Link between gender dysphoria and dissociation found

Here is an interesting study I just ran across from Collizi, Costa, and Toldarello, entitled “Dissociative symptoms in individuals with gender dysphoria: Is the elevated prevalence real?”, abstract pasted below:

This study evaluated dissociative symptomatology, childhood trauma and body uneasiness in 118 individuals with gender dysphoria, also evaluating dissociative symptoms in follow-up assessments after sex reassignment procedures were performed. We used both clinical interviews (Dissociative Disorders Interview Schedule) and self-reported scales (Dissociative Experiences Scale). A dissociative disorder of any kind seemed to be greatly prevalent (29.6%). Moreover, individuals with gender dysphoria had a high prevalence of lifetime major depressive episode (45.8%), suicide attempts (21.2%) and childhood trauma (45.8%), and all these conditions were more frequent in patients who fulfilled diagnostic criteria for any kind of dissociative disorder. Finally, when treated, patients reported lower dissociative symptoms. Results confirmed previous research about distress in gender dysphoria and improved mental health due to sex reassignment procedures. However, it resulted to be difficult to ascertain dissociation in the context of gender dysphoria, because of the similarities between the two conditions and the possible limited application of clinical instruments which do not provide an adequate differential diagnosis. Therefore, because the body uneasiness is common to dissociative experiences and gender dysphoria, the question is whether dissociation is to be seen not as an expression of pathological dissociative experiences but as a genuine feature of gender dysphoria.

Disclaimer: I have only read the abstract for this article and abstracts can be misleading sometimes, this is actually a problem with a lot of blog posts around these issues. I have since read the article

This article is interesting because it shows a link between dissociation and gender dysphoria and notes a link between the two. Further people with dissociative symptoms show more distress than those that do not. There is also a high rate of childhood abuse which is also seen in a few other studies. I consider my own dysphoria to be essentially dissociation and I wasn’t able to become truly embodied until I accepted my body as it is and let go of my cross-gender identity. Here is an article by twentythreetimes from the female detransitioner perspective.

This study showed a high amount of trauma, and even more so for the people with dissociative symptoms. Also this article showed that after treatment for gender dysphoria these patients showed lower levels of dissociation. This makes a lot of sense based on what I know about trauma.

Basically, in order to reduce the distress and symptoms caused by trauma is there are three things you can do, often in combination.

1) You can learn to cope with the symptoms and how to tolerate them better. You can learn mindfulness, and distress tolerance skills. You can learn to come back to your body quicker. You can learn not to panic about your symptoms causing distress on top of distress. This can help reduce the severity and intensity of the symptoms but will not eliminate them.

2) You can work on reducing / eliminating triggers. There are various ways to do this. There are behavioral techniques such as Exposure therapy and newer techniques like EMDR These are ways to alter or even eliminate the traumatic imprints make triggers effect one less or even not at all this. This can be a quick or lengthy process depending on the type and severity of the trauma.

3) You can avoid the triggers. Trauma is contextual. A person with trauma is usually not continuously in a traumatized state. They enter into the traumatized state in response to a trigger, which is a sight, sound or other environmental cue that holds an association to the original traumas then placing the person back in the place and time where it happened as if it is happening right now. If you can identify these triggers you might be able to avoid situations where they happen, however there is a significant cost for that in diminished aliveness.

In particular if the trauma is gendered, you might be able to avoid the context of trauma and the triggers by not seeing yourself or having others see you in that gender. In my own case my trauma was around it being unsafe to be a soft sensitive man, so I felt like I couldn’t be myself and be a man. I was perceived as an atypical woman when I was perceived as a woman too, but that was no problem because it didn’t trigger the context of the trauma. Of course I instantly felt unsafe if I was perceived as a man by others or even if I knew that people knew I was trans because that meant that I could really be a feminine man and hence in potential great danger. So transition did help me be more myself in that sense, however it came with significant costs as I was disconnected from my body and constantly stressed about people knowing if I was trans.

So it doesn’t surprise me at all that we see relief after transition. It is also important to note that 70% of the subjects studied did not have a dissociative condition and 55% did not have a childhood trauma history. Trauma is only part of the etiology of gender dysphoria, but I definitely think it is a large part for some.

This doesn’t mean that people with trauma shouldn’t transition, this doesn’t mean that those whose gender issues arise partially from trauma are somehow “less real” We should appreciate multiple factors of causality as is typical for most things in psychology.

Again, transition and gender dysphoria treatment are helpful that seems pretty clear from the evidence. I just think that gender should not be treated as its own special box and should be viewed holistically and connected to other parts of the psyche. I am also not saying that those with trauma should not transition, but ideally it would be best to work through as much of that as possible before making permanent changes. Sometimes this is not possible, and people may need to ease some of their gender distress in order to even begin working on trauma. That is part of why these issues can be so complicated.

Healing from Trauma – Embodiment

One of the most important ways I figured out what was right for me was learning to listen to my body. The body possesses an instinct that moves towards wholeness and a sense of its own integrity. This can be seen with things such as wound healing, where a cut will heal because the body has a sense of what is right for it. The difference between pleasure and pain is one of the most primitive life instincts, even possessed by bacteria. These instincts can lead us to what is good for us and away from what is bad.

