变性人心理辅导------2010 英文

Relationship challenges and relationship maintenance activities following disclosure of transsexualism C . A R A M B U R U A L E G R Í A p h d r n f n p - b c Assistant Professor, Orvis School of Nursing, University of Nevada Reno, Reno, NV, USA Keywords: families, qualitative research, relationship maintenance, transgender families, transgender nursing, transsexual families Correspondence: C. Aramburu Alegría Orvis School of Nursing/Mail Stop 0134 University of Nevada Reno Reno NV 89557 USA E-mail: aramburu@unr.edu; christinemaramburu@gmail.com Accepted for publication: 4 August 2010 doi: 10.1111/j.1365-2850.2010.01624.x Accessible summaryjpm_1624 909..916 • Transsexual persons are increasing their visibility in society, and health care pro- viders and others (such as social workers) will be called upon to help with issues that transsexual persons face. Challenges that face transsexual persons often include issues involving relationships. Psychiatric and mental health nurses and other car- egivers can increase their therapeutic skills in working with couples that include transsexual persons by becoming aware of these challenges and subsequent activities that can help with them. • This research study looks at couple relationships in which one partner reveals male-to-female transsexual identity. These are relationships that were established as man-woman and now will transition into relationships that include a male-to- female person and a female partner. • Common challenges for these couples include issues related to: (1) sexual identity and relationship uncertainty; (2) male-to-female transition decision making; and (3) presenting in public. • Relationship maintenance activities that helped the couples in the study maintain and strengthen their relationships through these challenges include: (1) communi- cation; (2) self-talk (for example, putting the situation in perspective); (3) social networks; (4) positive interactions; (5) impression management (for example, man- aging displays of affection in public); and (6) social activism. Abstract This qualitative study describes the relational dynamics that help sustain relationships of couples that include male-to-female transsexual persons (MTF) and their natal female partners (NF) following disclosure of transsexualism. Relationship challenges and relationship maintenance activities are identified. Each partner in 17 MTF–NF couples participated in individual surveys and interviews. The data were coded for themes related to relationship challenges and activities. MTF–NF couples experience challenges within the contexts of their relationships and of society. These challenges include: (1) sexual identity and relationship uncertainty; (2) male-to-female transition decision making; and (3) public presentation. Relationship maintenance activities enabled the study couples to maintain and strengthen their relationships through these challenges. These activities include: (1) communication; (2) self-talk; (3) social net- works; (4) positivity; (5) impression management; and (6) social activism. Via this report, psychiatric and mental health nurses can increase their therapeutic skills in working with MTF–NF couples. Journal of Psychiatric and Mental Health Nursing, 2010, 17, 909–916 © 2010 Blackwell Publishing 909 Introduction The visibility of transsexual persons is increasing within Western cultures, and most health care providers, know- ingly or unknowingly, will care for transsexual clients (Feldman & Bockting 2003). Psychiatric and mental health care nurses may be called upon to treat transsexual- identified clients and their families, for whom psychosocial issues are often paramount (Fitzpatrick et al. 2005). How- ever, educational preparation of clinicians to care for the transsexual population is lacking, and literature that exam- ines issues within relational contexts is particularly scant. As a result, clinicians often feel poorly prepared to care for this population and support transsexual persons in their interpersonal relationships. This paper takes a step towards filling this knowledge gap by illuminating the relational lives of male-to-female transsexual persons (MTF) and their natal female partners (i.e. female since birth; NF). Challenges following disclo- sure of male-to-female transsexualism within relationships that had been established as men-women are described. Relationship maintenance activities that help couples in meeting these challenges are reported. This examination of the transition of established ‘opposite-sex’ couples to ‘same-sex’ couples provides a unique opportunity to investigate couple relationships that transition from ‘main stream’ to ‘non-traditional,’ with its attendant challenges and opportunities for growth. Via this report, psychiatric and mental health nurses can increase their therapeutic skills in working with MTF–NF couples. Transsexualism Transgenderism is an umbrella term for