How do you know who you are? Are you able to be fully yourself? Have you ever been afraid to be genuinely yourself?
I ask these questions because it is a good way to begin reflecting on the questions of identity. I find it a helpful exercise to periodically examine myself, my motivations, and my attachments so I can be a better therapist. In today’s world, we are now experiencing greater visibility of many people who are ready to claim their authentic selves. They are tired of being erased for their race, ethnicity, body size, religion, sexuality, or gender. I welcome these societal changes because not only am I the mother of an adult transgender man,1 I cannot help but believe that openness leads, eventually, to acceptance for all people.
When my son came out in 2015, I knew I had a lot of catching up to do on the issues, and I was able to access support and factual information from the Transgender Resource Center of New Mexico (www.tgrcnm.org). As both a parent and a bodyworker, I wanted to know the best possible information on gender and body dysphoria (a general unease or dissatisfaction), the effects of hormones and binding, and what surgeries might be in the future for my son. The more I read and listened to people, and watched the changes my son went through, the more I recognized a real need for myself and other therapists to understand both the physical and social needs of the transgender community. I interviewed LMTs and transgender people about questions and concerns they had, and partnered with a transgender colleague to begin teaching an ethics class about the realities of what a transgender person goes through in order to safely navigate the world, as well as the physical effects that has on their body. I would like to share this information with other massage therapists and bodyworkers so that, together, we can ensure we’ve provided safe space for these clients.
Understand the Gender Spectrum
Biologists now recognize that both sex and gender exist on a spectrum.2 Many people are accustomed to the idea that sex and gender fit comfortably into one of two boxes, but that doesn’t make it true. The best current estimate of the adult transgender population is, on average, about 0.6 percent of the US population.3 The number of intersex people (see Terminology on page 69) is about 1.7 percent of the population.4 While that may not sound like a lot, think of it this way: the population of the United States is about 319 million—that means there are almost 2 million transgender and over 5.4 million intersex members of our national population. Those are not small numbers! People under 24 are the most likely to identify themselves as transgender, and so the numbers may climb as acceptance becomes more commonplace.
Many of us (especially those of us over 30) were never exposed to the idea of the gender spectrum at any point in our education; fortunately, that is changing as science improves and younger generations are embracing the diversity of the human species. It is still up to us as health-care professionals, however, to continue to study and learn about the great variety of humanity so that we may knowledgeably lay our hands on our clients with compassion and openheartedness.
In general, there is still a lot of misinformation and fear surrounding the transgender community, even though there has been a lot more openness and visibility in the last few years. As is typical when social changes are in process, strong backlash occurs even as progress is made. Anti-trans legislation at local, state, and national levels has made day-to-day living as a transgender person more challenging, to say the least. While “reality” television depicts well-supported people like Caitlyn Jenner or Jazz Jennings, the on-the-ground reality is usually quite different. Transgender and gender-nonconforming people report the highest rates of discrimination and barriers to health care, and have the highest rates of suicide, substance abuse, and homelessness. The majority of transgender and gender-nonconforming people have suffered from touch-related trauma, sex abuse, bullying, or harassment, all of which make it more difficult to accept nurturing touch even in a therapeutic setting. Transgender women in particular suffer such high rates of discrimination and harassment that 20 percent turn to sex work for survival.5 A person in survival mode is not going to be comfortable with touch—to expose would be so uncomfortable as to be unthinkable. If they have experienced abuse or harassment, the negative feelings are only going to be amplified. The mental and emotional cost, not to mention the physical risks, of coming out to yet another professional presents a real barrier to accessing bodywork for the transgender community.
Become Informed
Different gender identities and differences of gender expression are not pathologies. First, they are normal, they are real, and they aren’t going to disappear just because some people are uncomfortable with them.
Second, sexuality and gender are not the same. Sexual orientation is whom you are attracted to; gender is who you know yourself to be. The words lesbian, gay, bisexual, and asexual indicate sexual orientations. The words transgender and intersex are gender related and are medical terms.
Third, not all transgender people identify as being part of the LGBTQ community. Once a person has come to a level of comfort with their body by bringing it and their mind into closer alignment, they may simply identify themselves as male or female, without the trans identifier. Most importantly, transgender patients and clients should not be placed in the position of training their providers about their physical health-care needs. It is our responsibility to get informed.
Often, cisgender people (those whose gender identity corresponds to their biological sex) have many questions about working with transgender clients, but it is not the client’s responsibility to speak for all transgender people, so do your research and get current. You should never tell a trans person they were “born in the wrong body.” To do so devalues the humanity of their soul. Their bodies are unique and valuable and their own to do with as they want.
