Is “Reparative” Therapy Ethical? by Laura Acevedo A Paper Presented to Dr. Herman for Partial Fulfillment of the Requirements For the Course Psychology 604, Fall Semester, 2005 University of Hawaii - Hilo December 2, 2005

Introduction        When a client’s same-sex attraction does not agree with his or her religious convictions, counselors face an ethical dilemma.  Douglas Haldeman states the problem succinctly: "The major mainstream mental health organizations have all issued policy statements affirming that homosexuality is not a mental disorder and disavowing treatments based upon this premise. Diversity in religious expression is also supported by organized mental health. So what of the individual whose religious beliefs are at odds with an LGBT orientation? Should practitioners always view such individuals as having simply internalized homophobic doctrine and therefore limit access to the treatment that may facilitate an adaptation to a more ego-syntonic style of living on the basis of religious beliefs? How are the rights to treatment of such individuals supported without negating the gay-affirmative stance of organized mental health and endorsing homophobic treatments?" (Haldeman, 2002, p260)                Advocates of “reparative” therapy believe they have the answer.  According to Spitzer (2003), “..."reparative” or “conversion” (the terms are used interchangeably) therapists believe that same-sex attractions reflect a developmental disorder and can be significantly diminished through development of stronger and more confident gender identification. “Reparative” therapists say that their gay male patients (who comprise the majority of their caseload) suffer from a lifelong feeling of “being on the outside” of male activities and “not feeling like one of the guys.”  When therapy succeeds in demystifying males and maleness, they claim, romantic and erotic attractions to men diminish and opposite-sex attractions may gradually develop.   Background        Medical, psychotherapeutic, and religious practitioners have long sought to reverse unwanted homosexual orientation through various methods, including electric shock, nausea-inducing drugs, psychoanalytic therapy, prayer and spiritual interventions, hormone therapy, surgery, masturbatory reconditioning, rest, visits to prostitutes, and bicycle riding (Murphy, 1992). Early attempts to reverse sexual orientation were founded on the unquestioned assumption that homosexuality is an unwanted, unhealthy condition  (Socarides, 1978).        Behavioral programs designed to reverse homosexual orientation were based on the premise that homoerotic impulses arise from faulty learning (Haldeman, 1994). These “therapies” sought to countercondition the “learned” homoerotic response with aversive stimuli, replacing it with the reinforced, desired heteroerotic response. The aversive stimulus, typically consisting of electric shock or convulsion- or nausea-inducing drugs, was administered during presentation of same-sex erotic visual material. The cessation of the aversive stimulus was accompanied by the presentation of heteroerotic visual material, supposedly to replace homoeroticism in the sexual response hierarchy.        The psychoanalytic approach has been that homosexual orientation represents an arrest in normal psychosexual development, most often in the context of a particular dysfunctional family constellation (Bieber, I., Dain, Dince, Drellich, Grand, Gundlach, Kremer, Rifkin, Wilbur, & Bieber, T., 1962). According to this view, such a family featured a close-binding mother and an absent or distant father. Despite the relative renown of this theory, it is based solely on clinical speculation and has not been empirically validated (Haldeman, 1994).        Psychoanalytic treatment of homosexuality has been exemplified by the work of Bieber, who advocates intensive, long-term therapy aimed at resolving the unconscious anxiety stemming from childhood conflicts that supposedly cause homosexuality (Bieber et al. 1962), and Socarides, another psychoanalyst who, it is well-known, always disagreed with the decision to remove homosexuality from the DSM (Socarides, Kaufman, Nicolosi, Santinover, & Fitzgibbons, 1997). Bieber and Socarides see homosexuality as always pathological and incompatible with a happy life.        Fundamentalist Christian groups, such as Homosexuals Anonymous, Metanoia Ministries, Love In Action, Exodus International, and EXIT of Melodyland (also known as “ex-gay”  ministries) are the most visible purveyors of “conversion” therapy. Their workings are well documented by Blair (1982), who states that, although many of these practitioners publicly promise change, they privately acknowledge that celibacy is the realistic goal to which gay men and lesbians must aspire.        Most groups across the various Christian ministry programs view homosexuality as learned behavior, suggesting environmental, psychological, and spiritual components (Yarhouse, Burkett, & Kreeft, 2002). Although there is no one clear statement concerning the etiology of homosexuality for all persons, Exodus literature, for example, points towards various emotional hurts and deficits as playing a prominent role in the etiology of same- sex attraction. Although these deficits are not specified, they suggest that homosexuality is more of a psychological and spiritual issue shaped in many ways by one's environment rather than caused by one's genes or other predominantly biological variables.          The Homosexuals Anonymous (HA) literature also dismisses the biological hypotheses for the etiology of homosexuality (Yarhouse, et. al., 2002). Emphasis is placed on homosexuality being a learned preference that can be traced to three primary causes: spiritual, intra-psychic, and relational. The intrapsychic and relational factors are discussed in the HA literature and reference is made to the work of Bieber et al. (1962), and Socarides (1978). From HA's perspective, same-sex attraction can occur when attachment to the parent of the same sex is not achieved. Homosexual identification, according to the HA literature, is an attempt to meet legitimate developmental needs for same-sex intimacy.        Another program that is loosely based on the psychoanalytic formulation has been developed by Joseph Nicolosi (2000) for those he calls “non-gay” homosexuals, individuals who report being uncomfortable with their same-sex orientation.  He too believes that homosexuality is a reaction to a defect in the masculine self. Nicolosi's clinical experience is based on patients who are frequently devout Christians and who seek to change their sexual orientation either for religious reasons or because they disapprove of a  “gay life-style”.  Like the orthodox psychoanalysts of the 1950s and 1960s, Nicolosi uses clinical samples to make generalizations about all homosexual people.   “Nature made man complementary to woman, and to cling to the sameness of one's own sex is to look at the world with one eye,” he writes in his book Reparative Therapy of Male Homosexuality,  “I do not believe that the gay life-style can ever be healthy, nor that the homosexual identity can ever be completely ego-syntonic [and] I do not believe that any man can ever be truly at peace in living out a homosexual orientation.” (Nicolosi, 1991, p13)        As a result of political activism and accumulating empirical evidence that failed to link homosexuality with emotional disorder, in 1973 the American Psychiatric Association voted to remove homosexuality from the psychiatric nomenclature (Garnets & D’Augelli, 1994). Not until more than ten years later, in 1987, was the remaining reference to sexual orientation, ego-dystonic homosexuality (homosexuality which causes personal distress), eliminated from the diagnostic manual. Following the decision of the American Psychiatric Association, the American Psychological Association in 1975 adopted a resolution which states, in part, that “Homosexuality per se implies no impairment in judgment, reliability or general social and vocational capabilities.” In addition, APA urged psychologists “to take the lead in removing the stigma of mental illness that has long been associated with homosexual orientations” (Conger, 1975). Another landmark event occurred in 1976, when the president of the Association for the Advancement of Behavior Therapy urged that efforts to modify sexual orientation be terminated, arguing that they were ethically suspect (Davison, 1976). This effectively truncated the long-standing interest of most mental health professionals in “conversion” therapy (Garnets & D’Augelli, 1994).        To date all major North American mental-health associations have declared that homosexuality is not a mental illness, issuing resolutions, policy statements, and revised ethical codes to this effect (Spitzer 2003). Despite these mainstream moves, there has been "a discernable 'movement' of clinical dissenters" since the early 1990s (Zucker, 2003, p399). These dissenters founded the U.S. National Association for Research and Therapy of Homosexuality (NARTH) in 1992 (Zucker, 2003). NARTH describes itself as "a nonprofit, educational organization dedicated to affirming a complementary, male-female model of gender and sexuality". Its aim is to advance the conservative intellectual, political, and ideological position that clients who want to change their homosexual orientation should have their wish respected and treated. NARTH claims about 1,000 members who are either orthodox psychiatrists or associated colleagues from other professions. While this number is very small (Spitzer 2003), they are well organized with exceptional communications networks (Grace 2005). Many of these practitioners still adhere to the officially debunked “illness” model of homosexuality, and many base their treatments on religious proscriptions against homosexual behavior. Still others defend sexual reorientation therapy as a matter of free choice for the unhappy client, claiming that their treatments do not imply a negative judgment on homosexuality per se. They seek to provide what they describe as a treatment alternative for men and women whose homosexuality is somehow incongruent with their values, life goals, or psychological structures (Haldeman, 1994).        NARTH members have argued on the op-ed page of The Wall Street Journal that individuals unhappy about their homosexual feelings should have the right to seek treatment for change (Socarides, Kaufman, Nicolosi, Satinover, & Fitzgibbons, 1997). Their claims of supporting homosexual civil rights notwithstanding, sexual “conversion” therapists filed affidavits in support of Colorado's antigay Amendment Two (Socarides, 1993). They also supported unsuccessful defenses of sodomy laws in Tennessee in 1995 and Louisiana in 1998 (Cohen, 1998). Why do these therapists want to criminalize homosexuality, even though they believe it to be an illness? NARTH's president (Nicolosi, 2000) has said, “We believe harm would be done if our laws were to affirm homosexuality as indistinguishable from heterosexuality”.        Not surprisingly, the discourse between NARTH and its critics has been extremely heated. The rhetoric about “reparative” therapy has far exceeded any empirical evidence about its efficacy, or lack thereof, and has largely focused on ethics and sexual politics (Zucker 2003).  In an attempt to provide such empirical evidence, Robert L. Spitzer authored a controversial study that he presented at the 2001 APA conference, in which he reported finding 200 successful “reparative” therapy cases.  This study was hailed by proponents as important new empirical information and criticized by opponents as seriously methodologically flawed.        