Culture plays an important and crucial role in the determination of gender. Most cultures understand genders and sexes as binary entities. A plethora of societal characteristics, marked and tainted by gender roles, play the pivotal role of categorizing a person into either a male or female category. These can vary from physical appearance, clothes, haircut, and mannerism to even personal characteristics and career paths. This categorization is even more accentuated with gender stereotypes that predominate in our cultures: Girls are expected to wear pink and play with dolls, try on makeup and become housewives. Boys are expected to play football and go into professions such as engineering and medicine. Boys are expected to be “strong” and not show emotions while girls are expected to be sensitive and caring. In the dark Language, which is a central part of any culture, also plays an essential role in influencing the way we see the world around us. Countries using gendered languages where nouns, adjectives, pronouns, and sometimes verbs have a gender, showed less equality in comparison to countries that established neutral gender or genderless language systems (Prewitt-Freilino, Caswell, & Laakso, 2012). Arabic is considered a gendered language, the sociolinguistic (relational) level of Arabic is male-associated and the formal level of the language is androcentric (Alkohlani, 2016; Sadiqi, 2006). It is no surprise then that transgenders in the Middle East belong to an underground community (Whitaker, 2016). Being in the dark seems the only way for them express who they truly are all whilst avoiding all kinds of discrimination from personal, professional to judicial. There has been a witnessed shift of perspective when it comes to gender from a rigid dichotomy to a spectrum (Butler, 2011; Fausto-Sterling, 2000). According to biological determinism on the conceptualization of gender, femininity and masculinity naturally abide by the physical differences between males and females. However, according to the social learning theory, individuals acquire different gender roles by adapting to cultural and societal values of gender conduct. A third theory pertaining to cognitive development emphasizes the combination of an individual’s interaction with the world, their information processing and own conceptual thinking (Tiwari & Ghadially, 2009). Furthermore, according to normal cognitive and sexual development, children around 7 years of age identify the flexibility of gender expression (Bancroft, 2008). Cross-cultural studies show that children from countries where negative attitudes towards gender non-conformity are present express greater gender stereotyping compared to children growing up in countries that showed tolerance towards gender differences (Bancroft, 2008). In a world of uncertainties, a ‘leap of faith’ is at times needed to allow the person to self-actualize. Laws & Psychopathologies in the Middle East Transgenderism in the Middle East is often seen as cross-dressing and the Hadith of devout Muslims banishes these practices (Whitaker, 2016). At the World Conference on Women held between 1995 and 2005, conservative Muslim and Catholic delegations radically rejected the use of the term “sexual rights” in United Nations (UN) documents. During the UN Commission on Human Rights conference in 2003, the affirmation of protection and promotion of persons regardless of sexual orientation followed a backlash by Pakistan, Saudi Arabia, Libya, Egypt and Bahrain as well as other conservative delegates supported by the Vatican (Ilkkaracan, 2016). Middle Eastern countries do not acknowledge any gender identity other than the binary female/male. The right of social protection, freedom of gender expression privacy and basic human rights of individuals are therefore constantly violated by targeting and persecuting persons with non-normative sexualities and gender identities. Thus LGBTQ+ persons are continuously facing social discrimination, rendering their lives a living hell. © diane arbus But it doesn’t stop at social discrimination. “One of the main challenges we face besides the stigma is hospitalization. It is extremely difficult to be admitted to a hospital if you are a transperson. And this happened to me twice”: This is what Coco, a Lebanese transgender woman, told Jasad. Another main challenge Coco mentioned is the constant struggle to find a job instead of having to resort to sex work in order to make ends meet. Mimi, another trans woman, pointed out that on top of hospitalization, there’s another problem with insurance policies. She explained: “You have to pretend you are still a man, or lie by saying that your “sister” is going to renew the insurance on your behalf, in order to get things done. If they know you have undergone a sex change operation, they will consider the policy to be void because you deliberately “hurt” yourself”. Moreover, there is an immense lack of doctors who are specialized and knowledgeable about transgenders. “I haven’t met a single doctor in