Physical Issues You Need to Understand
It’s important to remember that a transgender person may elect not to do anything as far as making changes to the way they dress or act, and especially not to elect for medical treatments, which are expensive, often not covered by medical insurance, and may be contraindicated for the particular person. This does not mean they aren’t “really” transgender. Everyone’s experience is unique to themselves; everyone has their own comfort level with change, especially visible changes. Particularly with a person transitioning in later adulthood, after years or decades of living, working, and building within their cisgender persona, it is often emotionally and socially costly to give up the life, perks, family, etc., that one has built up. According to the Center of Excellence for Transgender Health, “… (N)ot all transgender people seek all interventions, and some may seek none. In contrast to past practices in which a set pathway involved a requirement of psychological assessment, hormones, [and] genital surgery, the current standard of care is to allow each transgender person to seek only those interventions which they desire to affirm their own gender identity.”6
According to Renee Baker, a counselor and massage therapist based in Texas, “It’s about taking power back if they have given it away to cisgender people, valuing transgender as equally as cisgender, and not comparing and judging. It’s OK to have a unique ‘queer’ body. It’s OK to change it, too; but honor it and talk to it like a friend.”
The issue of navigating through the world safely is so paramount that the first and easiest stop for many transgender people is clothing that reflects their identity. The least expensive, and therefore most common, ways to change outward appearance are by binding the breasts; wearing a prosthetic penis; padding the breasts, hips, and buttocks; and “tucking,” which is to conceal the penis and testicles between the legs. Each of these has physical impact beyond the concealment of birth gender. Many times, it’s a “do it yourself” kind of attempt because people can be ashamed to openly purchase such items; moreover, good-quality, properly fitting items can be expensive. Most transgender people understand very well that what they wear and how they wear it may be painful or even damaging to their body, but the pain of dysphoria is much worse than anything they do to conceal or change their body. These practices are nonetheless extremely important as ways for transgender people to exist safely in public spaces, because being identified as transgender can expose them to harassment and violence.
One particular item to remember is that public restrooms are, in general, not a safe place for transgender and gender-nonconforming people. In order to avoid the use of public restrooms, many transgender people will not drink enough fluids and become dehydrated, making them more tired and prone to headaches. People who avoid using the restroom for prolonged periods of time also suffer a higher incidence of urinary tract infections, bladder infections, constipation, and kidney problems from holding back an essential bodily function. This affects both transgender men and transgender women equally. Having a safe place for folks to get undressed, unbound, untucked, and use the restroom before and after treatment can be a huge burden lifted from the shoulders of many transgender people.
As a massage therapist, what will concern you most regarding a transgender client’s somatic issues are the postural distortions, backaches, and trigger points that accompany the compression of body tissues and bony structures.7 However, it is just as important to respect your clients’ comfort levels and heed requests not to remove their clothing and/or compressive garments. Each person will be in a different stage of their personal evolution and have different needs and abilities to trust a practitioner. Demonstrating respect at all stages of the therapeutic session goes a long way toward building trust.
The Effects of Hormone Replacement Therapy
A common fear among health-care practitioners is that hormone replacement therapy (HRT) is dangerous for their clients. However, according to retrospective studies, hormone therapy was found to be safe and to have minimal adverse effects.8
For a transgender woman taking estrogen and androgen-blockers, the most notable changes will be the development of breasts, loss of body hair and muscle mass, softer skin, and the redistribution of body fat from the abdomen to the hips, thighs, and buttocks. For a transgender man taking testosterone, the most noticeable effects will be the development of facial and body hair, an increase in muscle mass, and the redistribution of body fat toward the abdomen and around the internal organs. Many transgender men will have a hysterectomy within five years of starting hormone therapy because of severe, persistent pelvic pain.
For both cohorts, there is usually a positive emotional effect from bringing the body more in line with the internal sense of identity. Nonetheless, hormone therapy will not solve all body-image problems, nor will it change the person into someone else. Likes and dislikes, talents, skills, and other attributes will remain consistent.
Postsurgery
Probably the one area of most prurient interest to the majority of cisgender people is gender confirmation surgery. As massage therapists, we are most likely to see only “top” surgeries, that is, mastectomies and breast enlargements. If you see a client with scar adhesions, loss of sensation, or blocked lymphatic flow, you can treat them just like you would anyone else.
