taking dysphoria literally vs. symbolically

This article by Dr. Schwartz posted on the 4thWaveNow blog discusses the need for caution when working with transgender children. In particular, one thing he talks about is looking at the things that children are saying about their gender symbolically rather than literally. He says that differences in treatment philosophies arise from which lens the clinician views the child’s gendered self, as a literal truth or a symbolical one. In particular he says the following:

“It is possible to respond to children in a manner that is either organized around their literal narratives, or around psychological interpretations of those narratives, which themselves take into account such inner contradictions and perplexities as described above. Toward which path the clinician leans may be strongly influenced by the degree to which he or she shares the child’s apparent view of gender, that is, holds the assumptions of essential gender, or not. Simply put, if you believe gender is an internal reality, you will likely be guided or motivated to accept a literal hearing of the child’s narrative, since it matches that view. The child’s self-presentation may then seem straightforwardly comprehensible enough to guide you in clinical decision making. On the other hand, if your prejudice is to hear any claims about real, inner gender as necessarily—necessarily because you do not believe gender is real in the sense described above— composed of symbolic or metaphoric representations, then the child’s story instigates an active interpretive process, and clinical decision making proceeds differently”

Later on he goes on to say:

“There is much more to children than what they say. We owe to them a deeper listening than a literal one.”

This article is talking about children, but much of what he is saying applies to adults as well, who also have symbolic psychological processes, which just might be a little more buried. Giving this kind of deep listening and taking the time to do so is something that is not happening much with therapeutic work with gender issue currently. There is a sense of “well that is just your identity, and it shouldn’t be questioned.” This kind of deep listening also takes time, and is not something that can be done in a couple of sessions of therapy.

Indeed, I think this focus on taking gender thoughts literally is precisely what makes cross-gender roles in modern Western culture different from those of other cultures. Lots of cultures have cross-gender roles of some kind, but only in the West do we have the idea that one literally becomes the other sex, and that indeed the whole point of transition is to do just that. This also brings with it the idea of “passing”, proving your membership in the identified sex by becoming indistinguishable from natal members of that sex. This is also something that is not considered part of the gender-variant roles of other cultures.

If taking gender dysphoric thoughts and feelings symbolically, seems strange or a form of denial, it is helpful to see that this is something that we do all the time, and in fact it is quite important that we do so.

Consider being angry at someone for wronging you in some way. You might feel anger, and have the associated thought “I am going to kill that person”. Taking that thought literally would cause a great deal of trouble. There are lots of responses that you can have to the feeling of anger, and the thought “I am going to kill that person”, some of them healthy and some of them are not.

One possible response to the anger is to feel shame, that you are a “bad person” for having such angry thoughts, and a good person wouldn’t be angry and have the thought about killing someone. This would just add to the emotional pain and would not do anything to assuage the anger.

Another possible response is distraction, to pretend that it isn’t happening and distract yourself. This sometimes is a healthy response, as the emotion might be too overwhelming to deal with right now, or be related to some temporary chemical issue like meds or hormone levels. However, it does nothing to meet the underlying need of the anger, and even if something is heightened by brain chemistry issues, there still might be a real need underneath that. Anger is an important signal and shouldn’t be ignored. Distraction shouldn’t be an always thing, and many mechanisms of distracting from feelings escalate over time, such as numbing behaviors like drug use.

Another possible response is to try to repress it, saying “I’m not really angry”. This tends to only strengthen it.

It is also possible to construct an identity around it. “I’m an angry person, that is just how I am” This will make it a lot harder to work with as you take it as an essential part of your identity rather than as an emotion. This will also strengthen it.

Another response is to accept it, this doesn’t mean you literally do what it says, but that you acknowledge and accept it. The function of anger is to provide energy to deal with an obstacle. There is likely a real obstacle that needs to be dealt with in some way. Once you have acknowledged and accepted the anger you might get some insight into what that is, and sometimes it is obvious. Once you know you can act appropriately to meet that need, perhaps there is different way to meet the need, or perhaps you have to negotiate with that person, or perhaps you do need to engage in appropriate consequences for them. This can be hard in the moment of course. The important thing is that the anger is a real signal of your real needs and is not always unhealthy.