activity that crosses socially constructed gender norms (See definitions, Table 1). Examples of persons who practice transgenderism include cross dressers, drag queens, transsexual persons, and gender queer persons who may oscillate between genders (Meyerowitz 2002, Roen 2002). Transsexualism is a subset of transgenderism, though the terms are often used synonymously. In this paper, transsexualism is used to signify persons who experience incongruence between their birth-assigned sex (i.e. determined by external genitalia) and their self-identified gender (Vitale 2001); MTF trans- sexual persons self-identify as women and experience gender dysphoria as men. Marginalization, discrimination, and stigmatization of transsexual persons exist in Western culture, and trans- sexual persons experience greater rates of depression, suicide, substance abuse, HIV/AIDS, homelessness, and unemployment than non-transsexual persons (Clements- Nolle et al. 2006). Rather than risk social ostracism and associated potential adverse outcomes, transsexual persons often resign themselves to leading lives of conformance with their birth-assigned gender (Vitale 2001). Background Following cultural expectations, MTF persons often estab- lish relationships with females (Tully 1993). According to relational schema theory, partners’ views of their relation- ship and associated expectations are created through ongoing partner interactions (Baldwin 1992). However, as an increasing number of transsexual persons form social networks and share information online and face-to-face, they become aware of options for male-to-female transition and the possibility of an authentic and successful life fol- lowing transition. These realizations can motivate MTF persons to disclose to their partners their transsexual iden- tity and begin transition, altering established relationship norms and patterns of interaction. Existing literature on relationships following disclosure of transsexualism is scant. Gurvich (1991) found that wives’ initial reactions to their husbands’ disclosure of transsexualism include feelings of shock, betrayal, and anger, as well as the belief that their relationship could strengthen. They also report confusion in identifying their own sexual orientation, believing that labels such as ‘lesbian’ are incongruent with their self-view. Similar to wives of MTF persons, lesbian-identified female partners of female-to-male (FTM) persons report experiencing confusion regarding their future, sexuality, and relationship following their partners’ disclosure of transsexualism (Joslin-Roher & Wheeler 2009). Subjects Table 1 Definition of key terms Natal sex Identified sex at birth (i.e. male or female): Persons born with penises are male; persons born with vaginas are female. MTF Natal male who identifies as female; transsexual person FTM Natal female who identifies as male; transsexual person Transgender Umbrella term for persons who do not conform to gender norms in their identity and/or behaviour Transsexual Subset of transgenderism; persons who feel discordance between natal sex and identity En femme Natal male presenting as a woman Gender dysphoria Dissonance with one’s gender Cross gender Presenting or identifying in a manner that is usually associated with the opposite natal sex C. Aramburu Alegría 910 © 2010 Blackwell Publishing also reported stress related to presenting in public and losing social support within the lesbian community as they and their partners transitioned from same-sex to man–woman couples. Communication, self-exploration, and peer support led to individual and relational growth. A partner’s disclosure of cross-dressing behaviour or homosexuality also alters established relational interac- tions (Weinberg & Bullough 1988, Reynolds & Caron 2000, Buxton 2001, Baptist & Allen 2008), and research examining these relationships may provide additional insight into the challenges and adaptations of MTF–NF relationships. In studies exploring the impact of cross dressing on relationships, reactions to the disclosure have ranged from positive to unfavourable, with concerns related to social presentation taking dominance. Indeed, wives report their greatest concern is that others will learn of the cross dressing. Other concerns involve sexuality, including the possibility that husbands will seek same-sex relationships. Communication and setting limits on cross- dressing behaviour are activities that helped wives accept their husbands’ cross dressing (Weinberg & Bullough 1988, Reynolds & Caron 2000). In studies examining the relationships of couples in which one partner has disclosed as homosexual, partners receiving the unexpected news also report confusion regarding their sexual orientation and the future of their relationship. Similar to couples that have sustained disclo- sures of cross dressing, individual and couple growth occurred through communication and the development of new social networks, self-exploration, and