A transgender woman may elect to have breast augmentation surgery if she is not on HRT or wishes for larger breasts than what comes naturally from HRT. Implants are placed either subcutaneously or submuscularly, and have a lifespan of approximately 16 years. Revisionary surgery within five years occurs about 25 percent of the time, usually for requests in size change, leakage or rupture, or capsular contracture. Complications include seroma, hematoma, infections, changes in skin texture, rippling, displacement of the implant, rupture, or excess scarring; nipple numbness is also a somewhat common side effect. Generally, breast augmentation surgery has a shorter recovery time and fewer side effects than mastectomy, although if implants were placed submuscularly, the recovery time will be longer and the discomfort greater. Self-massage of the breasts will be recommended by the surgeon to start 3–5 days post-op.
Typically, transgender men undergo bilateral subcutaneous mastectomy and nipple grafting, and will have a pair of scars from the removal, as well as a pair of scars from surgical drains. Larger breasts will most likely be removed via an incision at the inframammary crease, whereas smaller breasts may be removed via a keyhole-type incision or inverted T, or a side-entrance keyhole, depending on the underlying anatomy. A peri-areolar (keyhole) incision will not involve nipple grafting. Breast tissue is removed via liposuction, and excess skin is cut away. Nipple tissue, if grafted, will be relocated to the lateral lower quadrant of the pectoral area to create a more masculine chest configuration. A new (as of 2016) procedure, known as the “button-hole,” relocates the nipples without removing them completely, which promises better postsurgical results both aesthetically and functionally.
The patient will experience large areas of numbness in the surgical area, from about an inch inferior to the incisions all the way up to the clavicles and into the axilla, which will persist for weeks to months as the nerves regrow. Range of motion (ROM) will be limited for several weeks.
Complications may include keloid scarring, rippling of the skin, seroma, hematoma, infections, or “dog ears,” which are a buildup of extra tissue under the arms due to surgical error and a frequent cause for surgical revision. Possibly the worst complication would be tissue death, especially of the nipple grafts.
Typically, a therapist can begin to gently work the scars after they have fully healed, around 3–4 weeks post-op. Avoid the nipple area until they are fully healed and have stopped peeling. Personally, I have found that gentle soma-type cupping has been very effective at mobilizing the tissue, increasing range of motion and the range of sensation, and decreasing adhesions.
In all cases, watch for strange swellings or pockets of fluid, discoloration, heat, or inflammation. A seroma needs to be drained like an abscess; a hematoma needs surgical intervention. Refer your client back to their doctor if you see something irregular. Each side may show varying (and asymmetric) progress in healing.
As stated earlier, many transgender men will have a hysterectomy within five years of starting testosterone because of persistent and severe pelvic pain. It is important for therapists to understand that transgender men can get their periods, get pregnant, grow uterine fibroids, suffer endometriosis, and have other concerns with their reproductive system if they still have a uterus, even if they are taking testosterone. Because of these concerns, we must word our intake forms in such a way as to alert us to the presence of a uterus and ovaries.
A Respectful Practice
Language can be used to empower or disempower your client. For this population, members of which are systematically erased from societal consideration on a daily basis, it is very important that we as therapists work actively to empower and respect our transgender clients. Transgender people experience the highest rates of discrimination and barriers to health care. This rate is even higher if the client is a person of color or is low income. By creating an inclusive practice, you will be creating a universally safer place for all your clients.
Your session with a transgender client begins with your intake forms. You can make them friendlier by including small things like a section for “legal name” and “preferred name,” which is helpful for everyone if you do a lot of work with insurance companies. You might include a question about preferred pronouns and allow the client to indicate how they like to be referred to. Instead of only offering “male/female” options for gender, open that part of your intake with a section like this:
Assigned sex at birth:
Male Female
Trans Other Decline
Current gender identity:
Male Female
Trans Other Decline
Do you have gendered health forms? That means you have a separate section for men’s and women’s reproductive health issues. This is easily remedied by combining those questions into a single section or by repeating the questions for both sections. If you are wondering about surgeries, remember that it is OK to ask if it is recent and pertinent, meaning you are going to be working in a particular area. Just as many cisgender people do not bother telling massage therapists about all their health issues and surgeries, transgender people deserve the same respect and consideration for their privacy. You might find out something in the course of your work, which you can note later.
