Thomas N. Wise, MD., Professor of Psychiatry and Behavior Science, The Johns Hopkins School of Medicine wrote the following to The Dartmouth, the newspaper of Dartmouth College. It appeared as a letter to the editor in the online version, October 12, 2001 with the title “Transgender Truths.”

“I am concerned that there is ongoing confusion regarding sexual minorities. It is clear that homosexuality is not a psychiatric disorder. The official diagnostic stigmatization of homosexuality was abandoned after lack of data that could establish any pathology associated with being either gay or lesbian. Gender dysphoria, unhappiness with one’s biological sexual designation, is very different from same sex attraction and is a psychiatric disorder. Individuals who designate themselves as transgender, which is not a formal medical or psychiatric term, often are not homosexual but have significant problems of self identity. As director of research at the Sexual Behaviors Unit at Johns Hopkins, we have spent the past 25 years studying such conditions. Transgender individuals are not bad people but often have serious conflicts and issues that are not a result of society but due to internal psychological conflicts. They need treatment as well as acceptance. I recognize that this is not a popular stance but in the long run will save much suffering by these individuals.”

Well, I have serious concerns about Dr. Wise’s comments, which, at most could very well result in an injection of considerable suffering for transgendered people and, at least, continues the tired mythological belief that transgender is just another way to say “we’re crazy.” Those who read his comments, made by a man of obvious standing and influence, may seize upon his “diagnostic” opinions of the now defunct DSM diagnosis of “gender dysphoria” (it is now described in the DSM IV as “Gender Identity Disorder”) and use it as another reason to fear transgendered people as potentially or completely unstable. This could worsen the already serious issues encountered by transgendered people in areas such as employment and housing, or in receiving adequate medical care or health insurance coverage, or in numerous other areas that mainstream society enjoys.

Although Dr. Wise and probably others have worked for years studying individuals who have significant problems with “self identity,” the idea of a “purely” psychiatric disorder involving “internal psychological conflicts” seems quite interesting to me. Dr Wise states that there is “lack of data” establishing homosexuality as a psychiatric disorder. Does this mean that there is data that transgender is a psychiatric disorder? After 25 years of study, there must be a vast body of information to support his assertion. If so, where is it?

There also seems to be little scientific curiosity or motivation to discover any physiological components associated with transgender. Yet studies that have been conducted over the years have often shown a physical component to emotional disorders, whether they are neurotic or psychotic in nature. As a result, most, if not all emotional disorders, are remediable to forms of medicine that are designed to relieve the symptoms presented, thus allowing the person to regain control and proceed with insight that leads to resolution of the problem(s). Thus, if a patient is suffering from an anxiety disorder, a medicine can be administered, such as valium, to relieve the physical symptoms while talk therapy continues.

Having no motivation to recognize the physiological components of transgender means that there are no medicines to impact the specific “symptoms” of transgender. Anti-anxiety medicine will not work. Anti-psychotic medicines will not work. Even electro-shock therapy will not work. In fact, there is no medicine to help a person relinquish the symptoms of a perceived “psychiatric disorder” defined by an unhappiness with a culturally assigned sex identity, that is often accompanied by a “delusion” of wanting to be the other sex and gender.

Counseling is an important adjunct to help support the transgendered person in navigating the stormy seas of cultural ignorance. What seems interesting is that the counselor will, at the request of the “patient,” write a letter to the person’s physician approving the administration of opposite sex hormones. Upon receipt of the letter, the physician will do so. Later in time, another letter might be written to a qualified surgeon to confirm that the person is appropriate for “reassignment surgery.” Upon receipt of the letter, the surgeon will do the surgery. This would appear to be antithetical to the idea stated by Dr.Wise, that “gender dysphoria” is a purely psychiatric disorder. Indeed, these actions would seem to be symptomatic of the counselor and the medical professionals being drawn into the “delusion” of the patient!

But, of course, that is not the case. It is a widely accepted belief among many in the professions that although there are physical elements in transgender, there is not, as yet, a precise understanding of these elements at this time. It is agreed, however, that it is absolutely crucial to provide transgendered people with competent assistance in the transitioning process, including supportive counseling, advocacy, resource referrals, and so on. Counseling almost always focuses on issues associated with being transgendered, not about the physical reality of transgender per se, which appears to be in-born and immutable.