broader concep- tualizations of sexuality and relationships. Engaging in activities of social activism (for example, becoming involved in gay rights) further strengthened relationships (Buxton 2001, Baptist & Allen 2008). In sum, disclosure related to sexual or gender identity within a relationship alters partners’ views of their relation- ships and established patterns of interaction. In particular, partners of those who disclose transsexualism or homo- sexuality report confusion regarding their own sexuality and the future of their relationships. Other concerns include losing community networks, others finding out about the behaviour or identity, and re-entering society as a gender-transitioned couple. Individual and couple growth can occur through communication, peer support, social networks, social activism, and self-exploration. Research questions To date, the examination of couples that include trans- sexual persons have been under-examined. To expand clinicians’ understanding of issues that affect transsexual persons and their relationships, the following research questions are addressed: 1. What relational challenges do MTF–NF couples face following disclosure and during male-to-female transition? 2. What activities benefit the couples to meet those challenges? Method Participants Seventeen MTF–NF couples, located throughout the western United States, were recruited via Internet forums and network sampling. All participants described them- selves as White/Caucasian. With the exception of one cohabitating and engaged couple, all couples were married and living together. Participants ranged in age from 30 to 69 (M = 51.6 years). Approximately three-fourths of the participants were between the ages of 50 and 69 (NF: n = 12; 70%; MTF: n = 13; 76.4%). More than one-half of the couples (n = 23; 67.6%) had a bachelor’s degree or higher level of education. Relationship duration ranged from 3 to 44 years (M = 21.8 years). Approximately one-third of the couples’ rela- tionships ranged from 20 to 29 years, and another one- third from 10 to 19 years. At the time of disclosure, the couples had been in their relationships from 1.2 to 35 years (M = 16.2 years). Average length of time since the disclo- sure was approximately 5 years. All MTFs self-identified as ‘female’ or ‘transsexual woman’. The stage of transition among MTF participants ranged from part-time en femme (i.e. as women), without body-altering procedures, to full-time en femme with sexual reassignment surgery. All MTF respondents reported using medications for feminization. More than three-fourths (n = 14; 82.4%) of MTF respondents lived full-time en femme. Procedures and instruments The study involved two phases: (1) questionnaires; and (2) individual semi-structured interviews. Questionnaires pro- vided an overview of couples’ relationships, including demographics, length of relationship, feminizing behaviour and relationship activities. For example, questions address- ing pro-relational activities included, ‘Please describe activities that you currently use to maintain your relation- ship, for example, going out with friends’ and ‘Are there activities that have changed since the disclosure?’ The interview schedule consisted of 17 open-ended questions grounded in the literature and developed by the Relationships and transsexualism © 2010 Blackwell Publishing 911 researcher, eliciting information on partners’ relationship challenges and activities, for example, ‘How did you ini- tially feel about the disclosure’, ‘Has your response to the disclosure changed’ and ‘Has/How has the relationship changed?’ The interviews were audio-taped and tran- scribed verbatim by the researcher. Data collection resulted in 34 completed surveys, 59.5 h of interview and 522 single-spaced pages of transcription. Ethical considerations The Institutional Review Board at the author’s university approved the study, ensuring that the protocol was sound and participants’ rights protected. Study participants were informed as to the purpose and procedure of the study, and informed consent was obtained prior to data collection. Participants were told they could refuse to answer any question or choose to withdraw from the study at any time, and that no identifying information would be included in the data analysis or reporting. Data analysis Deductive and inductive methods were used for data analy- sis. Deductive analysis included the use of a typology of relationship maintenance activities (Stafford & Canary 1991, Canary & Stafford 1992, Dainton & Stafford 1993, Haas & Stafford 1998). Fourteen pro-relational activities that couple partners may engage in are included in the typology (positivity; openness/communication; assurances; social networks, such as family and friends; sharing tasks; joint activities; small talk; mediated communication; topic and conflict avoidance; anti-social activities, such as teasing; affection; focus on self; seeking