Social Justice and Gender Therapy

This post is an expansion of this discussion I had in the comments on the 4thWaveNow blog. I am hoping to get back to focusing on working with dysphoria rather than political issues, but after spending the last three months in grad school surrounded by these ideas I thought this post was important.

A lot of what is currently going on with gender therapy is currently related to “social justice” ideology. The goal of social justice ideology is an admirable one. Its goal is to correct injustices that occur when groups are marginalized in various ways. This is a noble pursuit. Being part of a marginalized group and being subject to discrimination and prejudice is pretty awful, which is something I certainly learned after 20 years of living as a trans women.It is not the goals of social justice ideology that are problematic, but its methods. In fact, its methods sometimes cause harm to the very marginalized groups it purports to protect.

I have seen several stories from parents who take their children to see therapists for gender issues and the therapist sees the person only once and immediately recommends transition, dismissing any parental concerns as prejudice and bigotry. Likewise, people who see therapists of their own accord find their cross-gender identities are enthusiastically supported and exploration is dismissed as unnecessary. They are reassured that their gender feelings cannot relate to other causes. Some critics have suggest that therapists are just going along with trans people because they are money-grubbing and afraid of losing business if they don’t just go along with things. I don’t think this is actually true, for one I have known many therapists and none of them seem like money-grubbers, for another seeing people only once is a poor money-grubbing strategy. Rather, it is misplaced idealism that leads to this practice, which is harmful to very minorities it purports to support.

I have written in more detail about this particular ideology here. In particular there are two features that are relevant here. One is the idea of oppression. Social justice ideology sees people as members of “marginalized” or “privileged” classes. People in marginalized classes are seen as suffering from oppression and discrimination. This is true to some extent, but social justice ideology tends to see all of their problems as coming from that source.

Secondly, narratives are primary. What I mean by that is personal narratives and stories are the most important thing. The subjective triumphs over the objective. This also intersects with the idea of oppression, where members of a dominant class are seen as unable to understand the experiences of people of the marginalized class and therefore they must always take those experiences at face value.

This means that if therapist who has a strong orientation towards social justice and works with trans people they will tend to see their problems as due to oppression, and additionally feel they should not question the client’s narrative which must be taken at face value as they are oppressed people. At first I found it perplexing this practice of engaging in minimal assessment for something as serious as hormonal treatment and surgery. This seemed irresponsible especially given as I am trained as a therapist and understand how much focus is generally placed on assessment for other conditions. Now, I understand it is not so much irresponsibility, as morality. It is not that they consider it unnecessary to do assessment; it is that they actually consider it immoral to do assessment!

This is intended to help trans people and other marginalized people, but it actually can cause harm. What it means in essence is that if someone is a member of a dominant class they receive regular psychotherapy but if they aren’t they receive a special kind of social justice psychotherapy. I do think it is important that the legitimate issues that arise from social justice thinking be considered, but not at the expense of regular therapy. I feel I have been profoundly harmed by my original therapist’s failure to encourage deep exploration of my issues, versus simply “affirming my identity”.

Because of this, gender therapy is reduced to just a few steps, specifically:

1. Eliminate sources of oppression (internal and external). If the person does not accept their trans identity then that is internalized oppression, if someone else in their life questions their trans identity, than that is just due to their prejudice and privilege that makes them not understand the gender-questioning person in question.
2. Affirm and validate their identity. In particular don’t question their identity, or assume the possibility of other underlying causes, a privileged person should never question the narrative of a marginalized person.
3. Make them aware of their options and make sure they have adequate resources and support to get through transition.

A few months ago, I attended a conference about trans health. At this conference, there was a presentation titled something like “assessments for mental health” and I was excited to attend this presentation because I thought I might finally come across some good information on this topic, which every training and conference I attend never seems to have. Unfortunately, I was rather disappointed. The presenters presented a case study of a client who had psychotic symptoms, and issues with dissociation. Surely some caution would be indicated in this case. Of course, the answer was “we found a way to get them enough resources and support to have that surgery” and there was nothing about any kind of evaluation of whether they should do this or not.