There have been recent developments in research that provide important new and challenging insights concerning transgendered individuals. Ground breaking research studies reported in journals and the popular press within the past decade include work done with the BSTc in the hypothalamus at the Institute for Brain Research in Amsterdam, Netherlands by Dr. Zhou et al, and a study done with intersex infants at Johns Hopkins Hospital by Dr. Reiner et al. These studies have substantially challenged the traditional thinking about sex identity assignment, and present the thesis that sex identity is an inborn physical reality that originates in the brain. The genitals, which have been the focus of “biological” sex identity assignment for millennia, appear to be only incidental to sex identity, whether functional or not.

Current perceptions that view the transgendered person as psychiatrically disturbed or that transgender is an expression of bizarre immorality must be replaced by a new understanding based on hard data from research, i.e. that transgender is an inborn physical incongruity of sex identity. This shifting of the paradigm will be required of counselors, physicians, surgeons, the health insurance industry, the systems of justice, and the entire culture as well.

The dysphoria that Dr. Wise describes is, in all probability, not the result of purely “internal psychological conflicts” at all. It is very possibly a product of an incongruity in physical structure that has been missed in the past due to a lack of understanding about the true origination of sex identity, which is located in the brain, not the genitals.

Background Context

It is important to distinguish the terms we use. Transgender is not a sexual minority. It describes a gender identity minority. Gender identity is also distinguished from the sexual minorities in that identity describes “who am I?”(girl, boy, or whatever) and sexual minorities describe a sexual orientation toward another person, as in “who do I want to have a relationship with?”

I agree with Dr. Wise that transgendered people are not bad people. Actually, we are very good people. We are, in the main, above average in intelligence. We are mentally strong, creative, sensitive, reality based, and competent people. It is also important to understand that the transgender community includes a very diverse, broad continuum of personalities, lifestyles, sexual orientations, and gender expressions.

Although there are those who, like Dr Wise, believe that transgender is the product of an “internal psychological conflict,” this view is only one of several “schools” of thinking that have developed over the years, all of which have made contributions to our understanding of transgender, and all of which have their passionate devotees.

First, there is the school of thought that says a person has the right to express whatever gender, or claim whatever gender identity she or he desires, including androgyny. This is what I call the “naturalist school.” The view expressed by this school is that there is no need to prove anything or to explain the “why” of transgender. It just is and that is sufficient, period. Unfortunately, negative experiences with the whole range of professionals and the systems in which they work, have left proponents of the “naturalist” school suspicious of professionals in general. There is, then, a tendency to reject professional people, including transgendered professionals, and to dismiss professional views as arrogant, assumptive, trite, and unnecessary.

This school encompasses a significant number of transgendered people, including those who were our early “pioneers.” They are the true “sheroes” and “heroes” that continue to exert a powerful influence in the transgender community. There are also many advocates for social and legal justice who embrace this school of thought, as it espouses the human right of self-determination.

Secondly, there is the “anthropological-historical” school. This school, which is very supportive of the naturalist school, outlines the presence of transgender throughout history. The fact of historical presence further legitimizes the transgender community by revealing its roots.

In this school are those who also document current trends and events that occur in the present time. Sobering is the website “Remembering Our Dead,” which documents those of the transgender community who have been killed simply because they are transgendered.

Then, there is the “psychiatric school.” Proponents of this school believe that “gender dysphoria” is present in the so-called ‘transgendered’ persons. The “patient” reportedly suffers from an inner psychological confusion involving the biological sex identity designation, which, for some curious psychological reason, is unacceptable to that “patient.” The “dysphoric patient” is viewed as seriously neurotic, or perhaps even more seriously impaired, reflective of major diagnoses like schizophrenia, dissociative personality disorder, bi-polar disorder, and so on. Also in this school are those who feel that the male to female “dysphoric patient” suffers from a condition described as “autogynephlia.” To me, that designation seems evidence of, “when psychoanalysis goes bad!”

The psychiatric school sees the transgendered person as a patient, i.e. one who is ill (disturbed). Therefore, an appropriate “professional distance” from the “patient” must be maintained. This attitude, of course, inhibits meaningful collaboration between the naturalist and psychiatric “schools,” and provokes the flow of negative transference phenomena, so evident in the “naturalist” school toward the professional community in general.