There are several things can go awry with this process. One is that dissociation can make it impossible to know what is good and what is not. If we are stuck in our heads we are dissociated from our body, and cannot know what is good for us or what is not good. This is a common consequence of trauma.

Another issue is the presence of super stimuli We do not live in the environment that we evolved for, and can be led astray by these super stimuli. They are in effect too much of a good thing. Examples of these include fast food and pornography. The problem with super stimuli is that they may have unhealthy consequences. In addition, they can desensitize us to healthy stimuli. Also they can create an addictive spiral requires more and more stimulation to create the same effect. This is known as the hedonic treadmill

One can learn to distinguish between the feeling in the body of healthy stimuli vs. super stimuli. Notice the difference between how one feels when eating fast food vs. eating a meal that is truly nourishing. Likewise one can notice the difference between connected sex and pornography. These super-stimuli can be okay in moderation for some people like any vice, but one must be very careful that they do not spiral out of control.

Coming into connection with the body can be a gradual process. This is where titration can be important. Relationship is also important in this process as it is easier to heal in the presence of a supportive other.

Healing from Trauma – Titration

In Peter Levine’s excellent book about trauma, Waking the Tiger, he talks about the principle of titration. This means that when healing from trauma, one must make sure not to re-experience the trauma too strongly to the point where one becomes overwhelmed. There is something called the zone of tolerance, where one is experiencing some discomfort but not so much that they become overwhelmed and either dissociated or potential re-traumatized. This is important to remember if trying to work with trauma. Some discomfort is necessary, but it should not be overwhelming. Before I learned healthier practices, I was engaged in some spiritual practices that emphasized having intense cathartic experiences. This is not helpful for healing, instead a gentle gradual approach is best.

This also will help when attempting to get more into one’s body. This can easily bring up intense feelings and if the feelings are too intense it is okay to back out and go gradually. When one is dissociated, no healing can occur. This also will reinforce the idea that you are in control, and you get to decide when to go in and out of the trauma. This is an antidote to the feelings of being out of control and helpless that are commonly associated with trauma. It is also a way of being gentle and having compassion for oneself.

Healing from Trauma – Safety

The most fundamental principle of healing from trauma is safety. Without safety no healing can occur. Further, this safety is not a concept. It is something which is viscerally felt in the body and cannot be faked, no matter what thoughts one has about it. Also, safety requires control. The person must be able to control their boundaries in order to heal. This is the antidote to the lack of safety and boundaries they felt during their traumatic incidents. Spaces where these conditions exist are the key to healing.

This is something that I believe to be at cause for much of the incendiary rhetoric and toxic debate that happens around trans issues. It is something that made me reluctant to enter this arena. Both radical feminists, and trans activists, as well as the entire queer community are involved in an endless debate on what it means to be a woman or what it means to be female. Argument after argument is made and nothing gets resolved, there are only angry feelings, and eventually insults and threats. No one can seem to find common ground.

That is because this debate is not really about a scientific question, but it is about an emotional need, and both groups contain a lot of people that have been traumatized, particularly by men, and both need safety. However, these needs are also fundamentally incompatible in some ways which leads to the current impasse.

Because safety is a visceral, embodied response, what is relevant to safety is how the body responds. This has nothing to do with identity. The body needs what it needs to heal, and it doesn’t have to be rational. This might mean this process might be impeded by the presence of a trans woman, even if everyone affirms their identity on a thinking level. That is really horrible, and totally sucky for trans women, but the visceral embodied response of safety cannot be faked.

This issue was really brought home to me in my first therapy placement when I was still presenting as a woman and nominally female-identified. I was constantly being assigned lesbian clients because hey they requested a woman and I’m queer and they’re queer so seems like a good fit. However, this did not work so well because for me to be a good therapist for them they must feel safe. I found it particularly strange that once I declared myself to be male-identified, I was suddenly ineligible to see these clients and now eligible to see clients that only wanted a male therapist, even though I was exactly the same person!

Trans women experience their gender identities under constant assault. Further, trans women are also often in need of their own healing and can’t find the spaces for that. I’ve known a couple of trans women who were sexually assaulted, and couldn’t find groups to participate in due to their birth sex which was horrible and retraumatizing! Also it is no wonder that they would react angrily to this exclusion, as many of them are also seeking shelter from men and male culture, and are denied even that refuge.

There is no easy solution to this, I think there is space for multiple types of spaces, some that are open to all, some that are open to all women and some that are open to cis(?)-women (I feel like there is no possible term that won’t offend someone here) only.

I hope that both sides can have empathy for the other and maybe see what the emotional needs that underly the rhetoric are. For radical feminists to perhaps imagine what it is like to need healing and be deprived of even the spaces that they have for healing. For trans women to have empathy for the need for safe space, and that this does not necessarily violate their identity, but only is an artifact of the way trauma works. I think it is difficult to create such an understanding, but that it could start by attempting to imagine and empathize with what the underlying emotional need is under the toxic rhetoric.