Lebanon that knows about transgenders more than me,” she exasperatedly said. In 2007, during a speech in New York, the president of the Islamic Republic of Iran (IRI) stated that there are no homosexuals in Iran (Ilkkaracan, 2016). This political statement puts in context sexual freedom in a Middle Eastern country such as the IRI; it is simply deemed nonexistent. But, IRI authorities ironically offer homosexual individuals the choice between the death sentence and sex change operations partially funded by the government (Bahreini, 2009). This stance could appear beneficial towards transgenders seeking surgical transformation however it invalidates and illegitimates non-surgical transgender persons and limits irrevocably their freedom of choice. The IRI, in that regards, symbolizes a Middle Eastern country where gender non-conformity is perverse and harshly punishable by law, which makes sex reassignment surgeries a coercive strategy for homosexuals to conform to heteronormative orders. Article 534 of the Lebanese Penal Code clearly states the punishment of “unnatural sexual intercourse.” The judicial system in Jordan and Penal code of 1951 does not condemn homosexual conduct, but LGBTQI+ persons can be prosecuted for displaying public affection, which is considered a disruption of public morality. In Kuwait, Article 193 of the Penal Code condemns homosexual behavior up to six years in prison and Article 198 stipulates 8 years of prison for transgender persons. There are no written laws around homosexual conduct or Transgenderism in Saudi Arabia but, in strict execution of the Shariah Law, the State penalizes LGBTQ+ activity with a death sentence. It is the basic institutions’ responsibilities to allow the freedom of gender expression that may not be conform to the socialization process. Taking into account the dire living conditions of Transgender people, it is necessary to look into comorbid disorders that may be experienced by the transgender person in order to implement individualized treatment plans. The findings of the study conducted by Ibrahim, Haddad, and Richa (2016) in Lebanon portray significant differences in suicidality, major depressive disorder, anxiety disorder and post-traumatic stress disorder (PTSD) among transgender persons compared to control groups. Discrimination is a major risk factor of psychiatric problems among this vulnerable population; the marginalization of transgenders in the workplace further accentuates their financial instability and harsh living conditions (Ibrahim, Haddad, and Richa, 2016; Nemoto, Bödeker, & Iwamoto, 2011). However, a shimmering light is that a growing number of transgender persons are fighting for positive change in their communities by promoting self-actualization and self-disclosure on social media platforms (Miller, 2018) and this was seen in May 2020 when an Egyptian actor’s transgender son was revealed on TV (BBC News, 2020). Transgenderism and Existentialism We are responsible for our life’s meanings, choices, actions and ways of being and first and foremost, being true to one’s self. Can a transgender person live authentically if sex change is not made? “Sex change allowed me to feel alive in the body of a woman and to feel internally comfortable in my body,” said Mimi. However, she also believes that “you can live authentically without it and that sex change does not make you more or less of a woman”. According to her, it depends on what is it exactly that triggers your womanhood. Is it the genitalia or is it simply dressing up and feeling like a woman by socially presenting yourself as one? Another challenge that was addressed by Coco is that, even after undergoing the operation, your identity on paper is extremely difficult to change legally in the Middle East. “This is an essential barrier that stands in the way of a transgender being able to live authentically”, she told Jasad. © Terrance Hinch The risk of living in ‘bad faith’ becomes higher when sociocultural factors constitute a barrier to the person’s expression of their authentic identity (Sartre, 1958). In fact, human existence is constituted of a myriad of tensions, paradoxes and dilemmas and incongruence needs to be resolved between the basic dimensions of the person’s existence: the social world (eigenwelt), the physical dimension (mitwelt), and the personal microenvironment (umwelt) where the person recognizes and expresses their gender identity (Cooper, 2016). The therapeutic work revolves around exploring the client’s attitude to their own body, other people’s bodies, their own bodily needs, how they interact with the world around them, their own views about their strengths and weaknesses, how they define themselves and their sense of identity (Godman, 2018; van Deurzen, 1997). Existential psychotherapists may want to examine the client’s culture; the person’s response to the community they belong to, their values, their beliefs and challenge some of the clients’ world-views. The therapeutic process may lead to the integration of the person’s