A Case Study of Cross-Dressing

Strategic Theory Case Study: Sally (the Husband) and Pamela (the Wife)

Sally presented for couple’s counseling with a history of cross-dressing since he was a young boy. Sally did not always want to fully cross-dress but wanted to wear women’s undergarments at all times. Some things prevented him from always wearing women’s undergarments, like when the weather is too warm, when he participated in men’s sporting activities or air travel. Sally’s main goals in therapy were to continue his choice to cross-dress while receiving acceptance, or at least tolerance, from his spouse. Sally described his relationship with his wife, Pamela, as solid, lasting for multiple decades, and made repeated statements that he loves her and did not want to disrupt his marriage but still wanted to be authentically who he is and dress how he felt most comfortable which varied at different times in his life.

Once Pamela found out Sally had been cross-dressing, she reported an increase in personal distress. Pamela, at first, believed the women’s clothing belonged to another woman and that Sally had been having an affair. Once Sally revealed the clothing was his, the wife then suspected her husband was homosexual. Pamela stated Sally had repeatedly told her he was not having an affair and was not homosexual but was in fact a cross-dresser. Pamela stated she did not understand why he wanted to dress as a woman. Pamela reported her personal distress then became a fear that others, outside of the home, would discover Sally’s cross-dressing activity. Pamela associated a potential discovery of Sally’s cross-dressing behavior to be a threat to their social status, people potentially questioning her sexual identity, and her husband’s ability to remain lucrative in business.

Pamela vocalized her disapproval of Sally’s choices and initially stated she would leave the marriage if his choices did not stop. Sally shared that Pamela’s disapproval was terribly difficult for him and he frequently sought out cross-dressing in isolation and often felt isolated in his marriage. The couple entered therapy with patterns of behavior that increased individual isolation within the relationship. The couple was also blaming one another for their marital strains. The couple reported considering divorce. The couple expressed hope that the therapeutic treatment could assuage the tension they had reported experiencing for a year.

Counselor’s Use of Strategic Therapy: Phase One

In the first phase, the counselor asked for each person’s perspective as to the reason they believed they entered couple’s counseling, commending each individual in their courage and strength in inviting a counselor into their relationship. Joining the couple through praise for their strengths and courage to enter therapy, the use of empathy, genuine concern, connectedness to the couple, and a trusted relationship with both individuals is important because the clients will eventually be receiving directives from the counselor (Haley & Richeport-Haley, 2003; Nevels & Maar, 1985; Smith et al., 2011). It is important for the counselor to place an emphasis on the couple’s strengths and accomplishments, as well emphasizing the positive aspects of each person and the relationship (Nevels & Maar, 1985; Smith et al., 2011).

The counselor asked the husband and wife to reflect and articulate their perceived individual and couple strengths, accomplishments, and achievements. The counselor redirected the individuals when they wanted to complain about one another or the behavior concerns that appeared to bring them into counseling. Each time the individuals took the focus off of themselves, individually or the coupling, the counselor redirected the couple back to focusing on themselves, their concerns, and their feelings.

The husband’s complaints were his wife’s controlling behaviors and lack of acceptance. The counselor assisted in redirecting the husband, noting areas where his wife had supportive to him and their marriage. For example, the husband had a previous job which required the family to move on an average of every 2–3 years. The wife worked hard at adapting when needing to move, not complaining about moving and encouraging her husband to continue to “climb the corporate ladder,” integrating into the corporate social environment, taking care of the children’s needs for each relocation, and being the main caregiver to the children while the husband was readily unavailable because of a variety of work-related obligations. The wife’s voluntary choices to support her husband and their various moves were highlighted. Planting the seeds of her voluntary choices, related to her internal locus of control, became crucial in these first couple of sessions.

The wife’s complaints were her husband’s choices to cross-dress and her concern as to what others might think or say if they found out he cross-dressed. The counselor assisted in redirecting the wife, citing areas where her husband has been supportive to her, their marriage, acted out of love, and had been available to his wife for support, encouragement, and problem solving. The counselor also redirected the wife when she appeared threatened and worried about what the husband’s cross-dressing behavior meant. The counselor assisted the wife in receiving confirmation that her husband was faithful to her, he was not planning on leaving the marriage, nor was her husband homosexual.

