtually
every day for two weeks. The clinician had pasted a photo of her face onto female catalogue
models and administered a painful shock to her arms as she looked at each ofthem. Tired of
pain and feeling no better, she eventually resorted to telling him she no longer thought she
was a woman, and was prompdy told to go and get married in order to seal the cure. Therapies
that aim to cure are still available today, thus being transparent in philosophy and practice is
particularly significant to this population. Too frequently they are well acquainted with
Nathansons (2003) notion of shame, that "quintessential affect of feeling shorn from the
herd, of being alone and rejected" (p. 5). So there is a need for therapists to metaphorically
reach out their hand and be visibly welcoming.
Whilst many ordinary people, whose gender and physicality match, regard individual
variations as obvious and natural, those self-actualizing from a place where gender and
physicality are mismatched ofi:en feel obliged to keep within very narrow gender parameters,
in order to be seen, believed, and meet society's requirements. Here, essentialist beließ—that
things have a set of characteristics which make them what they are — can stifle the clients
essential autonomy and right to self-determination. Hence when working with trans-identified
clients, being able to affirm that wearing bright colors and caring for children are not solely
the province ofthe female, or that having a strongly competitive nature and rational mind
are not solely the province ofthe male, can facilitate client autonomy. As Haldeman (1999)
highlights, the "primary risk an essentialist perspeaive poses to the clinician is the development
of an a priori agenda for the client" (p. 65). He further warns against any leaning toward the
notion that "there is one right path for the individual and that the therapist's job is to set the
client in it" (ibid.). Thus, though social and physical transition may be necessary for some
trans-identified people, such treatment should not be regarded as a predetermined destination,
or a criterion for success. Nobody should feel that they need to fit somebody else's model of
being in order to be accepted as a valid person. Kit Rachlin's research showed that what trans-
identified clients found most helpfiil in therapy was acceptance from the therapist, respect
for their gender identity,flexibilityin the treatment approach, and that the therapist had
some connection with the transgender community (Rachlin, 2002).
It is by engaging phenomenologically with trans-identified clients and being willing and
open to engage at relational depth that we may assist our fellow human beings in liberating
themselves from the oppression of taboo, so that they can live more comfortable and
autonomous lives. Moving away from facades, away from "oughts," away from meeting

142 Person-Centered and Experiential Psychotherapies, Volume 7, Number 2

 Livingstone

expectations, and away from pleasing others, is hard for anyone; trans-identified people carry
the additional pressure of social stigma through being externally judged as disordered and
unnatural.
Fully to be one's own uniqueness as a human being, is not, in my experience, a process
which would be labeled bad. More appropriate words might be that it is a positive, or a
realistic, or a trustworthy process (Rogers, 1961, p. 178).
It feels to be time that society changed its opinion about gender diversity being disordered,
and acknowledged trans-identified people as equal human beings who can be trusted with
their own life decisions as much as anyone else. I believe the person-centered approach holds
the key to opening that relational door.

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