past gender and current identity. As a mater of fact, we are continuously forming and rewriting our narratives and might project them to the future Self which in turn may create ontological anxiety about the possible transition (Richards, 2011). In a world of uncertainties, especially in the Middle East where laws condemn LGBTQI+ communities, a ‘leap of faith’ is at times needed to allow the person to self-actualize (Kierkergaard, 1944; McLeod, 2007). It is essential to keep in mind the medical model with gender dysphoria while also bracketing all preconceived ideas of what transgenderism is. Hence, a trusting and containing environment is key in the therapeutic relationship and confidentiality measures are also necessary to keep the client safe from any persecution or lynching. Creating clear boundaries between the therapist and client helps them feel contained and sufficiently safe in the uncertain and chaotic internal and external world they are already living in (Strasser & Strasser, 1997). © Frida Kahlo In conclusion, gender identity is fluid, complex and personal, and certainly not defined by others. Gender identity and its expression pertain to a continuum between masculinity and femininity. Scientists and practitioners may pathologize the person’s own body experience as body dysphoria. But, the lived experiences of these individuals clearly show that the change in gender expression may alleviate the significant distress experienced. It is then the basic institutions’ responsibility, notably the family and school, to establish non-gendered discourses and to allow the freedom of gender expression that may not be conform to the socialization process (Dilanyan, Doğan, & Iluridze, 2017). Labels thus should be abolished and stigma reduced for the LGBTQI+ community, which in turn will lead to a better adaptation and transition of the transgender person. Advocacy in sexual education should empower transgender persons as well as promote inclusion among cisgender young people (Riggs & Bartholomaeus, 2018). A comprehensive approach towards their own body, desires, needs leading to a more authentic Self is also highly needed and encouraged. Although the word “disorder” in the DSM-5 was changed to “gender dysphoria”, the stigma is unfortunately still prevalent in our world. Can a transgender person live authentically if sex change is not made? Some relevant definitions: Sex is related to the biological and anatomical expression of the genitals and includes hormonal, genetics, and other components of the human body (Butler, 2011). But sex expression is not always as categorical and clear: a third sex or intersex category emerged in history and medicine (Ahmed, Morrison, & Hughes, 2004). Gender Identity is the person’s self-identification and deep sense of being male, female, something in between or neither. Biological sex is a distinct concept from gender, thus gender identity may be distinct from biological sex (Tiwari, & Ghadially, 2009). Gender expression is the person’s expression of their gender through characteristics manifested by society’s definition of masculinity and femininity. Gender is on a spectrum of expression (Knafo, Iervolino, & Plomin, 2005). It is a choice of pronouns, names, and physical appearance and it can vary in different contexts. For example, gender atypical behavior refers to boys behaving in a feminine way. Sexual orientation refers to the person’s sexual identity related to the gender they are physically or emotionally attracted to. The orientation can be heterosexual, homosexual or bisexual. Transsexual is a term introduced by psychiatrist Cauldwell in 1949 designating a person whose identity is strongly linked to the opposite sex (Bancroft, 2008). The person usually seeks medical assistance that pertains to sex reassignment surgeries and/or hormone replacement therapies (Ibrahim, Haddad, & Richa, 2016). Transgender is an umbrella term incorporating a plethora of gender identities and expressions. It designates “embodied movements across, between, or beyond the binary categories of male and female” (Hines, 2007, p. 1). Individuals identifying as transgender may or may not undergo permanent bodily changes; the person could use hormone treatments, endure reconstructive surgeries, or cross dress to express their authentic gender identity. Dr. Magnus Hirschfeld (1910), a physician and sexologist that examined human sexuality and actively advocated lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI+) minorities, placed Transgenderism in a distinct category from homosexuality and transvestism (Stryker & Whittle, 2006).  Gender dysphoria is defined in the Diagnostic and statistical manual of mental disorders (DSM-5) as any person who experiences significant difference between his or her expressed gender and his or her gender assigned at birth (APA, 2013). Gender nonconformity is not considered a mental health condition, but a person diagnosed with gender dysphoria experiences significant distress related to being non-conforming (Bancroft, 2008).