Another “school” embraces the “hard sciences” of medicine and research. In medicine, the transgender person is viewed by most as a congenital anomaly, which occurs during the gestation process. It is not described as genetic in origin. After the proper clearance from the “patient’s” counselor, the physician develops baseline data collection, followed by careful administration of hormones, if the “patient” is desirous of taking them.

Unfortunately, there is nothing to compel a physician to spend much time understanding transgender. Information and training in “transgender medicine” is not readily available, unless provided by the “patient.” Thus, treatment given to a transgendered person often feels to the physician like sailing in uncharted waters. Many physicians refuse to provide care to transgendered people because of perceived risks. Others feel compassion and try to be helpful. Still others accept transgendered persons in their practice yet seem unconcerned about the quality of care provided to them. Perhaps care is dumped on a nurse or physician’s assistant, or ARNP without much in the way of preparation. Some of these people turn out to be helpful, but in the main they seem to view the transgendered patient as an organism from outer space.

When a physician does accept a transgendered person for treatment, there is little, if any, sensitivity training provided to the office staff and nurses. All too often, the attitudes and behaviors of office staff and nurses destroy the “patient’s” motivation to trust the health care professionals or the process.

Yet, I thankfully acknowledge the many physicians, psychotherapists, surgeons, lawyers and their support staffs, here, and throughout the world, that have been truly supportive and helpful to the transgender community. There are, in fact, an array of professionals from many different disciplines who are crucial to our emotional and cal health and welfare. Unfortunately, there are far too few of them to meet the transgender community needs. The research arena of the “hard sciences school” is concerned with understanding the “why” of the condition, and looks for many concrete, physical variables to provide the answers. The research arena is very small, perhaps because there is little financial or cultural support for such work.

Even though the field of transgender study is relatively new, the “schools” maintain an independent belief system that creates a “turf” separateness from one another. As they are not compelled to work together, any attempt to identify an “eclectic school” or develop communication strategies that link the “schools,” would most likely encounter significant barriers.

As a “resolved dysphoric” and a surgically “confirmed” female Master’s level clinical social worker with thirty years experience, I learned long ago that each of us is a bio-psycho-social entity. As I have become acquainted with the various “schools” of thought on transgender, and reviewed much of the vast amount of wonderful material associated with each school, I have found good things in each of the “schools.” I agree with the “naturalists,” who feel that there is an implicit human right to be oneself (gender rights are human rights). I agree with the “psychiatric school,” except that emotional stress that is experienced by the transgendered “patient” is secondary to the physical reality of transgender. The etiology of this emotional stress involves external, cultural issues. The culture is dysphoric, not the individual, as I will explain later. I also agree with the “hard sciences school” that there must be a significant physical component that strongly contributes to the human motivation to express another gender or sex identity either on a part time or on a full time basis. Although I may be making premature assumptions from the studies done in Amsterdam, I believe that the ongoing work in the Bstc of the brain, will eventually prove to be an important factor that defines everyone’s genuine sex identity.

As I have said earlier, there are many good people doing a lot of good things to serve the transgender community. I do not believe that there is an evil plot against transgendered people. I believe that we are wrongly perceived by most of culture as a foolish, unwholesome, unstable, and worthless minority. All too often, these negative descriptors get further associated with all sorts of other negative images. In time, myths develop that undermine any legitimate effort at gaining equality for transgendered people.

Fortunately, tireless efforts by many transgendered individuals and organizations to educate everyone about the truth of transgender, will one day replace the fear and the many false and destructive myths about us. But I still continue to wonder why the archaic and mythological thinking about transgender is so amazingly persistent in professional circles, as well as in the general population, despite important research developments that have been reported in journals and the popular media during the past decade.

The situation with transgendered people is not so simple and easy to dismiss as Dr.Wise has stated, “not bad people who often have serious psychological issues.” With ongoing study, my own experience, and listening to countless anecdotal accounts from many in the transgender community, I have developed an explanation that, I trust, reflects a more accurate picture of reality, and embraces elements of all the schools of thought outlined above.

