Transsexuals, transgenderists, crossdressers and others, collectively known as "transgender individuals" may at some point in their lives find themselves at a unique crossroads, requiring different types of social, psychological and medical services. Subsequently, while many explore individual counseling or psychotherapy to learn about gender issues and receive support for their needs, they may also seek out additional assistance through support groups. Others who may be unable to afford or who are uncomfortable with or distrustful of individual psychological services, may rely heavily on information presented in groups to guide major life decisions. Clearly, support groups play a major role in assisting transgender individuals. This article will provide information useful to facilitators and support group participants.

During the past several years much controversy has evolved regarding the "gatekeeping" role that mental health professionals play in the lives of transgender individuals seeking hormone administration and gender confirmation surgeries. In fact, having a "dissenting point of view" has become de rigueur within many social circles. While such controversies may be fashionable, they fail to address several constant themes which envelope the quality of life of transgender peoples.

These themes include:

• The need for transgender individuals to receive accurate information about gender identity issues, preferably from providers with training, experience, and knowledge within this specialty field.
• The need for transgender persons to have services available which acknowledge an individual's right to gender-oriented self-determination and insure the preservation of medical and psychological safeguards.
• The need for recognition by transgender persons and emphasis by careproviders and consumer organizations that transgender individuals are consumers, not a mentally ill population. Up-to-date information reflecting this knowledge is needed so consumers and careproviders may interact on equal footing.

The development and clarification of these themes come as a result of my experience as principal author of the Recommended Guidelines for Transgender Care and while interacting with that resource's 21-member professional/consumer review committee. Although unique, that process reflected similar dynamics operating in most traditional support group settings. I found there to be sharing of information based on the experiences and insights of various persons. Brought to the "group room" were different political agendas which required sorting through. Some participants preferred to "lurk" or listen-in without contributing, while several others had difficulty following "group rules." Lastly, the review process incorporated great deal of concern for the well-being of transgender people.

During this process one concern voiced by several people was that some support groups are being facilitated by individuals who were early in their gender transition yet in facilitation acted as "instant experts" without having a working knowledge of gender identity issues. Such a situation presents the possibility that inaccurate information may be passed on to group members, crisis situations may not receive adequate attention and the facilitator may be unaware of resources designed to support individuals whose needs extend beyond a support group's function. Clearly, support groups need to be facilitated by individuals with sufficient facilitation experience and knowledge about gender identity issues, much as one would come to expect similar competency from other gender-specializing careproviders. At the very least, new group facilitators should have ample experience as a group member, if not actually having co-facilitated a group under the watchful eye of an experienced group facilitator.

The introduction of concerns such as these by a professional-consumer committee makes it apparent that support groups are playing an important role in transgender lives. This is especially so as individuals seek options which are more self-empowering and less pathologizing. With the expansion of support groups, what also becomes evident are the many parallel dynamics which exist between peer-facilitated support groups and professional support services. To such complimentary dynamics which introduce important questions for providers are "confidentiality" and the aspects of "group focus and homogeneity."

Establishing and reiterating confidentiality rules for new and established groups helps individuals feel safe sharing personal feelings and experiences, without concern that private information will be discussed outside the group. One may think that simply reminding participants that confidentiality is needed for maintaining a safe environment would be enough; however because support group confidentiality issues can be as complex and potentially damaging as those faced in professional careprovider situations, caution needs to be reiterated frequently.

Recently I provided counseling to an individual who had disclosed within her regular support group her intention to postpone Genital Reassignment Surgery because "now" just wasn't the right time. During group the following week, in her absence, her surgery postponement plans were discussed in the presence of newcomers. Returning to group a week later, the individual was very upset to find that this had been discussed in her absence and that several of the newcomers had questioned whether her presence in the group was appropriate since she had cancelled surgery and wasn't serious about her transition.

Situations such as the preceding one can be avoided by facilitators and participants remembering that confidentiality extends both within and outside a group. Typically, personal information regarding an absent participant should not be discussed without that individual's permission. Group facilitators can redirect such discussions by encouraging group participants to focus on their own current needs. Group participants in sharing personal information can also state they do not want their issues discussed in their absence. Lastly, individuals who are concerned about a participant's previous circumstances can extend privacy to that individual simply by asking if he or she has had any new developments regarding "the topic shared last week."

