Background
Treatment for any clinical issue can be difficult. The first stage of therapy usually focuses on improving awareness. As client awareness grows the root issue driving the problem becomes clearer.
For comparison, think of this as going to your doctor with a list of symptoms awareness comes when the doctor provides a diagnosis. In therapy diagnosis describes the symptoms of the problem, not the root cause of it.
Depression is diagnosed based on the symptoms which are consistent. The root cause could be any number of issues, hormonal, psychological, social, or bereavement. Without having some understanding of a root “cause” it’s not possible to provide treatment that will permanently “resolve” the problem.
With anxiety people often view the thing that triggered their anxiety as the problem. When I look at anxiety, I ask whether they experience it more in their thoughts or their body. Often clients respond with the body. This signals to me that their body has become overly sensitive to stressors. Treatment focuses on developing body resilience to stress. This reduces the experience of anxiety over time.
Culturally people often want to fully avoid uncomfortable emotions. They want to never feel anxiety. I help people build up a high tolerance so that when anxiety or stress comes, they have the capacity to face it. For some people this means recognizing that their circumstances may be quite stress inducing and focusing on what they can do to cope and be resilient throughout the experience. Think of caring for an aging parent. This will cause an unavoidable level of stress. How do you care for yourself through a sustained stressful period?
From a cultural standpoint transgender care focuses on increasing the comfort of the person experiencing gender dysphoria. From a therapy standpoint, I consider the person’s overall ability to function as a whole. Focusing exclusively on a person’s comfort and making them more comfortable makes them fragile, not resilient. When treating anxiety the client’s goal is to feel better. My goal is to develop resilience and tolerance for uncomfortable emotions. This has the byproduct of decreasing unwanted emotions.
Relevant Definitions
Trans – has two parts – identity and choice.
Gender Dysphoria – The clinical diagnosis for when a person feels distressed that their gender doesn’t match their sexed body.
Gender – whether someone feels more masculine or feminine
Sex – biological sex which determines our physical appearance
Fantasy – a thing which may or may not happen, this can include an expectation of emotions associated with an event.
How Culture makes Treating Gender Dysphoria Harder
With my gender dysphoric clients there is a tendency to describe their problem the same way, almost verbatim.
“My gender doesn’t align with my sex.”
“I feel dysphoric when people use my biological pronouns.”
“I feel uncomfortable with how my body looks.”
The responses feel almost scripted. It’s a curiosity since descriptions of other conditions vary widely even though they tend to have many similar traits. These scripts are learned from our culture and make it hard for clients to explore their experience on a personal level.
Getting clients off script
The primary challenge is that clients have a hard time considering their problem in a way other than what they have learned it to be.
I often work with clients to think more deeply about what they’re experiencing, but with gender dysphoria it’s like they get stuck. What they’ve learned is the only way they know how to describe their experience. Getting clients to explore themselves more deeply must be done in a more round about way.
I want to know what’s happening for the individual. What is this person’s root cause? What treatment plan does this individual need? Will transition be helpful or disappointing for this person? Will it add new complications?
Many times, the root cause is a sense of self impacted by internalized homophobia, misogyny, toxic masculinity, porn, stereotypes, neurodivergence, or sexuality. If these root causes aren’t identified, then they will still be there whether or not someone transitions. A root that isn’t resolved will pop up again eventually even if someone experiences gender euphoria after transitioning. Euphoria tends to wear off over time.
Reframing the Problem
In treatment it is routine for me to reframe the original issue the clients came in with. In couples therapy they may say “We fight. She nags. He withdraws.” I reframe this dynamic using the infinity loop. It’s not that anyone is doing anything wrong. This is a response to vulnerable emotions. What can you do to stop triggering their vulnerable emotions? What need isn’t being met for you?
This reframing of the problem is what facilitates the creation of solutions. The original problem leaves clients at an impasse. Gender affirming care frames the client’s body as the problem. If the body is the problem, then changing the body makes sense. If the feelings about the body are the problem, then changing the body may only provide temporary relief.
Unfortunately, this is what my colleagues see from clients who are re-engaging with therapy after living as trans for 20 years. Their feelings still haven’t been resolved.
Is the problem body image? Is it something else? What problem does altering the body solve?
Sex and Gender need to be distinguished
Another challenge is sex and gender often get conflated.
Gender is considered a social construct. How we style ourselves through our clothing, hair, make-up, etc. reflect our gender. Changing these characteristics is gender transition.
Changing your body to appear as the opposite sex through hormones and surgery suggests sex dysphoria, a discomfort with biology. The current use of gender dysphoria includes sex dysphoria, which creates confusion in people.
Nuance in therapy is important. It helps to clarify what’s happening and reveal root issues. If we don’t look at nuance then we’re not customizing therapy for the individual. We’re putting them on a conveyor belt without truly understanding their needs.
Role as Therapist
As a therapist I view my role as helping people understand their options and identifying things they may not have considered. This includes helping clients explore root causes they may not have considered.
Pre-transition clients have a fantasy about what transition will mean for them. It can include an expectation of increased confidence and comfort with their body. Since emotions tend to fluctuate and can be unpredictable, it’s important to recognize that even if someone’s expectations are met through transition the expectations, they had prior to transition were a fantasy. For many people their fantasies don’t live up to reality, regardless of what those fantasies are about. Is the client equipped to face any disappointment which may follow?
Considerations
I believe in the autonomy of individuals. I think adults should be free to make decisions about their physical appearance. I think it is important to be more cautious with treatment provided to minors. Minors should not be pursuing permanent changes if they have unrealistic expectations about the benefits or risks associated with pursing these choices. I think therapists serve an important role in helping clients reframe and rethink their experiences. The way a problem is defined determines the solution that is sought after.
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