To take dysphoria symbolically is similar. There is a feeling of dysphoria, which is distress and dissatisfaction combined with thoughts such as “I should be a woman”, or “I am a woman” or “I hate being a man” “Being a man is disgusting”, etc. Like anger, this distress is on a spectrum and can go from mild to quite overwhelming. To take it literally, is to go through transition / hormones / surgery. This may be the right thing, but it is not the only thing. There are other responses besides taking it literally.

Shame and repression have similar effects here that they do with anger, and denying it by saying “I’m really a manly man” or something like that and attempting to live that will also make things worse. Dyphoria points to the fact that something is wrong and needs to change, it is an emotional response that says something is wrong. The associated thoughts give a proposed solution, but like the “I want to kill this person” thought, it is not necessarily the case that they be taken literally. Constructing an identity around it also strengthens it like with the anger.

The question is what are the underlying needs? They may be sexual, but they may not be, and I think it is ultimately the psychological needs that drive one to transition (vs. just having a fetish) Ironically, one of those needs might be to avoid the shame of having a fetish. In any case, there are real and valid needs that are underneath the dysphoria and it is important to meet them. It is only important that they be met somewhere in your life, it is impossible to meet all of our needs in all aspects of our lives, and indeed we must make compromises in order to have relationships and connection with people, and that is the single largest determiner of happiness.

Sorting this stuff out is something that can take time, and indeed something I think there needs to be more of. Yes, adults at least should have the right to transition, and transitioning does improve some people’s lives. However I think there is the need for more exploration, I sure wish I had that. I was approved for hormones after just 2 sessions of therapy, working out everything took 150 sessions.

Here is a story of someone who worked through things symbolically. Here is a
from a man who work on integrating his own feminine side but wasn’t transgender. I also recommend the site Transcend Movement in which he talks about a similar process of working through things symbolically. I am not saying that everyone can deal with their gender issues through such a process, but I am saying that more people can than currently are.

The obstacles presented by ideology in discussing trans issues

One thing that makes discussion of trans issues very difficult is that it that it lies at the intersection of ideology and truth. Science strives to seek truth and to be ideology-free. It can never meet this goal because it is done by humans who are incapable of being ideology-free. Still, it is the best method we have for minimizing the effects of bias and trying to get at an accurate picture of the world.

Jonathan Hadit, who is one of my favorite psychological writers, studies moral reasoning. He wrote an excellent book about it called The Righteous Mind. One of the things he talks about is that people have certain values that they hold sacred. He talks about the ideological differences between liberals and conservatives as being largely due to the fact that they hold different values sacred. When the tribal values are threatened people are far more concerned with neutralizing the threat then what is true or not. These sacred beliefs essentially become religious beliefs and anything that challenges them feels like heresy.

This is just part of the natural condition of humanity, and the same people that can be very capable of reason and nuance about questions that do not concern their sacred values suddenly become incapable of it when they do. I remember having a co-worker who was a decent programmer. He was also a Scientologist, and would occasionally talk about how “L. Ron Hubbard was an incarnation of the Buddha, and a messiah” or other Scientology related topics. I found it perplexing that he could have the logical chops necessary to be a good programmer and simultaneously be a Scientologist, but once beliefs acquire a religious character they are immune to logic. It is much the same with political ideologies.

One of the other things Hadit talks about is the importance of diversity of ideologies in creating good science. Scientists, like all people have ideologies and sacred beliefs. Scientists are often quite passionate about their theories. They are far from neutral, disinterested observers. So, any one scientist runs the risk of having their bias interfere with their observations. Science has tools for neutralizing bias from double-blind studies to peer review. Peer review relies on other scientists looking over the science, but they too have biases. If you have an ideologically diverse set of scientists then the effect of their biases are minimized. However, to the degree that they are not ideological diverse, groupthink and other phenomena can prevail. This effect is increased if the scientific study in question contradicts the sacred tribal values of that particular group of scientists.

