Transgendered Emergence Review by Randall D. Ehrbar, Psy.D.
In the interests of full-disclosure, I wish to say at the outset that I know Ari Istar Lev through her past involvement with Division 44’s Transgender Taskforce which I have co-chaired for several years. That said, I highly recommend her book Transgender Emergence to clinicians working with transgender clients, transgender people, and anyone interested in learning more about transgender people as well as those interested in the study of gender. Ms. Lev approaches the topic from the standpoint that “transgenderism is a normal and potentially healthy variation of human expression” (Lev, 2004, p.xix).
Ms. Lev’s work is “informed by an eclectic framework of various theoretical models” including “an ecological social-work model,” “a feminist family systems perspective,” and “a post-modern and social constructionist view” (p. xix). Accordingly, she carefully examines issues of power in the therapeutic relationship which are especially important with this population as therapists often serve as “gatekeepers” for medical and legal interventions. She also does an excellent job of giving a historical perspective on the development of transgender identities as well as deconstructing sex and gender in general. Additionally, she tackles the difficult issue of the current diagnostic categories of gender identity disorder and transvestic fetishism. She also does a good job of reviewing (and deconstructing) various etiological theories of gender variance.
Ms. Lev is very thorough and addresses the needs of the full range of transgender people and their families, including people who cross-dress, bi-gendered non-gendered and other alternatively gendered people, transsexual people, and intersex people. She includes a thorough discussion of gender variance in childhood including a good overview of the controversial topic of whether this is a disorder and how to treat such children and their families. While she is frankly in favor of a non-pathologizing approach, she is fair and respectful in her presentation of other approaches. It is a real strength of this book that Ms. Lev does not focus her discussion only on those clients seeking medical transition nor exclusively on the process of evaluating clients for such transition. Instead, she discusses a much broader range of clients, client concerns, and ways in which therapy can be helpful to clients and their families.
The one area in which I was disappointed given the overall high quality of Ms. Lev’s work was the treatment of intersex children. While she accurately describes some of the challenges to the treatment model based on psychosexual neutrality for much of the past thirty years (p.356) and the concerns raised by intersex adults about problems stemming from treatment they received, she does not indicate the degree to which this is an area in which there is a great deal of controversy within the medical community. Thus while her description of intersex treatment may represent the experience of intersex people and their families who are now adult, it does not necessarily represent the current experience of intersex babies, children and their parents. This discrepancy is due to the shifting norms with regard to treating intersex infants, children, and their parents which have come about due to the efforts of intersex activists and allies (Preves, 2003). “The management of these conditions is in the midst of great change. Every aspect is currently under review including diagnostic techniques, timing and nature of treatment including surgery, and information given to parents” (Creighton, 2001, p.218). Ms. Lev notes that activists and medical professionals agree upon the need for “increased psychosocial support in the form of counseling or psychotherapy for parents who birth intersexed children and intersexed people themselves” (p.379). Norms are also shifting away from secrecy (Creighton, 2001). Issues which are currently contested are whether and when surgery should be performed on intersex infants, and who should decide this (see for example Berenbaum, 2003; Daaboul & Frader, 2001; and Diamond & Sigmundson, 1997), and to what degree parents should have input into their child’s gender assignment (Daaboul & Frader, 2001; and Diamond & Sigmundson, 1997). Hence there is a large range in potential treatments such children and families may face. Nor does Ms. Lev discuss the movement towards basing gender assignment of intersex infants on outcome studies of gender identity of intersex individuals with the same conditions rather than simply on the appearance of external gentalia and karotyping (Diamond & Sigmundson, 1997). Ms. Lev does outline an affirmative treatment approach for intersex children consistent with that advocated by intersex activists and some providers. That this section of the book was less up to date than other areas of the book was particularly disappointing to me because one of the great strengths of Ms. Lev’s book is that it is a current, transgender affirmative approach to assisting clients to become comfortable with their gender identity and role.
Ms. Lev’s post-modern approach to narrative, her use of an identity development model, and her attention to families make her book an eminently practical one both for transgender people and for clinicians looking for guidance on how best to assist transgender clients. She does not downplay the variety of challenges such people face in the process of becoming more fully themselves nor the impact this has on their family systems. Rather she provides useful guidance on how transgender clients and their therapists can face such challenges in a non-pathologizing, growth-promoting way which provides support for a variety of individual client choices and outcomes.