Formulation Concerning Transgender

First of all, “transgender” is an inclusive, umbrella term under which a continuum of behavior is revealed. At one end of the continuum is the most secretive/closeted transgendered. Behaviors along the continuum include progressively more open and frequent transgender expression from occasional to more frequent cross dressing to transgenderists, who live in the opposite gender role, to the transsexuals, who are at the opposite end of the continuum. Many in the transgender community feel that they are transcending the definitions and boundaries of gender. Yet, to me, they seem to be creatively confirming an interpretation, or a blending of genders that embraces the elements of two sex identities, one culturally assigned by looking at the genitals, and one that is physically present, but not visible, in the person’s brain. I think that what we see in transgender is related in some way to the intersex community. But in the instance of transgender, the person is born with two functional biological sex identities. In addition to the Amsterdam work, a study done at Johns Hopkins Hospital by Dr. Reiner et al on intersexed infants with incomplete external genitals, has demonstrated that the brain is the primary site in determining a person’s genuine sex identity. As Dr. Reiner stated:

“The sense of who one is (boy or girl) is a crucial existential aspect of humanity. It is powerful and inborn….. The most important sex organ is the brain.” (Johns Hopkins Hospital Magazine, September 2000).

This finding strongly reinforced the conclusions by many in the scientific community concerning the famous “twin study,” where one of the infants, David Reimer, was injured in a botched circumcision. Clearly, John Money, PhD was in error in his assumptions that genital manipulation could be done without the child ever knowing the difference. (A book about this experience entitled, As Nature Made Him, by John Colapinto outlines the case.) Despite all the surgical technology used to impose a female sex identity on David Reimer’s genital region, all the hormones administered, and all the psychosocial strategy with the family designed to reinforce the surgical sex identity assignment, he refused live as a girl. His true sex identity as a male, originating in his brain, would not be denied. Because the important research reported to date has been ignored by the medical community, the archaic protocol persists, i.e. the focus on the external genitals of the infant followed by a crude imposition of a “biological sex identity” upon that infant. Tragically, when this archaic protocol is used at the birth of a transgendered infant, a catastrophic error is made that will challenge the child throughout her/his life. Equally devastating is when the genitals are ambiguous, as is often seen in intersexed infants. Surgery is all too often the solution to a perceived medical or social emergency. In these cases, a transgendered person is all too often surgically created!

Yet the practice of surgical assignment of sex identity on infants continues to be done by rigid, unsophisticated professionals.

Culturally Induced Stress Disorder (Internal and External)*

When the transgendered community is viewed as a whole, a pattern of symptoms emerges that reflect the intense struggle that every transgendered person must go through in order to “be.” Frequently there is evidence of long-standing mild to moderate depression, isolation, anxiety, low self esteem, and other stress related elements. These phenomena are almost universally reactive, not endogenous in nature. There is a private inner struggle to understand their genuine sex identity vis-à-vis the culture’s assignment of sex identity imposed at birth. Once resolved internally, an external struggle to achieve acceptance by the culture begins. The culture should recognize the error made in the sex identity assignment, and then assist the transgendered person in the transition process to assume their genuine sex identity. But many in the culture, especially those who are in positions of authority, such as law makers, courts, law enforcement, the church, employers, and other persons in authority, refuse to accept responsibility for the suffering of the transgendered person. It seems that being “different” all too often results in a negative cultural perception. The stress phenomena experienced by the transgendered person is what I call “Culturally Induced Stress Disorder”(CISD)*. There is an “internal CISD” component and an “external CISD” component.

Internal CISD Process

The “internal CISD” component involves the struggle of the physical sex identity incongruity between the culturally assigned, genitally based biological sex identity with associated gender role expectations, versus the opposite and genuine biological sex identity that is physically present and expressed in the brain.

The inner struggle can be understood by referring to the process of homeostasis, (balance) as described by Walter B. Cannon, MD, ScD, in his book entitled The Wisdom of the Body, (Second Edition, WW Norton, New York, 1939). In the instance of transgender, the imbalance is the presence of two different inborn biological sex identities. But there can only be one sex identity that is dominant to achieve homeostasis. As the latest research indicates, that sex identity is the one expressed in the brain. The process of homeostasis, then, includes the person’s internal struggle to understand and accept that the culture’s assigned sex identity assignment that was imposed upon him/her at birth was a mistake, and then recognize and accept that the genuine biological sex identity located in the brain is what defines his/her true sex identity.

The process of working through the internal component of CISD to achieve homeostasis, is exceedingly difficult. After all, there are observable, normal genitalia. Everyone says she is a girl, or, he is a boy. Yet there is the continuous feeling that something is wrong, that things are slightly out of focus. For most transgendered persons, the awareness of the incongruity of their sex identity begins in early childhood as a preconscious awareness, which is not fully understood or articulated by the child.