It is important to keep in mind, when reviewing Spitzer’s data, that in 1973, it was Spitzer's suggestion that the DSM-II (American Psychiatric Association, 1968) replace homosexuality with a new diagnosis, sexual orientation disturbance (SOD) (Drescher, 2003). According to SOD criteria, only those “bothered by,” “in conflict with,” or who “wished to change” their homosexuality had a mental disorder. SOD, however, had two conceptual problems. First, the diagnosis could apply to heterosexuals, although there were no reported cases of unhappy heterosexuals seeking psychiatric treatment to become gay. In 1980, with Spitzer chairing the Task Force on Nomenclature and Statistics, SOD was modified in the DSM-III and replaced by ego-dystonic homosexuality (EDH) (Drescher, 2003). This new diagnosis, however, did not resolve the second, thornier issue of making patients' subjective distress about homosexuality the determining factor in making a diagnosis. Although SOD and EDH were a compromise in the 1973 debate, they were incongruous with an evidence-based approach to psychiatric diagnosis. In 1987, with Spitzer's reluctant approval, EDH was removed from the DSM-III-R (Drescher, 2003). Jack Drescher observes: "If Spitzer did not previously believe in the possibility of changing homosexuality, why did he invent the DSM disorders of SOD and EDH? In 1984, I heard Spitzer speak at a New York conference on homosexuality where he defended the still-extant EDH diagnosis, saying "If a guy comes to me and says he wants to change his homosexuality, I believe he should have the right to try and change." Thus, despite what the “conversion” therapy publicists would have the media and the public believe, it seems unlikely that Spitzer himself has undergone the conversion he now claims. Clearly, he has always supported trying to change same-sex attractions."   (Drescher, 2003, p449) Does It Work?                In the aforementioned study, Spitzer claimed that: "Some gay men and lesbians, following reparative therapy, report that they have made major changes from a predominantly homosexual orientation to a predominantly heterosexual orientation. The changes following “reparative” therapy were not limited to sexual behavior and sexual orientation self-identity. The changes encompassed sexual attraction, arousal, fantasy, yearning, and being bothered by homosexual feelings. The changes encompassed the core aspects of sexual orientation. Even participants who only made a limited change nevertheless regarded the therapy as extremely beneficial. Participants reported benefit from nonsexual changes, such as decreased depression, a greater sense of masculinity in males, and femininity in females, and developing intimate nonsexual relations with members of the same sex." (Spitzer, 2003, p 446).        Kenneth Cohen and Ritch Savin-Williams have serious concerns about Spitzer’s methodology however.  They ask: "Who were Spitzer's subjects and how could this collective effect the internal and external validity of his findings? In terms of venue, volunteers were recruited through "repeated" notices to ex-gay religious ministries, therapies, and political organizations that promote biasing conditions. Subjects were clearly not blind to the study's hypothesis or purpose and most, if not all, had compelling motivations to provide data that would prove the hypothesis correct. Indeed, subjects could not participate in the study unless their perceived experience supported the study's hypothesis. Thus, subjects had a strong desire to change (including 19% who were directors of ex-gay ministries or mental health professionals), strong desire to witness to others (e.g., 78% publicly spoke in favor of efforts to change homosexual orientation, often at church functions), strong desire to affirm their religiosity (93% reported that religion was "very" or "extremely" important to them), and strong desire to believe that their own “conversion” was successful. These biasing conditions are not conducive or even normative to scientific investigations. The intent to eliminate or at least reduce social desirability as a potentially damaging influence on the veracity of results is standard fare for scientific research and yet it appears that Spitzer did everything within his power to promote if not ensure his intended responses. Thus, it is exceedingly difficult to take at face value the independence of the study's data." (Cohen & Savin-Williams, 2003, p420)        Contrary to Spitzer’s findings are the reports of those who have been involved and are less impressed.  Founders of an aforementioned ex-gay ministry, Exodus International, have denounced their “conversion” therapy procedures as ineffective. Michael Busse and Gary Cooper, co-founders of Exodus and lovers for 13 years, were involved with the organization from 1976 to 1979. The program was described by these men as “ineffective … not one person was healed” (Newsbriefs, 1990, p. 43). They stated that the program often exacerbated already prominent feelings of guilt and personal failure among the counselees; many were driven to suicidal thoughts as a result of the failed “reparative” therapy (Haldeman, 1994).   Michael Johnston of Kerusso Ministries, an "ex-gay" who was portrayed in one of the religious Right's full-page ads in the Wall Street Journal, has dismissed many of the claims for “reparative” therapy made by others in the ex-gay movement, arguing that real change is not a matter of rational thought or rational discussion but of divine intervention. In an interview in The Village Voice, (Schoofs, 1998) Johnston stated, “I don't believe men and women can go into therapy and come out the other end heterosexual.” In response to the argument that ex-gays are simply repressing their homosexual orientation, Johnston has forthrightly replied, “There is a kernel of truth in what they say, that those of us who have chosen to follow Christ are repressing. ... What comes naturally to us is not righteousness, it is sin” (Pietrzyk, 2000).        Spitzer’s unsuccessful attempt to provide empirical evidence points out the challenge one faces in assessing these therapies.  That is, studies to date appear to be biased and based on self-report. This author’s search of the literature for sound research supporting or refuting “reparative” therapy claims was fruitless.   Ethical Arguments        Christopher H Rosik (2003) believes that “reparative” therapies are an ethical option for clients struggling with differences between their religious convictions and their sexual orientation.  It is his position that if clients are provided with informed consent in a noncoercive environment, some individuals with homoerotic attraction will want to pursue change-oriented therapy.   Because many of these clients are motivated to attempt change as a result of deeply held religious convictions, allowing them to pursue such therapy, he argues, respects religious diversity.  Others have countered, however, that it constitutes a cure for a condition that has been judged not to be an illness.        As noted earlier, the American Psychiatric Association's 1973 decision to remove homosexuality from its Diagnostic and Statistical Manual of Mental Disorders marked the official passing of the illness model of homosexuality (Haldeman, 1994). The American Psychological Association (APA) followed suit with a resolution affirming this anti-illness perspective, stating, in part, “… the APA urges all mental health professionals to take the lead in removing the stigma of mental illness that has long been associated with homosexual orientations” (APA, 1975). Homosexuality was replaced with the confusing “ego-dystonic homosexuality” diagnosis, which was dropped altogether in 1987. Proponents of “conversion” therapy continue to insist, in the absence of any evidence, that homosexuality is pathological. This model was rejected because of a lack of such evidence (Haldeman, 1994).        Another ethical concern is that “reparative” therapy promotes homophobia, which is bad for clients and society: it reinforces a prejudicial and unjustified devaluation of homosexuality.   Herek explains that: "Homophobia is defined as the irrational fear of people and things related to lesbians and gay men (Weinberg, 1972).   There are two kinds of homophobia, externalized and internalized. Externalized homophobia comes from the heterosexual community who dislike or fear homosexuals. Conversely, internalized homophobia comes from within the lesbian or gay man. From an early age, most lesbians and gay men internalize society's ideology of sex and gender roles. As a result of these ideal expectations, they usually experience a certain degree of negative feelings about themselves when they are aware of their same sex attractions. (Herek, 1996, p101)        Davison (1976, 1978, 1991) has detailed many of the ethical objections to “conversion” therapies. A behavior therapist once well known for his program to change sexual orientation, Davison believes that a disservice is done to the gay or lesbian individual by offering sexual orientation change as a therapeutic option. In Davison's view, “conversion” therapy reinforces antigay prejudice. He asks, “…how can therapists honestly speak of nonprejudice when they participate in therapy regimens that by their very existence—and regardless of their efficacy—would seem to condone the current societal prejudice and perhaps also impede social change?” (Davison, 1991, p. 141), and Murphy adds: "There would be no reorientation techniques where there was no interpretation that homoeroticism is an inferior state, an interpretation that in many ways continues to be medically defined, criminally enforced, socially sanctioned, and religiously justified. And it is in this moral interpretation, more than in the reigning medical theory of the day, that all programs of sexual reorientation have their common origins and justifications." (Murphy, 1992, p. 520)        Others are concerned that it is based on an outdated and biased theoretical foundation.  Yeoman (1999) points out that, to Nicolosi and his followers, gay male sexuality derives from a poor relationship between a boy and his father. If a father isn't a strong influence on the family, and if he doesn't provide emotional support and physical affection, they say, then the child won't learn to identify with adult men. As he grows older, the boy will start looking for the maleness he never acquired, and his search will take on sexual overtones.  "People are gendered. We are naturally gendered into male and female. So the male homosexual is trying to find his unfulfilled masculinity," Nicolosi declares. "His homosexual attractions are a symptom of his desire to find his masculine identification and same-sex emotional needs." (Nicolosi, 1991, p110)        Critics consider this a deeply flawed argument. Andrew Sullivan, former editor of The New Republic and a gay man, notes that if distant fathers were the cause, “…then most of the generations born between 1930 and 1980 would be homosexual. There might also, perhaps, be a startling rise in homosexuality among African-Americans in the last 20 years, when absent fathers have become the norm, rather than the exception” (Yeoman, 1999, p26).        Nicolosi's understanding of gay people is severely compromised by his personal negative belief system about homosexuality. For example, he stated that: "The inherent unsuitability of same-sex relationships is seen in the form of fault-finding, irritability, feeling smothered; power struggles, possessiveness, and dominance; boredom, disillusionment, emotional withdrawal, and unfaithfulness. Although he desires men, the homosexual is afraid of them. As a result of this binding ambivalence, his same-sex relationships lack authentic intimacy. Gay couplings are characteristically brief and very volatile, with much fighting, arguing, making-up again, and continual disappointments." (Nicolosi, 1991, p110)        But Friedman (1997) insists that there is no scientific evidence this depiction of gay relationships is valid. His 25 years of clinical experience with individuals and couples has impressed him with the similarities between heterosexual partnerships and those between men. “Such differences as do exist”, he said, “do not provide evidence that homosexual relationships are intrinsically more or less psychologically healthy than heterosexual relationships” (Friedman, 1997, p225).        