The previous case scenario also provides us an introduction into the subject of "group focus and homogeneity." The group in which our individual was a regular participant officially welcomed all transgender persons, regardless of self-identification or stage of transition. However, because all the participants happened to be transsexuals living "in role" and seeking surgery, it was assumed by several newcomers that a committed interest in undergoing surgery was the criteria for group participation. Clearly, misunderstandings of this nature can be prevented by group facilitators informing all new attendees of a group`s focus.

Within the transgender community there are a wide-variety of support groups, with different structures, target issues and sub-population outreaches. Thus, there are groups for crossdressers who meet "in drab" during a business-lunch hour to discuss common interests (and who would not welcome someone dressed in high drag) as well as groups for transgender individuals having difficulties with chemical dependency. The most common type of support group within the gender community is the local "drop-in" group where anyone interested in gender issues is welcome. These groups are valuable as they provide an excellent resource for individuals with basic "coming-out" questions as well as a contact point for those wishing to initiate or re-establish social contacts and gain new information.

In establishing or maintaining a support group, facilitators need be aware that different groups require both an understanding of the needs of group members served as well as those that do not attend, i.e., other transgender sub-populations. Gaining a working knowledge of the many types and needs of transgender individuals helps the facilitator dispel misunderstandings about other populations as well as recognize when a group member has concerns which reach beyond a group's focus. A facilitator can learn about the variety of transgender populations by co-facilitating or even visiting a basic drop-in group on a regular basis. If that is not possible, consulting with an experienced gender specialist is another option for achieving a wider exposure to gender issues. Typically even experienced gender specialists welcome consultation opportunities since this allows them to keep up-to-date on currently evolving information in the gender field.

In working with support groups, facilitators and group participants need to be aware of the benefits and drawbacks of groups comprised of heterogeneous versus homogenous populations. Homogenous groups, or those which have one focus and serve a specific group of individuals, allow members to examine a narrow spectrum of issues without secondary distractions. However, these groups exclude those who may benefit from hearing about the advanced experiences of others, particularly when an individual is still confronting difficult coming-out questions.

Heterogeneous groups on the other hand welcome all transgender individuals and subjects for discussion. They provide a great deal of content variety for group members but may not have enough structure or focus for those needing an in depth examination of issues in order to resolve difficulties. In these circumstances, such individuals should be referred to a homogeneous group and/or individual counseling.

The following information drawn from the Recommended Guidelines for Transgender Care may be used by individuals interested in starting up and maintaining a support group.

Basic Support Group Pointers

Start-up

If for reasons of location, timing or specialized interests, an individual is unable to find a support group, there always remains the option of starting one. Locating members for a group may be done by running a classified ad, posting notices in places frequented by transgendered individuals or even, on a computer bulletin board. Before venturing out on their own, new group facilitators are encouraged to have had experience co-facilitating a group with an experienced facilitator, or at the very least maintain consultation with an experienced gender specialist.

Confidentiality

The feelings, thoughts and experiences that individuals talk about should stay within the group. This makes it a safe place, without the fear of being found out or embarrassed at a later date. Sensitive information presented by group members should not be discussed in their absence without their permission.

Speak from one's own experiences

Being criticized, ridiculed, humiliated or bullied is inappropriate, harmful to participants and threatens the life of the group. While disagreement is OK, the best way to advise others of alternatives is to share one's own experience. Speaking from one's own perspective diminishes situations of individuals taking on the role of "instant expert."

Format

Establishing a format helps groups run smoothly. Start out with group member introductions, allowing time for each individual to mention their name as well as any pertinent questions or concerns they are bringing to the group. New group members should be advised of the group's focus. Provide each member with time to talk. Encourage questions and discussion on topics of mutual interest. Move toward closing time by asking if any individual has any questions or concerns which they haven't had an opportunity to raise. Close with affirmations of time well spent as well as discuss any disappointments. Announce the next group meeting date and time, and any other relevant community announcements. Following meetings should being with the introduction of new members and inquiry into whether there is any unfinished business from the last meeting.

Courtesies

After group, members and facilitators should clean up. This includes straightening chairs and removing refuse. Many groups are located in environments which will later be used by others. If donations are requested from group members, facilitators allow time for collection of funds at each group meeting as well as remind group members from time to time that their donations help offset expenses.