Using proper draping techniques and offering clothed treatment options really demonstrates your respect for a person’s body and their boundaries. Single-stall restrooms or nongendered restrooms make it clear you respect all people’s biological needs. If you work in a spa setting, giving people the option to have a private changing area will convey a sense of safety not only for transgender clients, but also for anyone who desires privacy.
All these considerations will make it clear to a transgender client that you are knowledgeable about—and supportive of—their existence, which goes a long way toward establishing a trusting relationship. You, as the therapist, will need to back up your intake forms by making sure you can approach transgender issues and people with sensitivity and a clear and compassionate outlook. Remember, it is not the client’s responsibility to teach you about transgender health needs for a whole population, just about their own specific needs.
How else can you help? You might choose to display an ally or rainbow symbol, or safe space wording, on your business card, office door, or website to indicate you are a safe and friendly practitioner. You can obtain Safe Space training from a local university; this educates allies about how to ensure members of the LGBTQ community feel safe and included. Make sure your client knows that with you they are part of a team working for the betterment of their own health. Develop and maintain a strong referral network of other transgender-friendly providers for specialty work. Be a real ally and advocate, and stay current on the research and the issues, because the subject is always evolving.
One Client's Perspective
By Max Galligan
It is important, now more than ever, that vulnerable populations have safe spaces where acceptance and understanding thrive. Oftentimes, these communities duck away from places or situations that could make them susceptible to discrimination, and unfortunately this could result in them avoiding seeking the help they need.
Massage therapy has proven to be very beneficial for trans individuals and has the potential to make waves within the community, because it allows those who carry large amounts of mental and physical stress to find a place of relaxation, comfort, and oneness within themselves. As a strong supporter of massage therapy and body memory work, I believe that proper therapeutic touch has the potential to relieve built-up, gender-related trauma, especially related to feelings of body dysphoria, a discomfort stemming from the existence or nonexistence of certain body parts and traits.
But, these needs cannot be met without first having “the conversation.” A safe space develops from asking a client about their gender identity, preferred name, and pronouns. By listing such questions on the client intake form, everyone from the MT to the receptionist will have the ability to make the client feel welcome. Circumstances of misgendering can lead to an uncomfortable situation for both parties, diminishing the overall benefit of the session.
Transitioning can bring on changes and challenges for the body. Although those who choose to embark on the journey of hormone replacement therapy clearly weigh the pros heavier than the cons, there are the possible risks and side effects lingering in the background. Consequences for trans women may include an increased risk for developing blood clots, gallstones, and breast cancer, and for trans men may include ovarian cysts, increased blood pressure and cholesterol, headaches, and acne. As a transgender male who has suffered from facial and body acne following hormone replacement therapy, I understand that massage is a great contributor to healthy and radiant skin, but it was important that my massage therapist also understand the tremendous sensitivity of my skin.
I can’t help but think that conversations such as these will help educate the masses and could result in a trans population that carries less stress, experiences an increase in feelings of happiness and contentment, suffers less chest and back pain from compressing/binding, endures less severe postsurgical scarring, and gains an increase in nerve regrowth due to a boost in tissue massage.
Max Galligan is a transgender male and massage therapy aficionado studying transgender issues in contemporary society.
One MT's Perspective
By Hannah Adkins, LMT
I’ll admit, I had to orient myself to Deborah. Deborah is the stepmother of a regular client of mine, Bradie. Bradie had already gifted me the book her mom had written about Deborah’s transition story from male to female (My Husband’s a Woman Now: A Shared Journey of Transition and Love, www.virtualbookworm.com, 2014). This backstory was so moving that I was honored when Bradie asked me to provide bodywork to her mother and Deborah as a Christmas present.
Having read the book detailing this couple’s journey and struggle, I can tell you that it was impossible to keep my knowledge from impacting the sessions that day. Both women remarked at how gentle I was; yes, this is usually part of my style, but my heart reached new levels of awareness. I could not help but provide massage with greater compassion than ever before.
I was suddenly hyperaware of my body language. I wanted to express total acceptance and make her feel relaxed (after all, it is massage). As I worked on Deborah, I sensed a chronic somato-emotional holding, as if her body was “holding it together” and/or protecting herself from potential physical or emotional harm. She asked if I had questions: I said no. I wanted for her to feel she didn’t have to prove herself, or explain herself; that she could just be.