Healing from Trauma – Overview

In this series I want to talk about some principles of healing from trauma and how it relates to transgender identity. As I said before, I do not think trauma is the whole cause of transgenderism, but it does play a role, and healing from trauma is beneficial whether it be childhood trauma, or trauma associated with transphobia after adopting a transgender identity. There is no question that gender-variant people suffer from a lot of trauma in our society.

I didn’t actually see my female gender identity as something that was problematic until the very end of this 20 year long journey after transition. All I knew was that I had a lot of tension in my body and had difficulty in forming relationships. There was a part of me that knew something was wrong and drove me to all of these different spiritual and psychological practices, including neo-paganism, meditation, 5 rhythms, biodanza and eventually psychotherapy and my own study of psychology.

In any case, healing from trauma is a reward of its own, and can help one make choices about transition that are in one’s best interest rather than coming from a place of wounding.

In my experience healing from trauma will:

  • Reduce the amount and intensity of triggering experiences
  • Allow for more pleasure-based “moving towards” and less pain-based “moving away”. Acting from trauma is always an attempt to move away from aversive experiences rather than move towards nourishing ones. This is one of the reasons I am suspicious of “dysphoria” as a healthy motivation. It seems too often to be a running away from rather than a moving towards. This is an example of applying general psychological principles to transgenderism
  • Create more embodiment, and a greater sense of connection to organic desires.
  • Allow for more flexible, open narratives. This is an example of how trauma interacts with narratives, two parts of the three-part model. Flexible narratives are a sign of psychological health, and rigid narratives are a sign of poor psychological health

Healing from trauma will not:

  • Change erotic imprinting (much). I believe trauma plays a role in erotic imprinting as well, but once the imprinting has happened, healing the trauma won’t heal the imprinting. It might however allow for expanding what one likes, being more connected to the body, and opening repressed behaviors. I managed to repress most of my attraction to women due to trying to fit in with my trans narrative until I connected with my body and discovered that was what my body craved.
  • Change the role of sex-hormones in well-being. A lot of people say they feel better on one hormone than the other. Discovering that I felt so much more functional on testosterone was an important consideration in my retransitioning. However it is important to note that feeling better on one hormone or another is not proof of any essential identity. Also hormones can be like a drug that makes you high, and the short-term psychological effect is not the same as the long-term, necessarily. That is a topic for another post.

Topics I hope to cover in this series include safety, control, titration, mindfulness, embodiment, community & witnessing, coming back from dissociation, and how therapy can help.

Dysphoria = Dissociation

Dysphoria, particularly sex dysphoria, is a disconnect between the body and the mind. It is a person saying they are something separate from their body, and that their body needs to change. Their body is somehow making them unsafe, preventing them from being who they are, or just feels wrong to them. This is a kind of dualism, saying that we are something separate from our bodies, when on some fundamental level we are our bodies.

To become separate from the body is to be dissociated. Dissociation is not necessarily bad. It is a mechanism that evolved to escape from pain, and to escape from trauma. In moderation, it is a healthy response. When it becomes habitual, it becomes problematic. Habitual dissociation often arises in response to trauma. It is a great way to escape from pain, particularly if horrible things are happening which you have no control over. This mechanism provides a way to survive the trauma, and to maintain sanity. Unfortunately the habit of dissociation remains long after the initial trauma has passed.

However, there is a cost to be paid for dissociation. Dissociation means to be disconnected from the real needs of the body. Long-term dissociation is often done by retreating into the conceptualized self, which is the story that one tells about oneself. It is possible to become completely disconnected from the body and live in a conceptualized self. There is a price to pay for this. For one, such compensations are fragile. On some level the person knows this is false and requires validation from others to maintain the compensation. Also, the person mistakes the conceptualized self for the embodied self which leads them to following their conceptualized self rather than what is truly nourishing for them.
Finally, it is never enough. The original need that the dissociation was created for has never been healed.

For me, I suffered from intense sex dysphoria. I hated everything male about my body, from my size, to my large hands, to its hairiness. Changing my body did not heal this. My body became softer, more hairless, and curvier. I did not always pass, but I was often seen as a woman by others. This did not heal my relationship to my body, and my body was frequently wracked in tension. My back was twisted in knots. I thought it was because I could not change it enough. I contemplated various kinds of plastic surgery, but never went through it.

I did not think my body tension had anything to do with my gender, but as I began to heal my relationship with my body I discovered its natural way of moving and being. The very source of the tension was the attempt to present myself as female. Unwinding this tension was a slow process as I had to work through my negative feelings about being male, both feelings that it was unsafe to be a feminine male, and feelings that men were evil and it wasn’t good to be one.

However, once I did that I found that things such as body hair or other male characteristics did not bother me anymore. I even welcomed their return when I went on T. I also found that I was no longer plagued by frequent dissociation and intense tension in my body. Things are certainly not perfect, but much better than they were. I still have tension in my body, but less. However, the dissociation is gone. For me dissociation and dysphoria were intricately linked.