Exacerbating the internal CISD struggle is the intensive and continuously reinforced socialization and enculturation mandates, that include a strong prohibition (taboo) on any conversation that questions the sex identity assignment made by the doctor, let alone the “preposterous” idea of “changing” one’s sex.

It should not be surprising that the transgendered person will most often choose to struggle with their sex identity incongruity alone. It will almost always be regarded as a private and carefully guarded “secret”-a “secret” that carries with it much suppressed fear, guilt, shame, and feelings of futility, i.e. that there is no way to solve the problem. As the years go by, the transgendered person becomes more aware of the need to resolve their sex identity incongruity. Like turning up the volume on a radio, the need to understand and find relief increasingly intensifies, forcing the person to pay more attention to the issue of their sex identity incongruity. Indeed, the internal CISD struggle will never end until homeostasis, i.e. a balance that reflects a congruent sex identity, is somehow achieved.

The details of the internal struggle are individualized for each person, their environment, experiences, perceptions, and so on. But there are many common guideposts in the journey. These common points are presented in the “Summary of the Stages and Tasks Inherent in CISD” section at the end of this paper. The range of coping strategies can go from acting out, to substance abuse, to just about anything else, including an outwardly “normal” adjustment.

Many attempt at conforming to the culturally assigned sex identity as a way to survive. But this approach is rarely satisfactory or successful, even with culture’s positive reinforcement.

The relentless internal struggle will eventually lead the person to information, counseling, support groups, private or public cross-dressing or cross-living, or a combination of these resources and activities, or, tragically, to lives of despair in the margins of culture often ending in suicide.

The resolution of the internal CISD (homeostasis) occurs with the acceptance of one’s genuine sex identity, as expressed in the brain. Once achieved, the outward expression of that resolution takes a multitude of formats, as seen in a continuum of gender manifestations and behaviors that can include cross-dressing, cross-living, a plethora other creative expressions, or complete transitioning that physically confirms the congruent genuine sex identity.

The achievement of homeostasis in such a basic, cornerstone reality of sex identity is very empowering. The relief in resolving the intensive and painful internal struggle brings an emotionally moving fulfillment that is described in many ways, such as, ‘for the first time in my life I felt a peaceful feeling inside,’ or ‘I felt a reduction of tension,’ or ‘at last I felt a comfortable feeling inside myself,’ and so on. There is a sense of euphoria, as occurs whenever anyone achieves an incredibly difficult goal. In the study by Dr. Reiner et al with intersexed infants described earlier, a discussion of Kayla, age seven, who had been born without a penis and was subsequently surgically made into a female, is a powerful example:

[After thorough evaluation, Dr. Reiner met with the parents. When he met with Kayla to tell him that “she” was in reality a boy], “his eyes opened as wide as eyes could open,” recalls Dr. Reiner. “He climbed into my lap and wrapped his arms around me and stayed like that.” As Dr. Reiner cradled the child in his arms, he felt as though an enormous weight had been lifted, and he himself was overcome with emotion. The child remained in his arms without moving for half an hour.” (Johns Hopkins Hospital Magazine, September, 2000).

Those who were born with a congruent brain sex identity and genital sex identity have a difficult time understanding what it is like to realize, at last, what one’s genuine sex identity really is. To them, all this activity seems foolish and absurd. After all, they always knew their sex identity without having to put forth any effort whatsoever. Yet it is important to understand that although the transgendered person has had an awareness of their genuine sex identity as well, they were wrongly identified at birth and wrongly socialized etc., resulting in an incredibly complex struggle to overcome strong cultural forces to reach the internal validation of their genuine sex identity. It is a very long and difficult journey for the transgendered person to reach “square one.”

External CISD Process

The transgendered person’s joy-filled proclamation in resolving her/his genuine sex identity struggle, is all to often met by a world that most likely will doubt it, and will probably label the transgendered person as psychiatrically disturbed. This is as catastrophic as the wrong sex identity made at birth, and initiates what I call the “external” component of Culturally Induced Stress Disorder”(external CISD).

There are various and seemingly relentless activities carried out by family, friends, and the culture in general that are apparently “designed” to force the transgendered person to conform to the genitally based sex identity assignment, or endure the consequent punishment, including emotional and physical abuse, neglect, exploitation, marginalization, and economic impoverishment. All too often, the punishments are so blatant and cruel that many transgendered people cave in, succumb to a worsened stress disorder, and commit suicide. Estimates are as high as 25% of the transgendered population, who successfully kill themselves.