The hostility, fear, and power struggle within the coupling appeared as negative feelings and behaviors and attempts to regain power or control. The counselor interpreted the negative feelings and behaviors as an attempt by both individuals to regain a feeling of internal control and a loving connection to one another. The counselor was able to ascertain the two key core conflicts in which the couple operated under: the need for control or dominance and the need to be forgiven or forgive. The counselor’s interpretations are crucial because a plan needs to be developed in order to begin changing the cycles of interaction between the clients and the structure, power, and control within the coupling (Nevels & Maar, 1985; Smith et al., 2011). These two key core conflicts became the focus of the preceding sessions and thus the focus of the specific interventions and the treatment plan chosen.

Counselor’s Use of Strategic Therapy: Phase Two

In the second phase, the counselor assisted the couple in reframing the presenting problem. Reframing the meaning of the presenting problem and effectuating change can happen with a multitude of strategic techniques called indirect directives (i.e., seeding, restraining, metaphors, ridiculous tasks, and paradox directives; Haley & Richeport-Haley, 2003). Initially, the husband’s cross-dressing was noted as the presenting problem. By reframing the meaning of the presenting problem, the cross-dressing, the counselor assisted the couple in coming to an agreement to the real, covert, presenting problems.

There were two key core conflicts. One key conflict was the wife’s loss of power. She felt internally out of control because her husband enjoyed and would not extinguish his pursuit of cross-dressing, which she expressed not understanding and fearing the consequences of the husband’s choices. The public discovery of the husband’s cross-dressing may have potentially occurred if she would not accept his cross-dressing behavior and permit him to cross-dress at home. This was a real concern as the husband admitted to cross-dressing many times away from the home as a way to fully express himself without fear of retribution from his wife or the threat of her leaving the marriage. The wife’s behaviors were seen as voluntary, as a way to regain perceived control over her fears and misunderstandings. The other key conflict was that the husband felt shame because of his desires to express his full authenticity through cross-dressing. The husband’s behaviors were seen as voluntary and drove him to continually seek forgiveness for being inauthentic and not who he originally presented to his wife.

The couple and counselor needed to come to an agreement on the specific presenting problems in order to frame the direction for change and meet the therapeutic goals (Nevels & Maar, 1985). The goals of the couple were desiring to remain married, faithful to the marriage, and wanting unconditional acceptance and freedom to express the self without fear of judgment.

An agreement on the presenting problem assisted the counselor in gaining a better understanding of how the couple wished to resolve the presenting problem and assisted the couple in viewing the problem in a different way (Haley & Richeport-Haley, 2003).

When reframing the presenting problem, the counselor used a technique called seeding. Seeding is planting ideas early in the counseling dynamic, which may allow the clients to become used to reframing the meaning of the presenting problem (Smith et al., 2011). For example, the counselor suggested ideas such as women are allowed to be softer, less in charge; when women wear skirts and dresses, they are not necessarily looking for outside sexual attention; the wife appears controlling because she does not understand the positive effects of cross-dressing and fears she will lose the marriage and lifestyle she has come to know for decades; the wife may be resistant to her husband cross-dressing because she does not want to be seen as homosexual when her sexual identity is heterosexual; the husband continued to hide his cross-dressing from his wife so he did not encounter her outside shaming; the husband remained disingenuous in order to achieve perceived harmony within the marriage, but still acted out by sneaking his cross-dressing; and the couple’s relationship suffered because of the inability for the couple to fully accept one another. When introduced early and reintroduced repeatedly, clients become used to the reframe and it is less likely to be seen as strange or new and uncomfortable (Smith et al., 2011).

The counselor assisted the couple, when they appeared uncomfortable or resistant about their underlying problems, by utilizing metaphors and analogies to communicate to the clients instead of speaking to them directly about their presenting problems. Several examples the counselor utilized in working with the case study couple were when a woman who wants to pursue an education or career in a predominately male field is discouraged to do so because she may be seen as not behaving gender congruent and she may become frustrated and discouraged, not trusting her support system and when a man wants to have the outward expression of vulnerable feelings, he may be referred to as weak and may not be perceived as being in control and he may lose respect or loyalty of people in his personal or professional life, leading to isolation and deep unexpressed distrust of others. Although it appeared the counselor was speaking to the couple about different topics, the counselor was really relating the metaphoric descriptions back to the presenting problems. However, once the couple detected the technique, the counselor deviated from this technique until the couple again became unsuspecting. The counselor then returned back to the presenting problems when the couple was not anticipating the counselor’s return to it (Smith et al., 2011).