I have attended four separate trainings on working with trans clients and they all were more or less like this. Everything in the training was about cultural competency and better understanding trans people. There might also be something about the nuts and bolts of transition as well. However there was never anything about how to help people deal with their issues without transition, or how to differentiate between those who will do well with transition and those who won’t.

Here is an example of a syllabus for a class for therapists to learn about trans issues. Notice that everything in the syllabus is about learning about the experiences of trans people and how to affirm them. Again, nothing about the dynamics that might lead to transition, what factors should lead to extra caution, or how to help someone figure out if they can deal with their issues without transition.

Again, it is very appropriate to consider social justice factors when working with trans people, but it should not be considered the sole factor and overshadow regular clinical judgment. Paradoxically, serving social justice requires making sure that social justice ideas don’t result in substandard therapy for sexual minorities like trans people.

25 comments

  1. I am so glad to read some criticial analysis of the kinds of “support” and “therapy” individuals who question their gender identity have been/are receiving. Too little, too late, for most, but at least this could open a conversation, perhaps cause a few to step back and remember their therapist training or improve upon it.

    The same superficial response often happens when a client comes in with domestic violence or rape trauma, or a client of an oppressed minority (heritage, religion, whatever) comes to therapy and complains about depression. Therapists are quick to absolve all other causes or not even to look into them. Instead, clinicians often attribute any and all symptoms solely to clients’ undoubtedly oppressive and dangerous circumstances, which may be factors but are not the entire picture of these clients’ mental status.

    There must be a better middle ground upon which clients and therapists can meet, without knee-jerk reactions, so that individuals can be safely and respectfully assessed and appropriate therapeutic modalities utilized, yes?

    Particularly before people start surgically removing body parts or irrevocably changing their family and community relationships, we need to have incorporated more accurate and thorough assessments, deeper conversations and reasonable passages of contemplative time.

    Best to you,

    Sally Ember, Ed.D.

    1. Thanks for writing. I have definitely seen this same phenomena in other contexts, an earlier draft of this article included a paragraph about parallel things I have seen in supervision groups when talking about minority clients, where everything is explained in terms of oppression. Further no one dare challenge these explanations lest they be accused of racism or some other ism. It leads to much the same result, alternatives aren’t considered and minorities end up receiving substandard treatment.

  2. Thank you for this. So succinct and to-the-point. Yes — as a parent of a teen daughter who is insisting she is a boy, this is what we are encountering everywhere. As her parent, I am telling the professionals that there are underlying concerns and I am met with, “Your child knows who “he” is and all of “his” issues and problems stem from the identity. You are a transphobe.”

    In that situation, I am left with no way to really help my child in a meaningful way. Every therapist and the psychiatrist and the educational system and even the state I live in, has been tailored to do whatever my 16-year-old kid says, as long as she prefaces it with, “I’m trans.” It’s like a magic word.

  3. Thank you for this excellent post, TWT. I hope it sparks some serious discussion amongst therapists who work with young people struggling with gender dysphoria. There is a strong need for therapists who can provide alternatives for youth, in particular, who are distressed about their identities. Not all dysphoric teens even WANT to jump on the transition train, and they so need thoughtful clinicians who will take the time to explore options. In fact, I just received this comment on my blog today from an 18-year-old man who is asking for referrals and advice. TWT, would you be willing to respond directly to “jose” on my blog? Here:
    http://4thwavenow.com/2015/12/09/nothing-wrong-with-your-body-that-the-truth-cant-cure-guest-post/comment-page-1/#comment-8520

    1. Thanks, I will comment over on your blog. I do hope we can have more discussion among therapists about these issues soon. I think there are starting to be more so that is a good sign, so I am cautiously hopeful.