Those that survive the challenges of internal and external CISD must face continuous instances of discrimination, public humiliation, and cultural marginalization, probably “designed” to force the transgendered person outside the mainstream of culture and into a marginal lifestyle very different from the one they knew before they “came out.”

The actions and reactions of culture often act as a self-fulfilling prophecy. Poverty, brought about by the removal of economic opportunities from the transgendered person, all too often results in a lifestyle of high risk behaviors that place the transgendered person in situations where many serious problems will develop, including stress related problems and health issues. These unfortunate outcomes are then weaved into false cultural myths that look at the status of transgendered persons and judge them as unworthy, even though it was culture that trashed the transgendered persons in the first place!

There is also a shockingly perverse and implicit “approval” in the culture that encourages people to do whatever they wish to do to transgendered people, perhaps as a way to force conformity or to punish them, as an example of what would happen to others who would dare to cross the culture’s rigid binary, genitally focused, sex identity designation lines. Hate crimes are all too frequent. According to statistics, there has been a hate filled murder of a transgendered person every single month since 1990.

The Role of Counseling

The internal stress experienced from having to deal with the sex identity incongruity, and the constant external pressure to conform to a culturally assigned sex identity with rigid gender role expectations, exacerbated by bullying etc., will ultimately result in various maladaptive behaviors by the transgendered person, ranging from acting out, to withdrawal, and everything in between. These behaviors along with various formats of unhappiness, anxiety, or other stress related symptoms inherent in CISD related complaints will often be expressed at intake. Sex identity issues may be verbalized, especially if the person has refused to accept the cultural assignment of sex identity and related gender role expectations.

In some instances there may be other diagnostic conditions concurrent with, but separate from, the presence of CISD, which can make the treatment process more complex. But however the presenting problem is described, the appropriate tasks for the counselor in these cases include: 1. the initial and ongoing careful assessment and history of the person; 2. defining the problems and issues; 3. the management of stress related phenomena; 4. the exploration and confirmation of the genuine sex identity as reflected in the brain, and 5. the understanding and exploration of the current biopsychosocial issues experienced by the person.

Along with the ongoing assessment, diagnostic, and intervention work, there are a number of other roles that the counselor will also need to play including, but not limited to, family counselor, civil rights advocate, and resource mentor.

The fact of transgender is not an issue for employing so called “reparative therapy” strategies that attempt to force the person to accept the roles of the “culturally induced” sex identity assignment. If attempted, these “strategies” will succeed only briefly, most likely as a way for the person to show compliance with the counselor. But over time, the relentless sex identity incongruity struggle will reassert itself. The person will then become aware that s/he has been seriously wounded by the process of “reparative therapy,” and will undoubtedly feel betrayed by the “counselor.” Then, confidence in the “counselor” as well as the process of helping and support will be seriously compromised, if not destroyed. Tragically, this cruel abuse of trust by the “counselor” quite often results in the person stopping counseling altogether and regard the process as useless, thus rejecting a crucial supportive system designed to assist in the successful working through of the many CISD issues related to being transgendered.

The primacy of the brain in determining sex identity cannot be overridden or ignored. It must be respected as the genuine sex identity of the person.

In Conclusion

It is a profound human tragedy that the transgendered person is consistently viewed as the dysphoric one, i.e. the one with the problem. The induction of stress by culture from the very moment of birth, that I call CISD, must be identified as a predominant causative factor in the internal and external suffering of transgendered persons. The stark reality is that the culture itself commits a serious crime against the true and courageous spirit of the transgendered person, who is only trying to correct a tragic mistake of a wrong birth sex identity assignment, and a wrong gender socialization and enculturation. In the final analysis, it is the culture that suffers from dysphoria, and not the transgendered person. It seems to me, then, that the culture must stop the wounding of transgendered persons and reach out to assist them medically, legally, in employment, in the process of public policy making, and by the exercising of acceptance and compassion toward transgendered people by the entire cultural population.

Summary of Stages and Tasks Inherent in Culturally Induced Stress Disorder (CISD)

Stage One: In the Beginning, there was a Catastrophic Mistake

  • Infant given biological sex identity designation by observation of the external genitals. Stereotypical gender specific reactions occur immediately.
  • Birth records are completed including the sex identity designation and the name of the child.

