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Jul
27

The Holistic Nurse: Gender Transitions

I am so excited to introduce you today to Reid Vanderburgh, LMFT, a retired marriage and family therapist who has a wealth of knowledge about supporting and caring for transgender clients. For me a HUGE part of holistic nursing practice is respecting where each of our clients/patients comes from, as well as acquiring knowledge that allows us to provide care with sensitivity and awareness. I have had the privilege of seeing Reid speak in the past and it is so exciting to have him post here – you can read more at his website: www.transtherapist.com.

Keep an eye out for more from Reid in the future – this is hopefully just the beginning! :-)

Many people have heard the acronym “LGBT” these days, usually used in the context of “the lesbian/gay/bisexual/transgender community.” However, when put like this, it becomes all the more confusing for folks to try to understand the various components of the acronym. This confusion is natural; using the phrase “LGBT community” implies a commonality among the identities that doesn’t exist. The topic of this article is the “T” component, its points of intersection and difference from “LGB.”

“L,” “G”, and “B” describe forms of sexual orientation – lesbian, gay, and bisexual.  The questions involved in considering sexual orientation are: “What kinds of people do I fall in love with? What kinds of relationships fulfill me most fully?” The “T” label is more deeply personal, about a person’s relationship to themselves. The questions under consideration involve gender identity: “When I look in the mirror in the morning and see a man or woman reflected back at me, does that work for me? Does what I see reflected fit my sense of identity in terms of gender?” The questions aren’t the same as those related to sexual orientation, because the type of identity in question is different.

I’ll use two hypothetical examples to illustrate how differently these two forms of identity play out in people’s lives. Let’s say Joe is a 44-year-old man, living in a medium-sized city. Joe has been married for 18 years, fairly happily, though always with a sense of duty and obligation driving his actions. He loves his wife, but much of his life has been driven by a desire to live up to other people’s expectations. This hasn’t bothered Joe much, as he sees this as part of the man’s role – support others, without undertaking the introspective process of looking at his own feelings. One day, however, a new couple moves into the house next door, and it isn’t long before Joe is experiencing a depth of emotion foreign to him. Eventually, his feelings overwhelm him and even the non-introspective Joe is forced to realize, “My God, I’m in love. I love my wife, but now I realize I never really knew what it meant to be in love. Now what???” Problem is – the object of his affection isn’t the woman next door, but her husband.

This is the path of a man who has realized midlife that he’s really gay and not the straight man he always thought he was. Joe is faced with a crossroad decision, now that he has this new level of self-awareness. Some men in this situation come out and completely alter their lives to live in integrity with their gay identity; others acknowledge the truth of their identity to themselves, while at the same time choosing to preserve the family they have already created. The path Joe chooses isn’t the focus of this article, however, so let’s leave Joe to come to his own decision.

Here’s another hypothetical example. Let’s say Steven is a 44-year-old man, living in a medium-sized city. Steven has been married for 18 years, to a woman he describes as his soul-mate. Steven and his wife Louise live a traditional life. Steven was in the military and learned the construction trade during his tour of duty. He is now a general contractor. They have three children, and Louise is a stay-at-home mom, by choice. While a number of their friends are divorced, or have had rocky marriages, Louise and Steven have always been admired as having the most stable and loving of marriages.

However, Steven has always had what he considers a secret demon inside him – since he was a small child, he has always yearned to be a girl.  All his efforts over the years to live up to the male role (joining the military, becoming a construction worker, getting married) never quite exorcised this demon. As the last of his kids approached college age, Steven increasingly faced thoughts such as, “When will it be my turn? How many more birthdays will I have to face as a man?” The last straw was the thought out of the blue, “If I don’t do something about this, I’m going to die a man.” It was this intolerable thought that made him despairingly suicidal, and scared him into talking to Louise about his feelings, for the first time.

The differences between Joe’s and Steven’s journey become apparent as one considers the ramifications of the choices each of them face. For Joe, living in integrity with a gay identity might mean changing the nature of his relationship with his wife to one of good friends, and finding a life companion in keeping with his sexual orientation. For Steven, living in integrity with “his” true gender identity would mean becoming Stephanie and using female pronouns. Louise might be able to wrap her mind around being seen as a lesbian, or not – Louise will have her own transition journey to undertake, to see Steven as a woman, whether or not they remain together.

Another difference involves the public nature of the transition process. While Joe might choose to be private about his gay identity at work, perhaps fearing for his livelihood and feeling an obligation to continue to support his family, Steven will not have the luxury of privacy if Stephanie emerges to live full-time as her true self, a process known as transition. Transition cannot be undertaken in the closet.

Another fundamental difference between the GLB and T identities lies in the involvement of the medical profession. If Joe acts on his gay identity, he may or may not disclose that fact to his doctor. However, most people who transition do so in part by changing their gender role/expression to match their internal sense of identity, but also by changing the hormone balance in their bodies. Legal access to hormones requires a doctor’s prescription, tying transition to the medical system.

While it would seem that surgical alterations are the primary tie between transition and the medical system, each surgery is a one-time process[1]. Hormones, however, are a lifelong process. Most who transition describe the experience of changing their hormone balance as one of achieving a sense of internal alignment and peace of mind never experienced with what felt like the “wrong” hormone dominant in their bodies. Thus, even after reaching a point of invisibility in their new gender role, few who transition stop taking hormones, unless forced to do so for medical reasons. They have no desire to revert to their old hormone balance.

Another profound difference is the journey family members undertake. Joe is still a brother to his siblings, a son to his parents. In transitioning, Stephanie is asking her siblings to see her as a sister rather than a brother, and her parents to see her as a daughter rather than a son. In English, only “cousin” is a gender-neutral family label; all other labels are gendered, with archetypal-level roles associated with each label. No one views “grandfather” as being exactly the same as “grandmother,” for instance.

Given the differences in type of identity and the processes involved, the question arises, “Why does the acronym ‘GLBT’ exist?” That’s fodder for a future article. This article is intended to provide a brief introduction to the process of transition. In future writings on this site, I will explore the GLBT acronym, as well as how various medical systems can best support people who transition.

Reid Vanderburgh, LMFT, is a retired marriage and family therapist whose practice focused primarily on working with transgender clients. Reid now works as a consultant, trainer and writer, still focusing on issues pertinent to transgender individuals. He is the author of “Transition and Beyond: Observations on Gender Identity,” now available in its second edition. 


[1] There are multiple surgeries possible for Stephanie, from genital-altering surgery to facial feminization surgery. The determining factors are (a) money (insurance usually does not cover surgeries undertaken for the purpose of transition), and (b) Stephanie’s transition goals.

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