Frustrating the couple is another technique used to assist in reframing the meaning of the presenting problems. When either the husband or wife was unwilling to cooperate or participate in the session, they were asked questions by the counselor and then were not allowed time to answer the questions when they appeared to be ready to answer. Example questions the counselor utilized were What might it be like to not be allowed to be authentic in your own home? What does it feel like to not be accepted by your spouse? What might the trust in your relationship look like if you felt accepted and permitted to fully be yourself? Although this technique can appear to be abrupt, it is highly effective in provoking self-reflection through redirection (Madanes, 1981; Riley, 1990; Smith et al., 2011).

The use of exaggerated statements is another technique utilized in reframing. For example, the counselor made statements such as well, clearly, since you want to be in control of every aspect of the marriage and your husband, you must want to be a man; since you want to occasionally dress in women’s clothing, then you no longer want your prestigious executive career, instead you just want to be a homemaker. Although these statements were untrue, the clients were forced to explain themselves through these exaggerated statements and the frustration it evoked (Smith et al., 2011). The individuals in the coupling appeared to align with one another, against the counselor, and thus heard one another and each other’s needs more clearly than when they entered therapy.

At some, the couple expressed hopelessness about being able to come to a common ground of understanding and acceptance of one another. This often brought about discussions of the marriage potentially ending. Restraining was utilized at these times in order to assist clients in making a change. Restraining was used to urge the client not to change due to the intricacy of the presenting problems (Madanes, 1981; Riley, 1990). Examples utilized were I am not sure why you two are coming here to work on this marriage when it may just be easier to walk away and forget the multiple decades of wonderful memories and hard work which got you to this point; acceptance and understanding are part of any relationship, you two must not really have a relationship. The technique of restraining can address the mistaken belief that change must happen immediately and become permanent or it is unattainable. The multiple decade comment is a prime example of demonstrating to the couple that change is never immediate. The restraining technique encouraged the couple to do the opposite of what the counselor was asking. The couple had the desired response to the restraining technique by becoming more concerned about proving the counselor wrong rather than making the change necessary to alter underlying command messages of the presenting problem.

Counselor’s Use of Strategic Therapy: Phase Three

In the third phase of strategic therapy, the counselor spent a majority of the sessions focusing on assessing the dynamics of the couple through observation and taking a brief history. The uniqueness of strategic therapy is grounded in how the counselor focuses on the marital problems (Haley & Richeport-Haley, 2003; Metcalf, 2011). The focus here was to delineate the problems. Because, according to strategic therapy, it is the resolution of problems which effectuates change, not discovering the origin of the problems. The couple benefited most from the counselor’s assessment of how the problem was being maintained and the actual purpose the problem served within the relationship dynamic (Haley & Richeport-Haley, 2003).

The patterns within the couple became obvious to the counselor after two counseling sessions with the couple. One pattern the wife maintained was nagging about the husband’s choices, behaviors, and thoughts which she did not approve. The husband’s patterned response was to feel poorly about himself, isolate, and cross-dress as a way to express the nurturing side of himself which he thought he was not capable of achieving without the wife’s initiation through nagging. Another pattern which became obvious was the husband continuously making himself unavailable to the relationship, emotionally and physically. The wife’s response was to withdraw from the relationship, search through her husband’s belongings seeking to understand a reason as to why he appeared distant and unavailable, or to make herself overly available to the husband. The wife revealed she had this pattern of fluctuating between these behaviors as an attempt to resolve the distance in the relationship on her own. The husband usually responded by remaining unavailable and isolated.

These patterns were reflected back to the couple. The wife and the husband were not initially welcoming to the reflection of patterns. Through the strategic therapy lens, the counselor could see the couple’s patterns as a set of family rules governing the relationship (Jackson, 1965). One unspoken rule was the female wears dresses, skirts, lingerie, and stockings or pantyhose and the male wears pants or slacks, jockey briefs or boxer shorts and socks. The unspoken rule is an assumption, not only of society but also within the marital relationship. Another unspoken rule was if my spouse appears discontented then I should retreat, not engage in conversation, and continue my behavior until the spouse returns to the unspoken family rules.

Although observation of these family rules can lead to insight into the origins of the family problems, strategic therapy does not use insight to lead to change, but action (Haley & Richeport-Haley, 2003). The family rules have been established to maintain homeostasis when there has been some disturbance in a known and familiar balance, and thus serve as a force against change (Smith et al., 2011). These unspoken rules, which govern much of the marital relationship, may have restricted which solutions the couple had been trying. The counselor can assist the couple by detecting the family rules through the observation of repetitive behaviors and interactions. Altering the couple’s organizational patterns can lessen the recognized problem (Riley, 1990). In this case, change is not only required in the behavior deemed to be problematic, but also in the unspoken or underlying rule (Smith et al., 2011).