Stage Two: Primary Socialization and Enculturation

  • Family celebration and announcement.
  • Intense Socialization and Enculturation begins immediately.

Stage Three: The “Awakening”*—the sex identity quandary is realized

  • The child awakens to a feeling of being “different” or of not “fitting in” with others. (*I thank Dr. Randi Ettner for this term)

Stage Four: The Internal Struggle to Understand (Internal CISD)

*This stage will take as long as the person needs in order to identify and resolve the sex identity incongruity. For some, it will take several years. For others, several decades. Common elements seen throughout the internal CISD struggle include:

  • Fascination with the opposite sex and gender roles.
  • Cross-dress openly or in secret discreet settings.
  • Continuous struggle with shame, guilt, fear and low self-esteem.
  • The purge/purchase phenomenon.
  • The child begins to struggle with the need to conform to outside expectations versus the need to explore and understand the internal genuine sex identity.
  • The important process of homeostasis.
  • Awareness of the social consequences of the desire to “change” results in suppression of desire, fear, guilt, shame, diminished self-esteem, and feelings of futility.
  • Use of magical thinking and fantasy in daydreaming and play to test out the roles of the internal existential sex identity.
  • As the child interacts with others inside and outside the home, there are often experiences of being a victim of bullying and other types of social wounding by others that exacerbates an already low self esteem.
  • The child decides to:
    • Carry on as the world has assigned her/him to be, OR
    • Demand assistance in sex/gender “change,” OR
    • Act out the inner conflict by:
      • Anti-social behavior,
      • Exhibiting emotional disturbance,
      • Developing addictions to escape the stress,
      • Other (e.g. become withdrawn, chronically depressed, or compliant in a passive aggressive way).
  • Continued relentless internal struggle compels the person to seek:
    • Information, AND/OR
    • Connection with the “community,” AND/OR
    • Psychotherapy, OR
    • An end to the pain through drug/alcohol abuse, drop out marginal lifestyle, acting out behavior, or, tragically through suicide.

Stage Five: The Victory—The conflict is resolved within and homeostasis (balance) is achieved!

  • Eventual resolution of the sex identity incongruity and acceptance of one’s genuine sex identity brings profound peace and euphoric happiness.

Stage Six: “Coming Out”—The formal Courageous fear-filled Step and the experience of External CISD

*Extremely stressful, because the primary internalized socialization and enculturation that transgendered people have integrated like everyone else, placed a strong prohibition on “sex change.” Yet, the fear of punishment is overruled by the power of homeostasis, which relentlessly compels the transgendered person to be their genuine self.

  • Who must know:
    • Telling family.
    • Telling friends.
    • Telling the employer and employees.
    • Telling others that need to know.
  • Dealing with the reactions:
    • Acceptance/celebration! (it does happen!) OR
    • At first OK! Then………
      • They have “problem with it,”
      • Avoidance by others,
      • Rejection and discrimination,
      • Physical harm (including outright murder),
      • Treating the person as if invisible,
      • Secretly held negative myths about the transgendered person.

Stage Seven: Living with CISD—Making a Life

  • Adjusting to other people’s reactions,
  • Overcoming the stress of cultural isolation and marginalization,
  • Networking within the transgender community, OR
  • Finding a new life in as normal a way as possible apart from the “community,” OR
  • Becoming an advocate/activist,
  • Finding a normal competency and routine in the true self sex/gender role, whether living full or part time in that sex/gender,
  • Dating and mating (what is your orientation?),
  • Setting goals and making a contribution or legacy for others,
  • Adjusting to life developmental stages, including aging gracefully,
  • Dealing with illnesses,
  • Planning one’s end of life care and burial,
  • Other

©Copyright 2001 by Lisa M. Hartley. All rights reserved.

Referenced Bibliography

Zhou, J.-N., Hofman, M.A., Gooren, L.J., and Swaab, D.F., A Sex Difference in the Human Brain and it’s Relation to Transsexuality, Nature Magazine, #378: pp. 68-70, November 1995.

Kruijver, Frank P.M., Zhou, J.-N., Pool, Chris W., Hofman, Michel A., Gooren, Louis J.G., and Swaab, Dick, Male to Female Transsexuals Have Female Neuron Numbers in a Limbic Nucleus, The Journal of Clinical Endocrinology and Metabolism, Vol. 85, No 5, pp. 2034-2041, 2000.