Some “reparative” therapy methods raise ethical eyebrows as well.  Hicks (2000) cites  electrical shock therapy, chemical aversive therapy, drug and hormone therapy, homophobic counseling, religious propaganda, isolation, unnecessary medication (including  hormone treatment), subliminal therapies designed to inculcate "feminine" or "masculine" behavior, and "covert desensitization" therapies that teach a young person to associate homosexual feelings with disgusting images as a few of the controversial methods employed by “reparative” therapists.        Considering the nature of such methods, it is not surprising that reports of harm have surfaced.  Even ardent supporters such as Yarhouse et. al. (2002) admit that there have been instances of sexual misconduct among some leaders of Christian ministry groups.  Homosexuals Anonymous has been particularly infamous in this regard (Haldeman, 1994).  An investigator attempting to research the efficacy of this program was denied access to counselees on the basis of confidentiality (Lawson, 1987).  Nonetheless, he managed to interview 14 clients, none of whom reported any change in sexual orientation. All but two reported that the founder had had sex with them during treatment.        According to Haldeman, (1994) individuals undergoing “conversion” treatment are not likely to emerge as heterosexually inclined, but they often do become shamed, conflicted, and fearful about their homoerotic feelings. He insists that it is common for gay men and lesbians who have undergone aversion treatments to notice a temporary sharp decline in their sexual responsiveness, with some subjects reporting long-term sexual dysfunction. Similarly, he says, subjects who have undergone failed attempts at “conversion” therapy often report increased guilt, anxiety, and low self-esteem. Some flee into heterosexual marriages that are doomed to problems inevitably involving spouses, and often children as well. Discussion        While both sides argue over the ethics of reparative therapy, issues remain unresolved.  First, there is the problem of empirical evidence.  As has been mentioned earlier, virtually all data available regarding efficacy and possible harm appears to have been gathered from self-report based studies.  There appears to be a need for properly designed and executed experimental research, but so far, social scientists have considered this too expensive or unethical to undertake (Spitzer, 2003).          Second, there is the question of the nature of sexual orientation.  Whether sexual orientation can or should be changed is at the center of this debate.  What is often not mentioned, however, is that the polarized straight/gay view that both supporters and detractors depend on to defend their positions is not universally accepted (Vasey, & Rendall, 2003).   Most notably with the work of Kinsey, Pomeroy, and Martin (1948),   it has become clear that not all individuals can be categorized dichotomously as either gay or straight: hence, the concept of bisexuality (Cornelson, 1998, Stokes, Miller, & Mundhenk, 1998) .        Andre Grace has this to say about  the outdated and exclusionary language used in the discourse surrounding “reparative” therapy: "In my other research I predominantly use the term queer to represent the spectrum of sex, sexual, and gender differences that lie inside and beyond heterosexualizing discourses. However, transformational ministers and “reparative” therapists tend to use just the binary descriptors heterosexual/ homosexual and male/female. When they use gay, it is usually in a pejorative sense, particularly when they talk about the dangers of the so-called gay agenda. They usually ignore bisexuality or dissolve it into gay and lesbian, thus avoiding consideration of the complexities of desire, need, and expression shaping that complex orientation and identity. As well, they evade mentioning transgender identity or transsexual issues in their “conversion” discourse. Thus categories like bisexual, trans-identified, and queer are too expansive and fluid descriptors to portray the narrowly construed sex, sexual, and gender differences taken up in this interrogation." (Grace, 2005, p146)        So if sexual orientation is not a matter of either/or, perhaps the entire debate is out of focus.  Perhaps the focus could be shifted to expanding acceptance of sexual orientation fluidity.  One possible solution to the ethical dilemma of counseling the spiritually and sexually conflicted client may be found in such an accepting stance.  John Bancroft provides the following guidance: "Every now and then, I see someone in my clinic who presents himself (and, more occasionally, herself) as confused or conflicted about sexual identity. Sometimes they are struggling with the idea of bisexuality. "Does bisexuality exist?" they might ask. In some cases, their sexuality is compartmentalized (e.g., "I find certain types of men very sexually arousing, but I can't imagine being in a loving sexual relationship with another man")--what might be described as a failure to incorporate one's sexuality into one's capacity for a close dyadic relationship, a problem by no means confined to those with homosexual orientation. How do I react to such patients after a career of reflection on this issue? I now have no doubts about how to respond and this involves some crucial sequential steps:"        "Step 1. Make it absolutely clear that, whatever the patient's values or beliefs might be, I have no difficulty whatsoever in accepting and valuing either a homosexual or a heterosexual or a bisexual identity. The issue is which is right for that person. In so far as I have personal values, they apply to issues of responsibility and the use of sex to foster intimacy in a close ongoing relationship. Neither is dependent on the gender of those involved. It behooves the therapist to be explicit about her or his moral values as they impact on the treatment process so that the patient can choose whether to work with that therapist or not."        "Step 2. Make it clear that in order to find out what type of sexual relationship works best, it may be necessary to experience more than one type of relationship, involving partners of either gender. Furthermore, during a lifetime, more than one successful relationship may occur, involving same sex and opposite sex partners at different times."        "Step 3. Emphasize the need to take time to work out what is right. The therapist, who is better designated as a counselor in this context, facilitates this process of search and discovery as appropriate. This may involve helping the patient to identify the different "compartments" of his or her sexuality, and how to incorporate them into a sexually rewarding, intimate, and loving relationship. This is more education than therapy." (Bancroft, 2003, p460)   References American Mental Health Counselors Association. (2001). Code of Ethics of the American Mental Health Counselors Association. Journal of Mental Health Counseling, 23, 2-20. American Psychological Association. (1991). Bias in psychotherapy with lesbians and gay men: Final report of the task force on psychotherapy with lesbians and gay men. Washington, DC    Bancroft, J.(2003) Can sexual orientation change? A long-running saga. Archives of Sexual Behavior, Oct v32 i5 p419(50) Bieber, I., Dain, H., Dince, P., Drellich, M., Grand, H., Gundlach, R., Kremer, M., Rifkin, A., Wilbur, C.,  & Bieber, T. (1962).  Homosexuality: A psychoanalytic study.    New York: Basic Books.   Cheng, Z,(2003).  Issues and standards in counseling lesbians and gay men with substance abuse concerns. Journal of Mental Health Counseling, v25 i4 p323(14) Cohen, K., & Savin-Williams, R. (2003) Are converts to be believed? Assessing sexual orientation "conversions", Archives of Sexual Behavior, Oct v32 i5 p419(50) Cornelson, B. (1998) Addressing the sexual health needs of gay and bisexual men in health care settings. The Canadian Journal of Human Sexuality, v7 i3 p261(1) Davison, G. (1976). Homosexuality: The ethical challenge.   Journal of Consulting and Clinical Psychology, 44, 157-162. Davison, G. (1978). Not can but ought: The treatment of homosexuality.   Journal of Consulting and Clinical Psychology, 46, 170-172. Davison, G. (1991). Constructionism and morality in therapy for homosexuality.   In J. Gonsiorek & J. Weinrich (Eds.), Homosexuality: Research implications for public policy (pp. 137–148). 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Journal of Psychology and Theology, Fall  v30 i3 p209(19) Yeoman, B. (1999). Gay no more? (Reorientation programs for homosexuals). Psychology Today, March  v32 i2 p26(1) Zucker, K. (2003) The politics and science of "reparative therapy". (Editorial) Archives of Sexual Behavior, Oct  v32 i5 p399(4)

Narrative Couples Therapy: An Appropriate Modality for Transgender Clients by Laura Acevedo Chapman University, San Diego December 3, 2003

Abstract         Narrative Couples Therapy is a post-modern treatment method that is particularly well suited for couples in which one or both of the partners identifies as transgender.  In this paper I shall define transgender as a social construct, explore the unique issues that this construct creates for couples in our culture, advocate for the use of narrative therapy as a deconstructive method for dealing with those unique issues and explain why specific narrative techniques are particularly appropriate for issues of gender identity.        Transgender, and indeed the concept of personal gender, are constructs created by social scientists and the medical community within the last century.  The modern study of what might be called transgenderism began with Magnus Hirschfeld (1868-1935) and the 1910 publication of his book, The Transvestites: An Investigation of the Erotic Desire to Cross Dress (Bullough, 2000). He argued that although the two sexes had usually been regarded as dimorphic, this was much too simplistic since there were many varieties of intermediates.  This was extremely progressive thinking for the time, and is still not embraced by most in our culture. Hirschfeld developed a model of gender dissonance. He did not see it as separate from sexuality, believing there was a continuum of sexuality, and that transvestism and transsexualism (terms he coined in 1910 and 1923 respectively) were at the extreme end of this continuum, beyond homosexuality (Vanderburgh, 2000).  I concur with Hirschfeld’s construct of a sexuality continuum, however I conceptualize gender identity and sexual orientation as two separate but related continuums.          Another pioneer in investigating the topic was Havelock Ellis, who in his first paper on the subject published in 1913, used the term 'sexo- aesthetic inversion' instead of Hirschfeld's word 'transvestism' (Ellis, 1913).        While Hirschfeld and Ellis were interested in gender variance from a philosophical perspective, those who wrote about the phenomenon after them were for many years dominated by psychotherapists of one kind or another whose mission was to find "cures" or "treatment" for those with gender dysphoria (Bullogh, 2000), which became a diagnosable disorder in the DSM.        