  4. Thank you for this. I am raising a teen who has come out as trans MtF but who has confounding issues (inherited psychotic mental illness, extreme trauma from poverty + primary residence with a single, alcoholic parent, and possible in-utero alcohol exposure). The medical & educational establishments have been quick to affirm a trans* identity without investigation of those confounding issues.

    The trans* identity is quite new despite having a laissez-faire “do what you will” upbringing. This kid was wearing mohawks and camo and using every stick as a gun while a younger brother acted and dressed as a girl – until just about the time this kid ‘came out’.

    The kid sees an endocrinologist for type 1 diabetes, and the very first time the child mentioned they might be trans, the endo offered puberty blockers. Did not try to talk to parents privately, did not ask about or consult MH specialists the child was seeing or refer the child to MH specialists, did not ask the kid what made them think it. Just said “it’s totally safe” without checking to see if there were other diabetic kids who were treated this way, without checking to see if the kids’ psych meds had been recently adjusted.

    There are so many reasons to question this kid; from their ‘other-other’ identity as an avian otherkin, to rejection of female social standards such as simply brushing ones hair before leaving the house, and ‘natural’ acceptance of male privilege such as expecting to be served by women, taking up lots of space by man-spreading and talking over women, and in large gatherings where male & female self-segregate, going with male groups. The kid does not seem to ‘map’ female social roles onto themself; but does seem to ‘map’ male social roles without hesitation.

    So, I must ask, what is the use of expressing stereotypically male behavior with a male body, while claiming to be female? Wouldn’t it just be easier to express yourself naturally in the body you’ve got, instead of changing the body to a state that is incongruous with one’s social behavior then fighting to be accepted as a masculine-acting female?

    1. Well, it isn’t really a rational thing, so people aren’t thinking strategically about whether it would be better to express male behavior with a female body or vice versa.

      Quite frankly, I probably resembled your child in some ways during my younger days. Looking back at it now I’m kind of embarrassed about it.

      I will say that there was actually something I kind of miss about being perceived as a somewhat masculine nerdy female in geek culture, as it was cool to be that in many ways and was viewed positively. It can be a social gain in those circles in some ways. Not to mention queerness is also generally viewed positively.

      It does sound like your child might have other confounding issues like you say, and I do believe that people should be looking at these things first (or at least simultaneously), especially before rushing to the transition solution.

  5. TWT, thank you for this explanation. I keep hearing that medical professionals are blindly accepting people as trans due to the financial benefits it brings, but I really don’t want to believe this. I want to think that most people out there have good intentions.

    I am a mother of a daughter who previously identified as FTM. I feel very fortunate that the second psychologist my daughter saw was able to work on why she felt disconnected to her biological sex. Had we kept her seeing the first psychologist (who has a strong social justice ideology), I know that my daughter would still feel adamant that she is my son.

    It concerns me that depending on the psychologist we chose, the outcomes could be so starkly different. And, I realize from reports from many parents I have read that it is difficult, if not impossible, in some areas to find a psychologist who will help their child try to feel comfortable in their body.

    I do hope for change–the sooner the better.

    1. I hope things change for the better soon too. People definitely mean well. It is difficult to convince people the social justice orientation itself actually serves as a barrier to social justice in this case.