support of similar others; and self-talk, specifically, viewing one’s relationship as being the same as other relationships). Activities used by the couples in the present study that could not be catego- rized by the existing typology were categorized inductively (for example, impression management). Inductive analysis included the use of the constant comparative method, an iterative process by which data are compared within and across subjects (Glaser & Strauss 1967, Strauss & Corbin 1998) and was also used to identify themes related to relationship challenges and activities. Intercoder reliability and member checks were employed to increase the credibility of the findings (Lincoln & Guba 1985, Miles & Huberman 1994, Creswell 1998). The researcher and a second coder independently coded the surveys and interviews for themes related to relationship challenges and activities. Coders coded questionnaire and interview data from three couples (three MTFs and three NFs). Upon completion of the independent codings, the researcher and second coder met and reviewed the catego- ries. Adjustments were made via consensus. Member checks with participants allowed them to vali- date the researcher’s interpretation of their experience. During the interviews, the researcher frequently repeated back to the respondents what they seemed to be reporting. This allowed respondents to rectify and/or clarify the researcher’s interpretation. Additionally, five couples (five MTFs and five NFs) were randomly chosen to participate in post-transcription member checks. All verified that the transcriptions described their experience. Findings and discussion R.Q. 1 What relational challenges do MTF–NF couples face following disclosure and during male-to-female transition? Consistent with previous findings of the disturbance expe- rienced by female partners of MTFs and FTMs (Gurvich 1991, Joslin-Roher & Wheeler 2009), NFs in the present study reacted to their partners’ disclosure of transsexualism with feelings of profound shock and confusion. Specifically, three themes were paramount: (1) sexual identity and rela- tionship uncertainty (100%; n = 34); (2) male-to-female transition decision making (97%; n = 33); and (3) public presentation (97%; n = 33). Sexual identity and relationship uncertainty The NFs reported that the concept of transsexualism was foreign to them, and that their partners’ disclosure made them question what the disclosure meant for their sexual identity, relationship, and personal and world-views. NF 9 stated: [The disclosure] made me question what it would mean for me and what it was. Is this normal or not, and if I’m in this relationship, am I normal or not. Am I a lesbian? In this situation that’s what you think about. [Trans- sexualism] never occurred to me. I don’t know anybody like this. It was just so out of my normal range of what my world included on a day-to-day basis that it shook everything else. It made me question a lot of things in the relationship and in the world that I don’t think I would have thought about otherwise. Male-to-female transition decision making Once MTFs disclosed their true gender identity, their moti- vation to transition quickly and fully from male-to-female took main stage, and was difficult to reign in. MTF 1 described this inevitable focus on transitioning: Once I opened the door it took over. I had kept it totally submerged. As things started coming out, it just accel- C. Aramburu Alegría 912 © 2010 Blackwell Publishing erated, and it was a struggle, but it was undeniable. There was no way to stop it. After denying it, hiding, for so long, I couldn’t stop it. The NFs reported that this sudden all-encompassing focus was fatiguing and detrimental to themselves and other areas of their lives. NF 14 illustrates: It’s a daily thing. It’s always there. It’s huge. I wish it wasn’t. I feel like the past two and a half years of my life [during transition] I’ve missed a lot. I feel like my focus went from the rest of my life to [MTF 14] really quickly, and it has stayed there. Public presentation Aware that cultural representations of transsexual persons portray deviancy, and that the potential for discrimination and harm exists, participants expressed trepidation regard- ing expanding the MTFs’ transition from the private to the public realm. MTF 8 illustrated: The scariest thing about being a transsexual is trying to do this in the face of disdain and disrespect from society . . . [The public] describes [transsexuals] unfortunately as one of two things, either a [laughable drag-queen] type of person, or a sex worker. As partners of FTMs expressed (Joslin-Roher & Wheeler 2009), NFs in the present study reported concerns related to marginalization, finding community in which they could feel comfortable and find acceptance, and being viewed as lesbian. NF 13 described evaluating her social network and viewing her position as unique: We have our straight friends in the neighborh