The major challenge to the psychiatric domination came from a new generation of social and behavioral scientists who challenged the dominance of the medical community as experts in sexology, and in the process, challenged the medicalization of much of sexual behavior. The key to the challenge was the development of the concept of gender (Bullogh, 2000). Gender is an old term that has been widely used in linguistic discourse to designate whether nouns are masculine, feminine, or neuter. It was, however, not normally used either in the language of social sciences or sexology until John Money adopted the term in 1955 to serve as an umbrella concept to distinguish femininity, or womanliness, and masculinity, or manliness, from biological sex (male or female)(Money, (1955).        This opened the door for a new discourse about the personal expressions of gender.  By 1960, individuals such as Virginia Prince began developing social structures that challenged the dimorphic view of gender (Bullogh, 2000).  Her social group gave the members permission to identify as something other than the medically approved dimorphic male, female or transsexual.  The terms transsexual and transvestite were redefined by Harry Benjamin in 1964 to describe persons suffering from gender dysphoria (transsexuals) as different from persons who dressed in cross-gender clothing without issues of gender identity (transvestites).        The term transgender was coined in the late 1980s by men who did not find the label transvestite adequate enough to describe their desire to live as women (Prosser, 1997) yet felt  the term transsexual was deemed inappropriate because many nontraditionally gender-identified persons did not necessarily want to reconfigure their bodies surgically and hormonally and did not share the desire to "pass," or to fit into normative gender categories of male and female.        Rather than a simple 'opposite sex' identity (most typical of Transsexual individuals), transgender individuals may have non-traditional and complex experiences of gender (Rachlink, 2002). It may be more appropriate to view these complex experiences as a continuum under the umbrella term of transgender.  Raj (2002) has compiled categories for various expressions on this continuum. These specific subpopulations include: transsexuals (TSs), transgenderists, transgendered people (TGs), androgynes, crossdressers, bigendered, 'two-spirit', intersexed and gender- variant (GV) individuals. Vanderburgh (2002) includes genderqueers, drag queens and drag kings. It is important to note that some individuals who do not fit dimorphic gender identities prefer not to be labeled in any way.  It is also important to note that the partners of transgender individuals experience gender very differently than their gender-variant loved ones. Vanderburgh states that: "The trans person grows up with an awareness of gender, and of "difference," that is not the experience of their non-trans partner. The trans person can imagine changing gender roles and bodily sex, because they grow up with the perception of having been that "square peg in the round hole." To the non-trans partner, however, unaware of the pigeonhole, the concept of changing genders is unimaginable, in a very literal sense. The partner cannot imagine changing what they have grown up seeing as a fixed part of reality." (Vanderburgh, 2002)        Being transgender is not in itself pathological or indicative of a need for psychiatric treatment. However, transgender individuals (and their partners) do experience a number of unique stressors and are no different from the rest of the population in their potential to experience emotional problems and other concerns which may lead them to seek psychotherapy (Rachlin, 2002). St.Claire (2002) posits that psychological distress in the transgender person is caused by psychological suppression of gender identity expression motivated by fear of social subjugation. She also cites social subjugation of the transgender person by individuals and institutions. She asserts that social subjugation of persons transgressing gender expression norms often leads to conflict between the instinctive desire to express one's gender identity and the desire to avoid the pain of social subjugation.  Vanderburgh (2000) suggests that this distress may result in isolation, paranoia, difficulty with intimacy, low self-esteem, substance abuse as a form of self-medication, history of suicide attempts, estrangement from family, rejection of spirituality and religion (conservative religions vilify transsexuals, equating them with equally-vilified homosexuals), depression, hopelessness and PTSD (for those who were physically or sexually punished for not acting enough like boys or girls).        Partners of transgender individuals may suffer unique stressors as well. It has been my experience that non-trans partners may face the perceived loss of a lover, and the accompanying grief, especially if they have been in the relationship for some time and the gender transition began after they met.  Imagine if your husband/wife or boyfriend/girlfriend changed so radically that you no longer felt a sense of sexual attraction.   It would be as if he or she had died, and someone else was now in their place.  What does that mean for the relationship? What about your sexual orientation? Vanderburgh explains:        "The ramifications of changing sexual orientation are profound for the partner. One obvious consideration is homophobia. However, it's too easy to say of a heterosexual woman, "She’s against her husband transitioning because she's homophobic and afraid people will see her as a lesbian." If a heterosexual woman has qualms about being identified as a lesbian, one must take into account the legitimate question of whether or not her discomfort is justified. If she truly feels heterosexual and not lesbian or bisexual, why should anyone expect her to be joyful about her husband’s transition to female?" (Vanderburgh, 2002)        What is needed is a therapeutic environment that addresses the unique circumstances of couples with a trans identified partner. Transpositive (i.e., gender-affirming) therapeutic support, as described by Raj (2002) speaks to the client's real-life, everyday needs (whether gender-related or not), in alignment with the client's stated goals, helps clients to consolidate their gender and sexual identities as transwomen and transmen, and enhances self-confidence. He believes that supportive therapeutic interventions which aim to affirm, rather than disaffirm, individual choices around self gender-identification are, by definition, transpositive, and as such, are urged as the treatment of choice over that of non-transpositive interventions (such as 'reparative' and 'conversion' therapies).  Vanderburgh (2000) believes that the clients know best and will make the best decision for themselves with the information available to them at the time. He states that the therapist’s job is to help clients uncover and bring to consciousness as much self-information as possible. Underlying this model is the belief that gender dissonance is not a psychological disorder to begin with, but an issue of core identity. Bocting (1997) asserts that treatment issues no longer center on assisting "gender dysphoric" persons in their adjustment to their new gender but include the possibility of affirming a unique transgender identity (Bockting, 1997). In this paradigm shift, the focus is not on transforming transgendered clients but rather transforming the cultural context in which they live. Bockting (1997) advocates that counselors assume a client-centered approach. Given the societal discrimination that transgendered persons must continually confront, the issue of trust is paramount when working with such clients. For this reason, constructivist therapy approaches are particularly helpful in working with transgendered clients. Laird (1999) advocates that practitioners assume a narrative stance in which clients fully tell their own stories unburdened by the prior assumptions of the therapist about gender and sexuality. She believes that counselors need to create an atmosphere in which the larger cultural narratives concerning heterosexism and gender are deconstructed. Laird recommends adopting an "informed not knowing" stance (Shapiro, 1996) in which the counselor leaves "behind her own cultural biases and pre-understandings, to enter the experience of the other" (Laird, 1999, p. 75). (Carrol, Gilroy & Ryan, 2002)        My personal experience with couple therapy confirms these views.  I also believe that it is critical for a couple to learn how to bear witness to one another, to see and feel to the greatest extent possible the struggle of transition from the other's perspective.  I believe that couples facing the issues of gender transition in our culture need a therapeutic model that is client driven, that deconstructs the dominant transphobic cultural narrative about gender and affirms rather than marginalizes persons of minority status. What is needed is a method that allows for each partner to express their complex and multiple stories so that they may create unique identities and that encourages these stories to be witnessed by one another.  Narrative Couple Therapy is just such a model.        Narrative Couple Therapy is a modality that developed in response to new ways of thinking about peoples’ problems.  In contrast to the “essentialist” view that dominated psychotherapy for decades, Narrative therapists suggest that we “construct” our realities through the stories that we hear and tell about ourselves (White, 2002).        This perspective is based in part upon the writings of Michele Foucoult, a French philosopher who has challenged traditional views of our dominant social structures.  I have excerpted an example of his writing from a symposium presented at the University of California at Berkeley in 1983:        "What I tried to do from the beginning was to analyze the process of "problematization" -which means: how and why certain things (behavior, phenomena, processes) became a problem. Why, for example, certain forms of behavior were characterized and classified as "madness" while other similar forms were completely neglected at a given historical moment; the same thing for crime and delinquency, the same question of problematization for sexuality.  The question I raise is this one: how and why were very different things in the world gathered together, characterized, analyzed, and treated as, for example, "mental illness"? What are the elements which are relevant for a given "problematization"? And even if I won't say that what is characterized as "schizophrenia" corresponds to something real in the world, this has nothing to do with idealism. For I think there is a relation between the thing which is problematized and the process of problematization. The problematization is an "answer" to a concrete situation which is real." (Foucoult, 1983)        Narrative therapists took Foucoult’s deconstruction of the relationship between “problematic” behaviors and the powers of their time and applied the principle to the “problematic” behaviors of their clients.  In other words, they would say that our identity and behavior results from the stories that we have learned about ourselves, stories that we internalize and repeat as if they were “truth” (Morgan, 2000).  Foucoult encourages us to question who is being privileged by these dominant narratives and who is being prejudiced.  He also encourages us to ask if there are non- dominant or minority narratives.        Narrative therapists have developed several techniques to implement the Foucoultian paradigm in a clinical setting.  These include telling and witnessing (Freedman & Coombs), externalizing (Carey & Russel, 2002) (White & Epston, 1990), “unpacking” negative identity conclusions (White 2001),  questioning “thin” descriptions to encourage “rich” descriptions (Morgan, 2000) (White, 2001) and reflecting(White, 1995). Telling one’s story of self and having one’s partner hear it is the cornerstone technique of Narrative Couple Therapy.  