On a deeper level, working with this transgender client reinforced what the healing arts have always taught me:
1. We are the sum of our experiences.
2. The whole person is greater than the individual parts.
3. Our bodies tell our stories.
4. Respect and acceptance are essential to the therapeutic relationship.
5. Every person deserves to be handled with care.
I learned much from my experience working with Deborah, but what struck me most is that, ultimately, hers was just another body. Another body with its own needs, injuries, surgeries, stories, successes, failures, loves, hobbies—a whole life. In the massage space, gender becomes neutral. When the truth of bodies speak, there is surrender to the beauty of the moment, of the healing and repose that is happening before your eyes and under your hands. In this space, there are no labels, no explanations—just being.
Hannah Adkins, LMT, RYT, BS, is sole practitioner of Inner Joy Therapeutics in Denver, Colorado. She is passionate about the power of healing arts to help overcome trauma. She facilitates others’ inner joy through multiple avenues: therapeutic and Thai yoga massage, private yoga, and specialty workshops. Contact her at innerjoytherapeutics@gmail.com.
Terminology
al•ly
A straight ally is a heterosexual and cisgender person who supports equal civil rights, gender equality, and LGBTQ social movements, and challenges homophobia, biphobia, and transphobia.
cis•gen•der
Noting or relating to a person whose gender identity corresponds to that person’s biological sex assigned at birth.
gen•der bi•na•ry
The idea that there are only two genders, and that they are distinct, opposite, and disconnected from each other.
gen•der ex•pres•sion
How a person chooses to present their gender identity.
gen•der i•den•ti•ty
Refers to a person’s innate, deeply felt sense of being; usually male or female, but not always.
gen•der neu•tral
Someone who does not identify with any gender. May use neutral pronouns such as they/them/theirs.
gen•der non•con•form•ing
Someone who is not interested in conforming to societal views of how any one gender should be portrayed.
in•ter•sex
A general term used for people who are born with a variety of conditions in which the reproductive or sexual anatomy do not fit typical definitions of female or male. Intersex conditions can be anatomical or genetic and may manifest in a wide variety of ways. Many genetically intersex people will never know of their condition.
sex (male/fe•male)
Refers to our biological and physical anatomy. Biological sex is used to assign gender at birth. For most people, sex and gender are aligned.
trans•gen•der
Noting or relating to a person whose gender identity does not correspond to that person’s biological sex assigned at birth.
trans man (FTM, F2M)
A person whose assigned sex at birth was female but identifies as male.
trans wo•man (MTF, M2F)
A person whose assigned sex at birth was male but identifies as female.
Notes
1. Unwinding the Threads, “Loving What Is,” July 2, 2015, accessed January 2017, http://unwindingthethreads.blogspot.com/2015_07_01_archive.html.
2. Claire Ainsworth, “Sex Redefined,” Nature 518, no. 7539 (February 2015): 288–91.
3. A. R. Flores et al., “How Many Adults Identify as Transgender in the United States?” The Williams Institute, June 2016, accessed January 2017, http://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-as-Transgender-in-the-United-States.pdf.
4. M. Blackless et al., “How Sexually Dimorphic Are We? Review and Synthesis,” American Journal of Human Biology 12, no. 2 (March/April 2000): 151–66. doi:10.1002/(SICI)1520-6300(200003/04)12:2<151::AID-AJHB1>3.0.CO;2-F.
5. S. E. James et al., The Report of the 2015 U.S. Transgender Survey, Washington, DC: National Center for Transgender Equality (2016), accessed January 2017, www.transequality.org/sites/default/files/docs/USTS-Full-Report-FINAL.PDF.
6. “Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People,” 2nd ed., ed. M. B. Deutsch, Center of Excellence for Transgender Health, June 17, 2016, accessed January 2017, www.transhealth.ucsf.edu/trans?page=guidelines-home.
7. Ibid.
8. J. D. Fernandez and L. R. Tannock, “Metabolic Effects of Hormone Therapy in Transgender Patients,” Endocrine Practice 22, no. 4 (April 2016): 383–8. doi: 10.4158/EP15950.OR; J. D. Weinand and J. D. Safer, “Hormone Therapy in Transgender Adults is Safe with Provider Supervision; A Review of Hormone Therapy Sequelae for Transgender Individuals,” Journal of Clinical and Translational Endocrinology 2, no. 2 (June 2015): 55–60.
Ellen Santistevan is a licensed massage therapist who practices craniosacral therapy and polarity therapy, and has additional experience in geriatric work and shamanic practice. She teaches ethics, polarity therapy, and reflexology in Albuquerque, New Mexico. Her practice integrates elements of all these bodies of knowledge, as well as the most current research on wellness. You can find out more about her at www.thirdgoddess.com.