  6. Thank you for this. I personally know many psychotherapists and they echo this as well. It seems so ironic and even more so, worrisome, that the gender specialized therapists are the ones with the least tolerance or skill sets to address the full picture of each client, because the social justice aspect takes up the whole approach. It’s so troubling. And it makes me sad to see the comments here from parents who likely have deep insights into the bigger story of their children’s worlds being told they are “transphobic” when they express any concern, hesitation or doubt. There is no room or tolerance for a more nuanced conversation about this anywhere. I know numerous people, myself included, terrified to join the conversation with any research or informed perspectives that challenge the social justice ideal for fear of being labeled “transphobic.” That scares me. I read something recently, quoting a “gender therapy expert” that “there is no inherent harm in “playing with hormones” or “de transitioning after transitioning.” Completely neglecting the wealth of information out there about the physical implications and long term effects of homone use, let alone the guilt, shame, increased isolation, increased lack of identity leaving the trans community, extra psychological weight that de transitioning brings with it. etc. etc. Blows. My. Mind. It’s spoken about by “experts” as casually as returning a dress that didn’t fit to the store. This will have serious implications down the road for so many. But who will have the courage to share those experiences given these huge social pressures? I think it will only lead to more isolation more feelings of shame and failure and confusion for many who need a broader understanding and true acceptance of all that encompasses. Much of which challenges the current blind dash forward toward choices that have serious effect. Thanks for doing what you do. Keep it up!

    1. Thanks so much for writing again! Yes having nuanced conversations is very important and very difficult in the current political environment. Particularly the flippancy which these very serious interventions are treated with is disturbing.

  7. Im planning in detransitioning ive lived my life as mtf for ten years i did not ever wanna have srs im only 31 years old i have surgies but nkt the big one is it too late for me do i have to pay cash that i dont have to be myself again ? What do whatever i need to do

  8. I don’t know if it’s just me but I’m absolutely fed up with the whole trans thing and its incoherence and tyranny over rational thought. The more I read about trans-things more is the emotional pressure accompanying dissipating and more insanity is revealed. I refuse to ’embrace’ any ‘diversity’ and ‘fluidity’ and ‘beauty’.

    I wonder how many years its gonna take until they realize there is something more to this than some gendered soul/psyche/brain/mind/whatever. Until that it seems difficult to get any real help.
    I found this but it seems to be one of the only more sane approaches:

    http://www.transconference.org.au/uploads/1/0/5/8/10587506/the_mental_health_professional__gender_diverse_people_az_hakeem.pdf

    Meanwhile I can only watch my mind make irrational assumptions all the time, and watch how other trans*-people are doing precisely the same (I have other disorders that have taught me a lot about things).

    1. I have read several of Az Hakeem’s papers and some of what I talk about with respect to “rigid gender schemas” come from his writings.

      Looking at underlying issues and deep exploration should be part of any gender transition, and ideally should be done before any permanent physical changes are made. It is a real problem that this has almost become forbidden in the current climate.

  9. Gender Stereotypes and “Trans”:

    I’ve definitely run into some people who’ve made me question the whole “trans” narratives as it has become these days. One thing is that I know a few people who fall into the “desisters” category: and they didn’t just desist in their early teens. I’ve met folks (many of whom had mild cases of what used to be Aspergers) who desisted in their 20’s, 30’s, 40’s or older-both with MTF and FTM inclinations. I knew one woman with Asperger’s who had FTM tendencies, who at the age of 32 got a Lap-band along with intense medical therapy for PCOS, and when the weight came off and her hormones improved the whole trans thing was GONE.

    It does seem that the whole concept of gender identity as pushed by trans advocates, is not “set-in-stone-by-birth” for everybody. I have no idea what if any therapies, could be alternatives to the transition solution, for people who don’t desist on their own…..hopefully not trying to straightjacket people into stereotypical views of their natal sex.

    As a bariatric patient who went for a “less invasive option” that being end VBLOC (a sort of stomach pacemaker/electric lap-bad), it seems like the bariatric world (which has the same gatekeeping that the trans advocates want to sack!!) is looking for less invasive options-at least at the high research level. While with trans the trend is in the opposite direction-sign people up for multiple invasive surgeries and lifelong hormone therapies with no alternatives pursued.

    The other side of it is that it has become clear that some trans people are mentally ill. And I know, one MTF who has HFA, and I cannot see how transition is in their person’s interest. She turned down vocational school, and opportunities to do intense OT and virtual reality for adult HFA, to transition. She obviously has massive psychological problems on top of the HFA and transgenderism-recovering addict with PTSD as well. And I suspect that a sex change is practically going to be a one way ticket into marginalization, poverty, and prostitution. I would be seen as a bigot for asking if being a guy could possibly be just so awful that living such a marginalized life with no treatment or vocational treatment as a trans woman would improve much.