The overarching goal of strategic therapy is to encourage the marital relationship to change the distinct behavioral patterns associated with the identified problem (Gardner, Burr, & Weidower, 2006; Thomas, 1992). In the case study couple, the distinct behavioral patterns associated with the identified problem were as follows: each person was to adhere to the societal gender norm expressions; the relationship would maintain a sense of homeostasis if each person would remain inauthentic; and problems were too anxiety provoking to be addressed so acting out behavior was seen as more permissive.

Within the third phase of strategic therapy, the counselor’s focus became the couple’s communications, because people are always communicating. In essence, problems are believed to be a result of how the clients are communicating with one another through content and command messages (Gardner et al., 2006; Metcalf, 2011; Riley, 1990). The couple benefits when the counselor views the couple’s problems and symptoms as a result of how the couple is communicating with one another (Smith et al., 2011). Counselors utilizing strategic therapy believe by changing the organizational patterns within a marriage and by altering the communication patterns the identified problem will be alleviated (Riley, 1990).

The content message conveys the information of the communication. The counselor was able to distinguish the content messages through the threats and ultimatums both individuals used with the other. The couple had been communicating through negative reinforcing messages (i.e., if you don’t … then I’ll … or I will not …; and, if you do … then I will …). The command message, on the other hand, may be the unspoken or indirect portion of communications. The command message may appear as facial expressions, inflection, tone, breathing, and body posture (Metcalf, 2011). The couple’s command messages were expressed through: pulling away from one another; not communicating at all by using the “silent treatment”; and disapproving glances. Command messages are seen as unspoken family rules and most clients are usually unaware of the family rules (Jackson, 1965; Smith et al., 2011).

Command messages become patterns of communication called feedback loops. These feedback loops are patterns which connect a series of stimulus and responses. Problems are intensified in positive feedback loops, whereas problems are lessened in negative feedback loops. When the couple attempted to resolve problems by utilizing the same unsuccessful coping methods by nagging and isolating, a positive feedback loop was created and reinforced (Haley, 1984; Metcalf, 2011). The feedback loop was considered a first-order change and was the couple’s frequent immediate and interim quick-fix attempts in order to the change within the system (Haley, 1984). The case study couple’s first-order change transpired when each individual attempted to repeatedly resolve problems with the identical solutions (nagging, threatening, and isolating) but only increased the level of intensity (Coyne, 1984; Fraser, 1982).

Strategic therapy asserts underlying causes cannot usually be changed. Therefore, focusing on the couple’s interaction assisted the counselor in evaluating what was perpetuating the problems, which could be changed. A second-order change needed to occur. Focusing on generating a second-order change allowed the family system to shift into a new level of homeostasis and may have allowed for a lasting change (Foley, 1986). Change is not only crucial in the problematic behavior but also in the underlying rule (Haley, 1984). By changing the existing rules within the family system, new behavioral responses could be implemented as a response to the identified problem (Fraser, 1982).

Generating a negative feedback loop and thus a second-order change occurred through several strategic therapy techniques: an ordeal intervention, paradox directives, unbalancing, encouraging resistance, and encouraging relapse (Metcalf, 2011; Riley, 1990; Smith et al., 2011). The strategic therapeutic interventions are curious in how a change can be effectuated because the interventions create what is considered to be a therapeutic double bind. When the couple was placed in a therapeutic double bind, the couple was forced to make a choice and take an action. Action caused the change in the couple, not insight into the origin of their problems (Haley & Richeport-Haley, 2003). By allowing a couple to choose between the presenting problematic behaviors or the worse alternative, it became an opportunity for the couple to make an autonomous decision (Smith et al., 2011; West & Zarski, 1983).

Prescribing an ordeal, as another worse alternative intervention, the couple began to recognize the cost of maintaining the isolation, shaming, and escaping behavior. The strategic counselor must impose a suitable ordeal to the problem of the person who desires to make a change. The prescribed ordeal intervention needs to be more severe than the problem, causing more anxiety and distress than the problem itself. It is the actual distress produced by the ordeal which will result in a change within the system (Haley & Richeport-Haley, 2003; Smith et al., 2011). The counselor asked the couple to totally cross-gender dress and to commit to keeping a regular schedule, for an entire weekend. The couple processed what that may look like to them as individuals and discovered that the ordeal would be too extreme. As a result, the clients began to extinguish the behaviors which affected their interpersonal interactions (Haley, 1984). By avoiding the ordeal, the couple began the process of change (Metcalf, 2011).