Freedman & Coombs describe telling and witnessing as they practice it in their clinical work: "A rhythmic alternation between telling and witnessing characterizes narrative work.  We set up a structure early in our work with couples that we come back to over and over again.  We ask one member of the couple to tell his/her story while the other listens from a witnessing position.  Then we ask the witnesser to reflect on what he/she has heard.  Next we switch positions, so that the partner who had been in the witnessing position can tell his /her story." (Freedman & Coombs, 2002)        I believe that telling and witnessing is a vital step for couples dealing with gender transition.  Even partners who think they know one another well may not be aware of the other’s gender identity story.  As Vanderburgh (2000) has pointed out, trans and non-trans partners have very different life experiences and self concepts of gender.  This could be a source of couple discord that could be addressed by telling and witnessing. Once the pattern of telling and witnessing is established, Narrative therapists encourage clients to view themselves in alternative ways.  Carey & Russel describe externalizing:        "One of the key contributions of narrative therapy is the determination not to locate problems as internal to people, but instead to externalise problems and to understand that the ways in which problems are constructed and experienced are related to matters of culture and history (see Carey & Russell 2002; Epston & White 1990). Externalising conversations involve the identification of problems (separate from persons), locating the problem in history and in a storyline, and tracing the effects of the problem on the person’s life and relationships. Once a problem has been externalised in this way it then becomes possible to identify unique outcomes (times and ways in which a person has resisted the influence of the problem) that can gradually be woven into alternative story-lines." (Carey & Russel, 2002)        Externalizing helps the couple take the burden of discord off of one or both of them as persons and provides the opportunity to view the discord as a project that they can work on together.  Instead of blaming the trans partner for causing the problem, or blaming the non-trans partner for not being accepting enough, the problem can be externalized and named.  Then the couple can be encouraged to recognize how much of their discord is a result of the conflict between the trans partner’s identity and the cultural norms that they both have internalized (Carrol, Gilroy & Ryan, 2002).                This is what White (2002) has called unpacking negative identity conclusions.  He explains this unpacking as follows: "Often when describing and demonstrating the utility of externalising conversations, I have illustrated the extent to which these conversations can contribute to the unpacking of people’s negative identity conclusions – which I often refer to as thin conclusions (after Geertz’s thin description [1973]). In fact, I believe that one of the primary achievements of externalising conversations is this unpacking of the thin conclusions that people have about their own and about each other’s identity. In this activity, these conclusions are deprived of the truth status that has been assigned to them – these conclusions cease to carry the authority that they did." (White, 2002)        What are these thin descriptions in terms of Narrative Couple Therapy? Morgan and White describe thin description as follows: "Thin description allows little space for the complexities and contradictions of life. It allows little space for people to articulate their own particular meanings of their actions and the context within which they occurred.  Often, thin descriptions of people’s actions/identities are created by others – those with the power of definition in particular circumstances (e.g. parents and teachers in the lives of children, health professionals in the lives of those who consult them). But sometimes people come to understand their own actions through thin descriptions. In whatever context thin descriptions are created, they often have significant consequences." (Morgan, 2000)  "Thin description often leads to thin conclusions about people’s identities, and these have many negative effects.  Thin conclusions are often expressed as a truth about the person who is struggling with the problem and their identity. The person with the problem may be understood to be ‘bad’, ‘hopeless’, or ‘a troublemaker’. These thin conclusions, drawn from problem- saturated stories, disempower people as they are regularly based in terms of weaknesses, disabilities, dysfunctions or inadequacies." (White, 2002)        I believe that the traditional medical/psychotherapeutic diagnosis of dimorphic gender dysphoria is a thin description of gender identity that leads to the thin conclusion that gender variant individuals are pathological.  This dominant narrative ignores the rich variety of gender expression that Raj (2002) and Vanderburgh (2002) have identified.  Unpacking the dominant narrative can help the couple develop a richer description of gender identity, which would depathologize the trans identified partner and allow both partners to understand more clearly their unique attributes.   Carey and Russel describe rich description in their practice: "As narrative therapists, we believe that it is the rich description of the alternative stories of people’s lives that provides people with more options for action and therefore enables significant changes to occur. Life is not only about problems and difficulties, or for that matter ‘strengths’. It is also about hopes, dreams, passions, principles, achievements, skills, abilities and more. All of these aspects of our lives are up for exploration and rich description!" (Carey & Russel, 2002)        Once a narrative pattern has been established and unique alternative stories are being developed, Narrative Couple therapists may choose to employ the technique of reflecting.  Reflecting can be done by the witnessing partner, the therapist or a reflecting team of outsiders brought in specifically for that purpose.  White (1995) describes the dynamics of reflecting in the context of a team using Barbara Myerhoff’s (1986) concept of definitional ceremony: "To the extent that the reflecting teamwork that I am describing here establishes ‘conditions that conspire’ to engage people as ‘active participants in their own history’ and in ‘making themselves up’, I believe that Barbara Myerhoff’s ‘definitional ceremony’ provides a particularly appropriate metaphor for this work, and serves to clarify some of the processes involved in it." (White, 1995)        Witnessing and reflecting Definitional ceremonies deal with the problems of invisibility and marginality; they are strategies that provide opportunities for being seen and in one’s own terms, garnering witnesses to one’s worth, vitality and being. (Myerhoff 1986, p.267) Myerhoff calls attention to the critical role that the ‘outsider-witness’ plays in these definitional ceremonies. These outsider witnesses are essential to the processes of the acknowledgement and the authentication of people’s claims about their histories and about their identities, and to the performance of these claims. The participation of the outsider-witnesses in definitional ceremonies gives ‘greater public and factual’ character to these claims, serving to amplify them and to authorise them. The outsider-witness also contributes to a context for reflexive self-consciousness - in which people become more conscious of themselves as they see themselves, and more conscious of their participation in the production of their productions of their lives. The achievement of this reflexive self-consciousness is not insignificant - it establishes a knowing that ‘knowing is a component of their conduct’, making it possible for people to ‘assume responsibility for inventing themselves and yet maintain their sense of authenticity and integrity’, for people to become aware of options for intervening in the shaping of their lives. (White, 1995)        In her book What is Narrative Therapy? Alice Morgan summarizes the overall approach: "Narrative therapy seeks to be a respectful, non- blaming approach to counselling and community work, which centres people as the experts in their own lives. It views problems as separate from people and assumes people have many skills, competencies, beliefs, values, commitments and abilities that will assist them to change their relationship with problems in their lives. Curiosity and a willingness to ask questions to which we genuinely don’t know the answers are important principles of this work. There are many possible directions that any conversation can take (there is no single correct direction). The person consulting the therapist plays a significant part in determining the directions that are taken." (Morgan, 2000)        Further evidence of the appropriateness of Narrative Therapy for members of gender and sexual minority groups can be found in this announcement posted on the Dulwich Centre  Website, May 13, 2002: "We were recently contacted by someone in North America who informed us of the possibility that one or more therapy practitioners may be using narrative therapy techniques with the aim of ‘converting’ gay and lesbian people to heterosexual lives. While there’s been no confirmation of this, the possibility of this occurring has greatly saddened us. There is a long history within the psychological and therapeutic fields of marginalising lesbian, gay, bisexual and transgender people. A part of this history of marginalisation has been, and continues to be, the use of ‘therapeutic approaches’ to attempt to ‘cure’, ‘treat’ or ‘convert’ homosexual desire. Dulwich Centre would like to publicly express that we are deeply troubled by any use of narrative therapy that constructs homosexual desire as in anyway less acceptable than heterosexual desire. We celebrate lesbian, gay, bisexual and transgender choices and lifestyles." (Dulwich Centre, 2002)        Given the above, I would recommend Narrative Couple Therapy for couples struggling with issues of gender identity.  This modality allows couples to deconstruct the social construct of gender that is so problematic for those who don’t conform, so that they may address issues of social subjugation.  It does not apply a medical model to gender variance, but rather depathologizes “variant” persons.  Non-trans partner’s concerns such as issues of sexual orientation and loss of attraction can be voiced, reflected on and honored.  It is more than nonjudgmental, it is affirming of clients' minority stories and expressions.  It can help clients consolidate their gender and sexual identities through the unpacking of negative self identities and the construction of affirming identities.  It is antithetical to “reparative” or “conversion” therapies which aim to “cure” the “perversion” and have been shown to cause harm (Ford, 2001). That is why I incorporate Narrative Couple Therapy into my clinical work. References Benjamin, Harry (1964). "Trans-sexualism and Transvestism," in Transvestism: Men in Female Dress, ed. David Cauldwell New York: Sexology Corporation Bockting, W 0. (1997). Transgender coming out: Implications for the Clinical Management Of Gender Dysphoria. In B. Bullough, V. L. Bullough, & J. Elias (Eds.), Gender Blending (pp. 48-52). Amherst, NY: Prometheus Books. Bullogh, V.L. (2000).  