Hendricks, Melissa, Into the Hands of Babes, Johns Hopkins Magazine, September 2000.

Chung, Wilson C.J, DeVries, Geert J., and Swaab, Dick F., Sexual Differentiation of the Bed Nucleus of the Stria Terminalis in Humans May Extend into Adulthood, The Journal of Neuroscience, February 1, 2002, 22(3): 1027-1033.

Cannon, Walter B. The Wisdom of the Body, Second Edition. WW Norton, New York, 1939.

Wilchins, Riki Anne, et al, First National Survey of Transgender Violence. April 1997, GenderPac, 332 Bleecker Street, #K-86, New York, NY 10014-2980.

Ettner, Randi. Confessions of a Gender Defender: A Psychologists Reflections on Life Among the Transgendered. Chicago, Spectrum Press, 1996.

Additional Recommended Bibliography

Colapinto, John. As Nature Made Him: The Boy Who was Raised as a Girl. HarperCollins publishing, 2000.

The Harry Benjamin International Gender Dysphoria Association, Inc. Standards of Care for Gender Identity Disorders, Sixth Version. February 2001.

Moir, Ann and Jessel, David, Brain Sex: The Real Difference Between Men and Women. New York, Dell Publishing, 1991.

Ettner, Randi. Gender Loving Care: A Guide to Counseling Gender Variant Clients. New York, WW Norton & Company, 1999.

Bockting, W. and Coleman, E. editors. Gender Dysphoria: Interdisciplinary Approaches in Clinical Management. New York, Haworth Press, 1993.

Denny, D. Gender Dysphoria: A Guide to Research. New York, Garland Publishing, 1994.

Walworth, Janice. Transsexual Workers: An Employer’s Guide. Center for Gender Sanity, P.O. Box 10616, Westchester, California, 97296-0616, 1998.

Feinberg, Leslie. Transgender Warriors. Boston, Beacon Press, 1996.

Bornstein, Kate. Gender Outlaw: On Men, Women and the Rest of Us. New York, Vintage Books, 1994.

Bornstein, Kate. My Gender Workbook. New York, Routledge Press, 1998.

Boenke, Mary. Our Trans Children. Washington, DC, PFLAG, 1998 (Booklet).

Boenke, Mary. Transforming Our Families: Real Stories About Transgendered Loved Ones. Imperial Beach, California, Walter Trook Publishing, 1999.

Stuart, Kim Elizabeth. The Uninvited Dilemma. Metamorphous Press, P.O. Box 10616, Portland, Oregon, 97296-0616, 1991.

Benjamin, Harry. The Transsexual Phenomenon. New York, Julian Press, 1966. Last reprinted in 1989 by the Outreach Institute and Renaissance. Can also be reviewed on the internet in the International Journal of Transgenderism, electronic books published by Symposion.

Sullivan, Louis. From Female to Male, The Life of Jack Bee Garland. Alyson Publications, Inc. 1990.

Brown, Mildred and Rounsley, Cloe Ann. True Selves: Understanding Transsexualism. San Francisco, Jossey-Bass Publishers, 1996.

Kirk, Sheila and Martine Aliana Rothblatt. Medical, Legal and Workplace Issues for the Transsexual. Together Lifeworks, P.O. Box 93, Watertown, MA, 02272-0093, 1995.

Devor, Holly. FTM: Female to Male Transsexuals in Society. Indiana University Press, 1997.

Evelyn, Just. “Mom I Need To Be A Girl” Imperial Beach, California, Walter Trook Publishing, 1998.

Bohjalian, Chris. Trans-Sister Radio, (A novel) New York, Harmony Books, 2000.

Morris, Jan. Conundrum. New York, Henry Holt and Company, 1987.

Cossey, Caroline. My Story. Boston, Faber and Faber, 1991.


Lisa M. Hartley, ACSW-DCSW is a Master’s level Clinical Social Worker with thirty years post Masters experience that includes clinical, supervisory, administrative and educational arenas. She began active transitioning from male to female in 1994, and completed her real life test in 1996-97. She underwent her confirmation surgery by Dr. Yvonne Menard in Montreal, Quebec, Canada on August 18, 1997. She has lectured to thousands of people about the transgender experience, including the sharing of her own story.