Another core intervention which the counselor utilized was directives. The couple may view the directive as bizarre, weird, or an out-of-the-ordinary ordeal and thus the problem behavior is often resisted by the clients (West & Zarski, 1983). The clients then may either choose to follow or refuse to pursue the directive. Straightforward directives are when the counselor sets rules and boundaries; this designs structure within the family (Madanes, 1981). The counselor told the couple they were to sit with each other, holding hands, looking at one another, while refraining from conversing about their problems. This was not only a directive, but also a paradoxical directive. A paradoxical directive and an unbalancing intervention are when the counselor introduces an opposite and drastically different behavior choice to the client in order to arrest a repetitive pattern (Riley, 1990). A paradox directive may also be utilized when only one member of the couple would be more likely to follow a directive (Haley & Richeport-Haley, 2003; Madanes, 1981). The counselor identified the husband as, initially, the most willing person to make the smallest changes (Gardner et al., 2006). The husband was asked to let his wife know every time he was going to cross-dress, to follow through with his choice, and to not isolate before, during, or after cross-dressing.

The counselor also used a paradoxical directive, such as the couple who could not use punishing words, disapproving looks, and isolation and, instead, had to sit with one another when using the quiet connecting time once a disagreement arose within their relationship. The couple reported some successes and some reversions back to the old command messages. When the counselor reframed the couple’s attempts at utilizing the directives, even when the previous command messages reappeared, the couple became encouraged to reattempt the directives. The counselor reframed the couple’s behavior as cooperative; the reframing assisted in a second-order change taking place (Foley, 1986; Gardner et al., 2006).

Observing the relationship interactions assisted the counselor in being able to formulate a hypothesis and then an action plan to assist the couple (Gardner et al., 2006; Madanes, 1981). The hypothesis was the individuals within the coupling did not have explicit permission to be authentic and the family unit would be compromised if each individual did not adhere to the unspoken societal gender norms. The plan the counselor devised was to work with the couple to achieve safety within the relationship to allow each individual to become and express authenticity without retribution or abandonment. In addition, the counselor believed honest communication needed to exist without the couple needing to agree. Each individual within the coupling needed to feel supported and heard throughout their disagreements. The perceived need for either individual to be seen as correct needed to be extinguished as a way to strengthen the coupling. Lastly, the underlying content and command messages needed to be revealed and the couple needed the counselor’s support in order to surface the content and command messages and alter them.

Counselor’s Use of Strategic Therapy: Phase Four

In the fourth phase of strategic therapy, the counselor and couple set clear achievable and measurable goals. The couple’s goals were to regain the feeling of individual autonomy, to have open and safe interpersonal communications, and to not feel controlled or isolated. Gaining an explicit vision and direction of what the couple wanted to achieve assisted in reducing distractions from the main problem(s) in the therapeutic process (Haley & Richeport-Haley, 2003). The main goal of strategic therapy is to solve the hierarchal unbalance and problems (Metcalf, 2011; Smith et al., 2011). The behavior patterns, not the feelings, of the clients are explored because the belief in strategic therapy is how clients express their feelings (Metcalf, 2011).

The actions the counselor decides to take can vary within the strategic therapeutic approach. The main working phase of strategic therapy occurred when change was amplified during the third phase. During the fourth phase, the couple received more assistance when the counselor remained neutral in how their change was occurring. By remaining neutral, the counselor allowed for the couple to view themselves as responsible for the long-term second-order change. In addition, the couple was less dependent on the counselor and more invested in the each other’s ability to effectuate change. The less the counselor took credit for or shared the change in the couple’s dynamic, the less likely it was the couple would relapse back into the presenting problem (Haley & Richeport-Haley, 2003).

The fourth phase was the termination stage. Once progression towards resolving the key conflicts were made, the counselor began to disengage from the therapeutic process. Eventually the couple saw themselves as the solution and worked towards terminating from the therapeutic relationship after 10 sessions (Haley & Richeport-Haley, 2003). The couple’s presenting problems were reduced to two strategic theories key core conflicts: the need for control or dominance and the need to be forgiven or forgive. And, once the clients began resolving the feedback loops related to these two key core conflicts, the couple became masters in resolving their own presenting problems.