    Finally, the most troubling thing to be as is that the “Free to Be You and Me” of the 1970’s is dead. Replaced with the notion that every gender stereotype known to man is innate, biologically hardwired, and immutable. While not all transsexuals buy old fashioned gender stereotypes, it seems that much of the media and society understands the whole trans things in terms of stereotypes that were considered passe some decades ago. Feminists who question these trends are labeled as TERFs or bigots, even if they never made any blanket condemnations of transsexuals.

    1. Its interesting, I was talking about these issues with a friend a while back who does some work with bariatric patients and she instantly noticed the parallels in expectations and other things between that population and people considering gender reassignment.

      The connection between autism/Asperger’s and gender issues is well known to exist in the clinical community but it is difficult to sort out the why and the what causes what.

      I think it is really important to hear more stories from desisters, how they developed gender issues and how they desisted. Those stories tend to never get told, because the person has just moved on with their lives and never went through a medical process. This would help to show the possibility of desisting to those struggling with these issues as well as to give insight into how that happens.

  10. Yes, I agree that much better assessment and ongoing support is key to ensuring that people (especially teens and young adults) are making the right decisions for themselves and that they will be able to handle the stressors involved with the dramatic changes: social, physical, psychological and interpersonal, that come with gender reassignment.

    It seems that in the treatment of Gender Identity Disorder and/or body dysphoria, the person seeking treatment is reduced to this narrowly defined pathology. A person walks in as (let’s say) Chris who is (perhaps) introverted, bright, sensitive, artistic, from a middle-class home and/or a religious family and is lonely and prone to depression … and in one session Chris is reduced to being “transgender” as if their gender identity was the only factor to consider in their well-being and long-term stability.

    If the same person came in as Chris who is suffering from bulimia and depression, the therapist would undoubtedly want to explore the person’s history more carefully and would address issues like family dynamics, religious beliefs, history of sexual or physical abuse etc. And certainly it would be understood that this person would need a great deal of support, time, etc. to get to the root causes for their eating disorder and depression.

    But I have friends who have been put on hormones immediately with no adequate evaluation … just a quick check list and enough time to sign liability release forms. They are not doing well and there is no support for them (other than late night talks with one or two faithful friends.)

    1. TWT, I needed to correct typos and strengthen a few points. THANKS!

      I think that is is important tot add here:

      I think that for me, what has been most helpful is to focus on my strengths … and to not be labeled as “broken” or defined by any pathological condition but rather to be seen as a human being with the innate capacity to heal and to live a meaningful and healthy life.

      Psychotherapy was not the answer for me and at times it was actually very damaging because there was often so much of a focus on what “went wrong” or what needed to be “fixed” when I really needed support in discovering who I am (at my core), what resonates best with me and how I want to proceed in living my life more fully.

      For me, I realized that my experience of radical non-binary gender expression was a part of my natural inclination toward strength, leadership, courage and athleticism and that although society often neglects to recognize these characteristics as “feminine” they are as feminine as any other characteristic that women may possess.

      Over time, I also grew to appreciate that while dissociative experiences were (at times) extremely inconvenient, uncomfortable and even dysfunctional (in certain contexts), my inmate ability to dissociate was a gift in that it helped me to survive extreme trauma.

      So, with the “Social Justice” model – I think that one can validate and honor a person’s life experience, coping mechanism and reality without the need to reduce or restrict that person’s experience/expression/reality to the confines of a diagnosis. The person can be seen as a whole person, complete with complexities and subtle intricacies that are not related to their gender or dissociative experience, traumatic history, etc. I would encourage, instead of focusing tightly on pathology to see and appreciate each person as one who holds (or holds the potential to achieve) balance, wellness and health and to focus on this.