Transgenderism and the Concept of Gender  International Journal of Transgenderism, Volume 4 Number 3, July - September 2000 Carey & Russel, (2002). Externalising – Commonly Asked Questions. International Journal of Narrative Therapy and Community Work, 2002 No.2 Carrol, L., Gilroy, P & Ryan, J. (2002). Counseling Transgendered, Transsexual, and Gender-Variant. Journal of Counseling and Development. Alexandria: Spring 2002. Vol. 80, Ellis, H. (1913). "Sexo-Aesthetic Inversion," Alienist and Neurologist, 34, part 1 (May), 3-14; part 2 (August), 1-31. Freedman, J. & Coombs, C., (2002). Narrative Couple Therapy in Gurman, A & Jacobson, N., eds. Clinical Handbook of Couple Therapy, Third Edition, New York: Guilford Press Ford, (2001). Healing Homosexuals: A Psychologist’s Journey through the Ex-Gay Movement and the Pseudo-Science of Reparative Therapy, Journal of Gay & Lesbian Psychotherapy Vol. 5 No. 3 / 4, 2001, pp 69-86 The Haworth Press, Inc. Foucoult, M. (1983). Discourse and Truth: the Problematization of Parrhesia. six lectures given by Michel Foucault at the University of California at Berkeley, Oct-Nov. 1983 Geertz, C. (1973). ‘Thick Description: Toward an Interpretive Theory of Culture.’ In Geertz, C., The Interpretation of Cultures. New York: Basic Books. Hirschfeld, M. (1991). The Transvestites: An Investigation of the Erotic Drive to Cross Dress.[Die Transvestiten]. Translated by Michael Lombardi-Nash. Buffalo: Prometheus Books. [Originally Leipzig: Spohr, 1910] Laird, J. (1999). Gender and sexuality in lesbian relationships: Feminist and constructionist perspectives. In J. Laird (Ed.), Lesbians and lesbian families: Reflections on theory and practice (pp. 47-89). New York: Columbia University Press.   Myerhoff, B. (1986). ‘Life not death in Venice: Its second life.’ In Turner, V. & Bruner, E. (eds), The Anthropology of  Experience. Chicago: University of Illinois Press.) Money, J. (1955). "Linguistic Resources and Psychodynamic Theory." British Jounal of Medical Psychology 28, 264-6.) Morgan, A. (2000). What Is Narrative Therapy? Adelaide: Dulwich Centre Publications Prosser,J. (1997). Transgender. In A.  Medhurst & S. R. Munt (Eds.), Lesbian And  Gay Studies. A Critical Introduction (pp. 309-326). Hemdon, VA Rachlin K, (2002). Transgender Individuals' Experiences of Psychotherapy. International Journal of Transgenderism 6,1 Raj (2002) Towards a Transpositive Therapeutic Model: Developing Clinical Sensitivity and Cultural Competence in the Effective Support of Transsexual and Transgendered Clients [On-Line], Available:  http://www.symposion.com/ijt/ijtvo06no02_04.htm Shapiro, V (1996). Subjugated knowledge and the working alliance: The narratives of Russian Jewish immigrants. In Session: Psychotherapy in Practice 1, 9-22. St.Claire, R. (2000) How Being a Transgender Person Causes Stress [On Line], Available:  http://www.transgendersoul.com Vanderburgh, R. (2000) Gender Dissonance: A New Paradigm (Masters Thesis) [On Line], Available: http://www.transtherapist.com/writings/thesis.html Vanderburgh, R. (2002) For Partners Only [On Line], Available: http://www.transtherapist.com/writings/forpartnersonly.html White, M. (1995). Reflecting Teamwork as Definitional Ceremony by Michael White, Chapter 7 from: White, M. 1995:  Re-Authoring Lives: Interviews and Essays. Adelaide: Dulwich Centre Publications White, M. (2000). ‘Reflecting-Team Work As Definitional Ceremony Revisited.’ In White, M.: Reflections on Narrative Practice: Essays and Interviews Adelaide: Dulwich Centre Publications White, M. (2001). ‘The Narrative Metaphor In Family Therapy.’ An Interview In Denborough, D. (ed): Family Therapy: Exploring The Field’s Past, Present & Possible Futures. Adelaide: Dulwich Centre Publications White, M. (2001). Narrative practice and the unpacking of identity conclusions   Gecko: A journal of deconstruction and narrative practice 2001 #1. Adelaide: Dulwich Centre Publications White, M. & Epston, D. (1990): Narrative Means to Therapeutic Ends. New York: W.W.Norton.

Cultural and Social Influences on Gender Identity: Deconstructing the Dimorphic Paradigm by Laura Acevedo Chapman University Department of Psychology, San Diego Campus April 9, 2004

Even a limited review of the literature demonstrates an awareness among social scientists and psychologists of the pervasive social and cultural influences on the formation of gender identity.  What appears somewhat absent, however, is an awareness of  the function that these influences serve to inculcate the traditional dimorphic paradigm of gender within our culture and society.  Within this text I propose to define gender as a social construct, review a portion of the research that has been conducted concerning cultural and social influences on gender identity, compare dimorphic and multivariate paradigms of gender identity, and advocate for adoption of a more multivariate paradigm in the interest of   those persons whose gender identity is presently invalidated by the prevailing social view.      Gender is a social construct          The concept of gender as a personal attribute apart from but related to one’s biological sex is a construct created by social scientists within the last century.  The modern study of what is now called gender began with Magnus Hirschfeld (1868-1935) and the 1910 publication of his book The Transvestites: An Investigation of the Erotic Desire to Cross Dress (Bullough, 2000). He argued that although the two sexes had usually been regarded as dimorphic, this was much too simplistic since there are many varieties of intermediates, including transvestites and transsexuals.   Hirschfeld accounted for this variety by conceptualizing sexuality as a continuum (Vanderburgh, 2000).  I concur with Hirschfeld’s continuum construct, however I conceptualize gender identity and sexual orientation as two of at least five separate parallel related continuums (see Appendix A).  I will discuss this in more detail later.       Gender is an old term that has been widely used in linguistic discourse to designate whether nouns are masculine, feminine, or neuter. It was not normally used in the language of social sciences, however, until John Money adopted the term in 1955 to distinguish femininity, or womanliness, and masculinity, or manliness, from biological sex (male or female) (Bullogh, 2000).        In 1964 Stoller proposed the concept of core gender identity. He saw this as produced by the infant-parent relationship, the child's perception of its external genitalia, and a biologic force. Stoller believed that the core gender identity is established before the fully developed phallic stage, although gender identity continues to develop into adolescence or beyond. He further stated that the beliefs comprising the "mental structure" of the core gender identity are the earliest part of gender identity to develop and are relatively permanent after the child reaches 4 or 5 years of age (Stoller ,1992).        In 1966 Kohlberg suggested that children's concept of gender develops in a series of Piagetian-like stages in which they first acquire gender identity (“I am a girl/boy”), then gender stability (“I have always been a boy/girl”), followed by gender constancy, that is, understanding that gender is a fixed and immutable characteristic that is not altered by situational changes (Poulin-Dubois,  Serbin, Kenyon, Derbyshire, 1994).        Slavin (1998) defined Gender-identity formation as a complex process in which children incorporate the biological and social aspects of their gender into their behavior, attitudes, and self-understanding. Gender identity can be fluid        Stoller’s and Kohlberg’s view of a “permanent” “fixed and immutable” gender identity have been challenged, however, by writers such as Fausto-Sterling (2000), Bornstein (1998), Feinberg (1996), Queen and Schimel (1997) and Vanderburgh (2000).  The combined work of these authors chronicle the experience of hundreds of transgender individuals and confirm my personal observation that gender identity can be fluid.   That is, a person’s sense of femininity and/or masculinity may change after their gender identity has formed.  Parents, care-givers and other adults have observed that gender differences emerge in very young children. If gender differences are naturally of the order which we routinely observe, then they would be immutable. Instead, research demonstrates that what emerges as maleness or femaleness changes in fundamental ways over time, across cultures and in different socio-economic circumstances (Clark & Page, 2002).         A large body of research indicates that a child’s gender identity emerges by age three, before social and cultural influences are primary forces. (Vanderburgh 2000; Leinbach & Fagot, 1986; Sen & Bauer, 2000; Thompson, 1975;  Weinraub, Clemmens, Sockloff, Ethridge,  Gracely,  & Myers, 1984; Clark & Page 2002).    In a study with unacquainted same-sex and cross-sex pairs of 33-month-old children, most of whom had had little or no experience in preschool or day-care settings, Jacklin and Maccoby (1978) found considerably higher levels of social interaction in same- sex pairs. These findings suggest that a foundation for gender segregation exists before children enter group settings.  Unger (2001) asserts that the process of becoming gendered begins virtually at birth.  She further states that even infants react differently to males and females.  For example, male strangers tend to inspire more anxiety. Infants may even begin to form rudimentary gender categories by the middle the first year (Greenberg, Hillman, & Grice, 1973).  Studies by Fagan and colleagues (Fagan & Shepherd, 1982; Fagan & Singer, 1979) showed that infants as young as 5 months old can distinguish pictured faces according to gender, although they do not show a preference for faces of either gender. It appears that infant’s ability to make gender distinctions emerges well before they have the linguistic capacity to apply gender labels to themselves and others (Maccoby 1988).  Poulin-Dubois, et al, (1994) found that infants' gender categories include intermodal knowledge about female faces and voices by the age of 9 months. These simple categories may enable infants to begin associating other attributes with gender (Unger, R., 2001). For example, when presented with male or female faces paired with objects, 10-month-olds show increased attention to new face-object pairs only when a face of one sex is paired with an object previously associated with the other sex. These findings suggest that infants can detect correlations between gender and other attributes, in a sense forming primitive stereotypes (Levy & Haaf, 1994).  Slavin (1998) also observed that children are able to apply gender labels to themselves correctly by about age three. Young children appear to base gender labeling on easily observable differences such as hairstyle and clothing. They do not seem to grasp the importance of genital differences in determining gender at this stage.        With regard to gender constancy, it has been demonstrated that considerable sex typing occurs before the age of acquisition of gender constancy (Bem, 1989; Emmerich, Goldman, Kirsh, & Sharabany, 1977). For example, children develop rudimentary notions about the sex typing of toys and clothing some time between 2 and 4 years, which is much earlier than the age of acquisition of gender constancy (Weinraub & Brown, 1983; Weinraub et al., 1984). Kuhn, Nash, & Brucken (1978) report that even 2- and 3-year-old children have begun to form stereotypes about the activities associated with each sex.       Another well-documented phenomenon is the tendency to confine social interaction to same-sex partners, which seems to emerge during the third year of life (Maccoby, 1988). In response to these findings, several formulations of cognitive developmental theory suggest that gender constancy predicts an increase in responsiveness to gender-related information rather than the emergence of responsiveness (Stangor & Ruble, 1987).        If gender identity formation is well underway before a child has had broad exposure to social and cultural influences, what function might theses forces serve?  Perhaps they serve, in part, to perpetuate embedded cultural values.  One of the most deeply embedded constructs in our present social environment is that of sex and gender dimorphism.  