      Ironically, I learned all of this from friends who have survived similar traumas, not from psychotherapists. I have found Osteopathic Medicine and Eastern Philosophy to contribute in supporting these values in my process as well.

      1. I agree with a lot of what you say here. It is interesting because my initial psychology training was in a holistic program where we definitely focus on the person’s strengths and how to be a whole person and not “fixing” them. I am sorry that you had experiences with psychotherapy that were not like that. Now that I am in more academic/scientific psychology there is a very different orientation it is true and I do think there is a lot of focus on symptoms and pathology. A lot of my concern about gender transition is that it is often driven by dysphoria rather than by self-actualization, which is a moving away from pain rather than a moving towards life.

        I also agree that dissociation is a gift and serves an important purpose, it did protect me also from my trauma. I lived most of my life in a dissociated state, so much so that it seemed like just normal, and times of non-dissociation had almost a spiritual quality.

        I also have found Eastern Philosophy, particularly Buddhism to be very helpful.

        1. Thank you fro sharing this TWT. It is nice to know that I am not the only one with this history and experience … we are the “lucky ones” in that we made it into adulthood and we are both committed to helping others.

  11. There’s starting to be some professional pushback. Note the MANY comments in support of an open letter regarding the closure of Toronto’s CAMH Child and Adolescent Gender Identity Clinic and ouster of Ken Zucker. These are professionals in the field, correctly identifying the level of sociopolitical belief that is now driving this express train to transition for kids and teens — flying in the face of medicine’s current push toward evidence-based solutions. I was heartened by the number of comments that are not hiding behind anonymous labels, either.

    http://www.ipetitions.com/petition/boardoftrustees-CAMH

  12. I think that for me, what has been most helpful is to focus on my strengths … and to not be labeled as “broken” or defined by any pathological condition but rather to be seen as a human being with the innate capacity to heal an olive a meaningful and healthy life.

    Psychotherapy was not the answer for me and at times it was actually very damaging because there was often so much of a focus on what “went wrong” or what needed to be “fixed” when I really needed support in discovering who I am, what resonates best with me and how I want to proceed in living my life more fully.

    For me, I realized that my experience of radical non-binary gender expression was part of my natural inclination toward strength, leadership and athleticism and that although society often neglects to recognize these characteristics as “feminine” they are as feminine as any other characteristic that women may possess.

    Over time, I also grew to appreciate that while dissociative experiences were (at times) extremely inconvenient, uncomfortable and even dysfunctional (in certain contexts), my inmate ability to dissociate was a gift in that it helped me to survive extreme trauma.

    So, with the Social Justice model – I think that one can validate and honor a person’s life experience, coping mechanism and reality without the need to reduce or restrict that person’s experience/expression/reality to the confines of a diagnosis. I would encourage, instead, to see and appreciate each as a one who holds (or holds the potential to achieve) balance, wellness and health.

    Ironically, I learned all of this from friends who have survived similar traumas, not from psychotherapists. I have found Osteopathic Medicine and Eastern Philosophy to contribute in supporting these values in my process as well.

  13. Some people claim that group therapy by a therapist is just taking somebody’s money but it’s not such a bad idea if so many people suffer from isolation and loneliness. Even though I detransitioned, I still take hrt because I like it. My reasons for desisting were because society doesn’t accept me as female and I’m exhausted with the transition process…but if this experience of not fitting into a gender framework is common, perhaps transgender people should form better support networks. I’m sure the desire is there, if only at a periphery…I see successful transsexuals in society and they can identify me…this support must be limited to message boards and blogs. Knew one person I met during therapy whose family wouldn’t let them attend the group sessions and I liked talking to this person about various topics. Talk therapy would benefit more gender questioning people.
    Fort Lauderdale does have a support group along these lines…regardless of how well someone passes or is adjusted…unfortunately I never attended when I was in the area…so for my isolation, that’s something I’ll probably do.

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