For example, note the emphasis on dimorphism in this quote from Maccoby (1988, p.760) ;“Children know unequivocally that they belong either to the group of males or the group of females, and their identity is bound up in this group membership” (italics added).        The following partial review of the literature demonstrates not only an awareness of the pervasive influence that society and culture have on gender identity, it also shows the pervasiveness of the dimorphic paradigm of gender within this discourse.        Lloyd and Duveen (1990) have argued that many features of the cultural environment may be structured according to gender categories. In their analysis of gender marking, objects such as toys, clothing, names, and other things were found to be assigned to more or less exclusive gender categories. “As far as pressures from socialization agents are concerned, boys and girls are treated quite differently (and homogeneously within sex) when it comes to gender identifiers. They are given sex-distinctive names and dressed in ways that permit others to know whether they are boys or girls” (Maccoby 1988, p.757).        Clark & Page (2002) discuss the role of language in our understanding of gender because language shapes reality, and limits what concepts are available in a particular situation.  Ideas and understandings available through language shape our practice in a variety of ways in everyday interactions. For example, Walkerdine’s (1994) research shows how teachers' talk about high-achieving girls frequently draws on deep cultural assumptions about femininity.       Turner-Bowker (1996) noted that language is often utilized as a media tool to maintain the gender status of individuals in our society. Therefore, the language in books can be used to encourage or eliminate stereotypes (Kortenhaus & Demarest ,1993).       Gooden and Gooden (2001) cite the work of LaDow (1976), Arbuthnot (1984), Bender and Leone (1989) and Easley (1973) in discussing the importance of reading books on gender identity development.  They claim that books may be the primary source for the presentation of societal values to children and that books are a powerful vehicle for the socialization of gender roles.        “Children's books have been around since the early 1500s. The traditional values of the times were reflected in these early books. Children's books also served as a socializing tool to transmit these values to the next generation. Additionally, the traditional view of the male work role appeared to be accepted by the majority of authors writing children's literature” (Gooden & Gooden 2001, p.89).       Further evidence of gender roles also are modeled in children's literature (P. Purcell & Stewart, 1990; Turner-Bowker, 1996). For example, males are more often depicted in titles and pictures than are females, and they are described as more potent, active, and masculine. P. Purcell and Stewart note that gender stereotyping in children's readers was not as pronounced in 1989 as it had been in 1972, however. (Turner-Bowker, 1996, p.461)        The literature suggests that reading sexist material might be harmful to young readers. Both males and females suffer as a result of gender stereotypes. Children's choices of what they want to become or accomplish is limited by stereotypes. Gender bias prevents individuals from exploring the activities and interests that are best suited to their personality and abilities. (Gooden & Gooden, 2001, p.99)        Women on Words and Images analyzed the contents of 134 grade-school readers and found gender-stereotypic portrayals of male and female characters, gender-stereotypic themes, and male dominance to be the rule. Boys outnumbered girls as major characters by five to two; in 2,760 stories examined, only  three mothers were shown working outside the home. Systematic studies of children's television have produced similar results. (Slavin, 1998, p.258).        In addition to children's storybooks and textbooks, Furnham, Abramsky & Gunter point out the influence of the media, which includes television programs, commercials, cartoons and comic strips.        Over the past 30 years a considerable body of research evidence has accumulated which has indicated that television disproportionately represents men and women. Furthermore, when women do appear on screen, there has been a tendency to use them in a narrower range of roles than is the case with men (Gunter, 1995). In its role as a potentially powerful socialising (sic) agent, particularly among young people, concern has been voiced that this pronounced stereotyping of the sexes may cultivate distorted views about the character of, and appropriate social and professional, roles for women (Butler & Paisley, 1980; Durkin, 1985).(Furnham, Abramsky & Gunter, 1997, p.92)        Advertisements on children's television have been found to contain a preponderance of male characters (Doolittle & Pepper, 1975; Riffe, Goldson, Sexton & Yang-Chou, 1989). A British study of children's television advertising in the run-up to Christmas found that boys and girls were equally represented in the adverts themselves, but male voice-overs were more numerous than female voice-overs. The nature of boys and girls roles varied as well, with boys playing more active and boisterous parts, and girls occupying more passive and quieter parts. (Smith & Bennett, 1990, p.98)       Traditional gender roles also are frequently portrayed in video games (Dietz, 1998).  Even children’s educational software has not been immune to such portrayals, despite a concerted effort by manufacturers to present gender-neutral characters (Drees &  Phye, 2001).        The important social influence that peers impart has been recognized by many (Bailey, Bechtold, & Berenbaum, 2002; Maccoby, 1998; Burford & Foley, 1996; Fagot, 1977; Fagot & Patterson, 1969; Lamb & Roopnarine, 1979).   Slavin (1998) described the shaping influence of peers as differential conditioning.  She observed that children's behavior becomes sex typed because children watch other males and females regularly behaving differently. They then repeat the modeled differential behavior because of  differential rewards and punishments for girls than for boys. This conditioning often strongly reinforces traditional gender roles, particularly in early childhood, when children's gender concepts tend to be more rigid than those of adults. Peers may also be the source of misinformation (for example, "girls can't be doctors; girls have to be nurses") .        Maccoby (1998) explored the socializing influence of adults and older children.  He called it the socialization-personality model. In this model, children's sex-typing is presumed to be a result of the shaping of each new generation of children by previously socialized members of a society, the older children and adults in the child’s life. They treat children of the two sexes somewhat differently, using reinforcement, punishment, and example to foster whatever behaviors and attitudes a social group deems sex-appropriate. Socialization pressures are also applied to inhibit sex- inappropriate attitudes and behavior.       Clark & Page (2002) reiterate the role that social interaction plays in gender identity formation.  They state that children actively develop a sense of themselves as gendered people by interacting with the myriad of messages and practices which they encounter.  They also argue that gender formation can be more an aspect of group identity than self identity. As an example, they state that both girls and boys may experience intense contradictions between the kinds of behaviors they engage in as part of their peer group and their sense of self as experienced in more intimate personalized contexts.        Drees & Phye (2001) have investigated the role of society in the formation of gender identity.  Their research indicates that children are exposed to a vast amount of information in society, and they use that information to formulate identity.  They believe that the gender identity of most children is shaped by the beliefs about gender roles that are held by the majority of persons in their society, and that gender roles are formed through interaction with parents, teachers and peers.        Shaw’s (1998) position is that gender roles are the behaviors that society teaches are "correct" for boys and "correct" for girls. Gender stereotypes are often the basis of gender roles. Shaw further stated that these are assumptions made about the characteristics of each gender, such as physical appearance, physical abilities, attitudes, interests, or occupations.       Slavin (1998) cites Kohlberg in discussing the developing knowledge of cultural gender expectations that children use to teach themselves to adopt culturally defined gender roles (self-socialization). Kohlberg argued that children acquire a strong motive to conform to gender roles because of their need for self-consistency and self-esteem. A young boy says to himself, "I am a boy, not a girl; I want to do boy things, play with boy toys, and wear boy clothes.” (Slavin, 1998, p. 260)        Ruble & Martin (1998) point to the role that schools play in providing children with models of sex-differentiated behavior. “For example, women are more likely to be teachers, especially for early grades, whereas men hold a disproportionate number of administrative positions” (Ruble & Martin, 1998, p. 935).        The literature clearly demonstrates two things; first, that there are pervasive social and cultural influences on a child’s gender identity, and second, that the dimorphic paradigm is a pervasive assumption in the social sciences (Stanley & Stanley 2001).      The problems of a dimorphic gender paradigm        I find this dimorphic paradigm of gender and sex to be problematic because it does not account for the existence of transgender or intersex persons.  There has been an emerging awareness of alternative paradigms as research follows the lead of the socio/political  transgender and intersex  movements (Dreger, 1998; Herdt, 1996).  Anne Fausto-Sterling epitomizes this awareness succinctly in an essay she published in 2000, excerpted in part below:        "In the idealized, Platonic, biological world, human beings are divided into two kinds: a perfectly dimorphic species. Males have an X and a Y chromosome, testes, a penis and all of the appropriate internal plumbing for delivering urine and semen to the outside world. They also have well- known secondary sexual characteristics, including a muscular build and facial hair. Women have two X chromosomes, ovaries, all of the internal plumbing to transport urine and ova to the outside world, a system to support pregnancy and fetal development, as well as a variety of recognizable secondary sexual characteristics."        "That idealized story papers over many obvious caveats: some women have facial hair, some men have none; some women speak with deep voices, some men veritably squeak. Less well known is the fact that, on close inspection, absolute dimorphism disintegrates even at the level of basic biology. Chromosomes, hormones, the internal sex structures, the gonads and the external genitalia all vary more than most people realize. Those born outside of the Platonic dimorphic mold are called intersexuals."        "Transsexuals, people who have an emotional gender at odds with their physical sex, once described themselves in terms of dimorphic absolutes--males trapped in female bodies, or vice versa. As such, they sought psychological relief through surgery. Although many still do, some so-called transgendered people today are content to inhabit a more ambiguous zone. A male-to-female transsexual, for instance, may come out as a lesbian. Jane, born a physiological male, is now in her late thirties and living with her wife, whom she married when her name was still John. Jane takes hormones to feminize herself, but they have not yet interfered with her ability to engage in intercourse as a man. In her mind Jane has a lesbian relationship with her wife, though she views their intimate moments as a cross between lesbian and heterosexual sex."        "It might seem natural to regard intersexuals and transgendered people as living midway between the poles of male and female. But male and female, masculine and feminine, cannot be parsed as some kind of continuum. Rather, sex and gender are best conceptualized as points in a multidimensional space. For some time, experts on gender development have distinguished between sex at the genetic level and at the cellular level (sex-specific gene expression, X and Y chromosomes); at the hormonal level (in the fetus, during childhood and after puberty); and at the anatomical level (genitals and secondary sexual characteristics). Gender identity presumably emerges from all of those corporeal aspects via some poorly understood interaction with environment and experience. What has become increasingly clear is that one can find levels of masculinity and femininity in almost every possible permutation. A chromosomal, hormonal and genital male (or female) may emerge with a female (or male) gender identity. Or a chromosomal female with male fetal hormones and masculinized genitalia--but with female pubertal hormones--may develop a female gender identity."        "The Medical and Scientific Communities have yet to adopt a language that is capable of describing such diversity. In her book Hermaphrodites and the Medical Invention of Sex, the historian and medical ethicist Alice Domurat Dreger (1998) of Michigan State University in East Lansing documents the emergence of current medical systems for classifying gender ambiguity. The current usage remains rooted in the Victorian approach to sex. The logical structure of the commonly used terms "true hermaphrodite," "male pseudohermaphrodite" and "female pseudohermaphrodite" indicates that only the so-called true hermaphrodite is a genuine mix of male and female. The others, no matter how confusing their body parts, are really hidden males or females. Because true hermaphrodites are rare--possibly only one in 100,000--such a classification system supports the idea that human beings are an absolutely dimorphic species."        "At the dawn of the twenty-first century, when the variability of gender seems so visible, such a position is hard to maintain. And here, too, the old medical consensus has begun to crumble. Last fall the pediatric urologist Ian A. Aaronson of the Medical University of South Carolina in Charleston organized the North American Task Force on Intersexuality (NATFI) to review the clinical responses to genital ambiguity in infants. Key medical associations, such as the American Academy of Pediatrics, have endorsed NATFI. Specialists in surgery, endocrinology, psychology, ethics, psychiatry, genetics and public health, as well as intersex patient-advocate groups, have joined its ranks." (Anne Fausto-Sterling, 2000)      A multivariate gender paradigm        In a previous essay, Dr. Fausto-Sterling (1993) created quite a stir in the scientific  community by suggesting that five sexes (male, merm, herm, ferm, female) may be more appropriate than two.  She now realizes that even five sexes would be too limiting.  I agree with her analysis of biological and interpersonal variability.  I conceptualize, however, a more organized pattern of sex and gender than her “points in a multidimensional space”. I propose that chromosomal sex, anatomical sex, gender identity, gender expression and sexual orientation form a pattern of parallel related continuums (see Appendix A).   Chromosomal Sex would be described in terms of genetics and would vary from XX to XYY, with XY and chromosomal variations besides XYY somewhere between the poles.  Anatomical Sex would be described in terms of physiology and would vary from female to male, with intersex somewhere between the poles.  Gender identity would describe a persons’ innate sense of womanliness (or girlishness) and/or manliness (or boyishness), with transgender (including, but not limited to, transvestite and transsexual) somewhere between the poles.  Gender expression would describe the manifestation of gender identity  that a person presents to others, and would vary from feminine to masculine with cross dressed, gender queer, and androgynous somewhere between the poles.  Sexual orientation would describe the gender of   one’s object of romantic and/or sexual attraction, and would vary from exclusively homosexual to exclusively heterosexual with bisexual/omnisexual somewhere between the poles.        It is easy to understand why the dimorphic paradigm of gender dominates the social sciences discourse.  This has been the prevailing view since Darwin, and reflects an ancient tradition of binary, either-or thinking in western culture (Stanley & Stanley, 2001). Our religious institutions fiercely defend this position (Stanley & Stanley, 2001). It is, in a way, self-perpetuating (Herdt, 1996).  As a result, there is a dearth of research on the prevalence of intersex and transgender persons.   The best estimates that have been produced indicate that the incidence of intersex (Fausto- Sterling, 2000) and transgender (Vanderburgh, 2000) persons represent approximately one percent of the population each, for a combined incidence of approximately two percent.  In a nation of 300 million, that would be about six million persons.  The social and medical implications of denying six million persons their right to a natural sense of core gender identity are immense.        Fortunately, there is hope.  Researchers are beginning to respond to the changing social climate of acceptance for a wider view (Herdt, 1996).   As intersex and transgender persons make their voices heard, minds are opening (Fausto-Sterling, 2000).        Maccoby (1988) noted when discussing binary and protypical gender concepts, that while they are always available, that does not indicate they will be activated.  They can be overridden or bypassed when other available category systems are called into play.   Fausto-Sterling (2000) writes:        "What is clear is that since 1993, modern society has moved beyond five sexes to a recognition that gender variation is normal and, for some people, an arena for playful exploration. Discussing my "five sexes" proposal in her book Lessons from the Intersexed, the psychologist Suzanne J. Kessler of the State University of New York at Purchase drives this point home with great effect:"        “The limitation with Fausto-Sterling's proposal is that ... [it] still gives genitals ... primary signifying status and ignores the fact that in the everyday world gender attributions are made without access to genital inspection. ... What has primacy in everyday life is the gender that is performed, regardless of the flesh's configuration under the clothes.”        "I now agree with Kessler's assessment. It would be better for intersexuals and their supporters to turn everyone's focus away from genitals. Instead, as she suggests, one should acknowledge that people come in an even wider assortment of sexual identities and characteristics than mere genitals can distinguish. Some women may have "large clitorises or fused labia," whereas some men may have "small penises or misshapen scrota," as Kessler puts it, "phenotypes with no particular clinical or identity meaning."        "As clearheaded as Kessler's program is--and despite the progress made in the 1990s--our society is still far from that ideal. The intersexual or transgendered person who projects a social gender--what Kessler calls "cultural genitals"--that conflicts with his or her physical genitals still may die for the transgression. Hence legal protection for people whose cultural and physical genitals do not match is needed during the current transition to a more gender-diverse world. One easy step would be to eliminate the category of "gender" from official documents, such as driver's licenses and passports. Surely attributes both more visible (such as height, build and eye color) and less visible (fingerprints and genetic profiles) would be more expedient."       "A more far-ranging agenda is presented in the International Bill of Gender Rights, adopted in 1995 at the fourth annual International Conference on Transgender Law and Employment Policy in Houston, Texas. It lists ten "gender rights," including the right to define one's own gender, the right to change one's physical gender if one so chooses and the right to marry whomever one wishes." (Fausto-Sterling, 2000)        It is my belief that members of the social science, medical and helping professions have an obligation to educate themselves about and advocate for intersex and transgender persons. Important first steps would include an analysis of the effects of our prevailing dimorphic paradigm and consideration of alternatives.  With so many individuals affected, this issue cannot be ignored. Gender variant persons are at greater risk for suicide as they struggle with animosity and rejection (Vanderburgh 2000). In 2003, there were 35 confirmed homicides that have been attributed to a violent act in response to the victim’s perceived gender (Transgender Hate Crimes 2003).  For some, it is a matter of life and death. References Arbuthnot, M. H. (1984). Children and books. Chicago, IL: Scott Foresman & Company. Bailey, M.,  Bechtold, K.  Berenbaum, S.(2002) Archives of Sexual Behavior. New York: Aug 2002. Vol. 31, Iss. 4;  pg. 333, 9 pgs Bem, S. L. (1989). Genital knowledge and gender constancy in preschool children. Child Development, 60, 649–663. Bender, D. L., & Leone, B. (1989). Human sexuality: 1989 annual. San Diego, CA: Greenhaven Press. Bornstein, K. (1998). My Gender Workbook. New York. Routledge Bullogh, V.L. (2000).  Transgenderism and the Concept of Gender.  International Journal of Transgenderism, Volume 4 Number 3, July - September 2000 Burford, H. &  Foley, L. 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Television, sex roles and children. Milton Keynes, UK: Open University Press. Easley, A. (1973). Elements of sexism in a selected group of picture books recommended for kindergarten use. East Lansing, MI: National Center for Research on Teacher Learning. (ERIC Document Reproduction Service No. ED104559) Emmerich, W., Goldman, K. S., Kirsh, B., & Sharabany, R. (1977). Evidence for a transitional phase in the development of gender constancy. Child Development, 48, 930– 936. Fagan, J. F., & Shepherd, P. A. (1982). Theoretical issues in the early development of visual perception. In M. Lewis & L. Taft (Eds.), Developmental disabilities: Theory, assessment and intervention, New York: S. P. Medical and Scientific Books. Fagan, J. F., & Singer, L. T. (1979). The role of single feature differences in infant recognition of faces. Infant Behavior and Development, 2, 39–45. Fagot, B.I., (1977). Consequences of moderate cross gender behavior in preschool children. Child Development, 48, 902-907. 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Appendix “A” Chromosomal Sex XX--------------XO----------------------XXY------XXYY---------------------------------XY----XYY Anatomical Sex Female-------------------------------------Intersex----------------------------------------------Male Gender Identity Woman-----------------------------------Transgender-----------------------------------------Man Gender Expression Feminine---------------------------------Androgynous----------------------------------Masculine Sexual Orientation – Attracted To: Males---------------------------------Intersex/Transpersons------------------------------Females

NGC 6302: The Butterfly Nebula   Credit & Copyright: Very Large Telescope, ESO

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