In the therapy world we are also concerned with the biases of therapist interfering with the therapy and making it hard to see the client clearly. This phenomenon is called countertransference, which is where the therapist projects their own stuff onto the client and does not see the client clearly. Being aware of this is a start, but therapists are people too and are often blind to their own biases and personal hooks. One way to counteract this is through consultation groups, to get the opinions of others who do not have the same biases that you do, and therefore can see things clearly that you can’t see. However, if the therapists in the group share the same ideological beliefs and biases, then this does not help, and can even make things worse as phenomena such as groupthink take over.

Having a strong conviction that the “other side” is absolutely wrong about everything is a sure sign of being engaged in tribal thinking. The truth is messy and cuts across ideologies. It can be very difficult to let go of tribal thinking as it gives a sense of belonging, which is a primal need. If one does commit to the truth wherever it leads you, you are likely to be denounced by all ideological tribes. That can be a very lonely path. Speaking out for truth that goes against your tribal values is very difficult. I recently read Alice Dreger’s excellent book Galileo’s Middle Finger where she talks about the conflict between truth and activism. Indeed, Dreger, as someone committed to truth over ideology, is often denounced for both being a “crazy liberal” and “neo-reactionary conservative”. I once read two articles denouncing her in these opposite ways within 10 minutes of each other.

The community of psychologists and therapists is far from ideologically diverse. Hadit, who is a social psychologist, gave a talk to a group of around one thousand social psychologists and asked them how many identified themselves as conservative or moderate. As described in this article in the New Yorker,
only 20 or so identified as centrist and only 3 identified as conservative. There might have been more conservatives that feared the career ramifications of openly identifying themselves as conservative. Further research in the article confirms that 37.5% of those social psychologists surveyed would be less likely to hire a conservative colleague, so their feelings would be entirely justified. This article describes social psychologists specifically, but similar phenomena exist with clinical psychologists, social workers and other mental health professionals.

I have come to the reluctant conclusion that it is progressive ideology itself that is the one of the things that gets makes it difficult to work on these issues. As a life-long liberal, and former card-carrying member of the ACLU back when that was a thing, it has been tough to come to that realization. I have long considered liberals to be my tribe and to see this ideology as itself being a problem makes me feel like I am without a tribe. However, since tribalism itself is the issue, perhaps that is a good thing. I want to emphasize that all ideologies get in the way of seeing the world clearly, it is just that the particular ideology that dominates the psychological profession is on the left. In particular, the following aspects of progressive ideology, particularly the specific progressive ideology of the psychological profession come in to play:

Privilege / Power Dynamics

Progressive ideology views the world in terms of privilege and power dynamics. People are divided into privileged and marginalized people across various axes. Why this is relevant is that is trans people are seen as a marginalized class while cis people are seen as a privileged class. This brings in to play various aspects of progressive ideology which is concerned with equalizing power dynamics. Indeed, helping marginalized people have a voice is a noble goal, however sometimes this ideology can cause harm to the very people it is trying to support.

One for the related ideas is that a marginalized class has been silenced and it is important that their voices be heard, particularly about their own experience. The privileged class is deemed to not understand the experience of the marginalized class and should listen to them. This is indeed true, and there is a long history of medicine centering men and treating women as afterthoughts and other examples of only paying attention to the dominant class. So it is indeed good and important for trans voices to be heard about their own experience.

However, this ideology leads to trans narratives being taken at face value by clinicians, and digging underneath them to be seen as being against the tribal values of the clinicians working on these issues. This is a well-meaning attempt to bring social justice to the marginalized people.

However, digging underneath things can be very important. Psychology is full of ideas about how people have defenses, self-serving rationalizations and all kinds of ways in which they don’t necessarily understand their own motivations. This is just as true whether someone is privileged or marginalized, and to ignore this when working with marginalized people is to do them a disservice. Indeed it is giving them lesser care, than you give to privileged people.

Primacy of narrative / lived experience

Another part of this ideology is the primacy of narrative and lived experience. This means the subjective is more important than the objective, and that lived experience trumps scientific research. This goes triple when it intersects with the ideas of privilege/oppresion referenced above. This is another idea that has good roots but can be taken too far. Narratives and lived experience are indeed important. As a therapist it is important to bracket aside theory and make sure that you are not treating a client as an object, or a theoretical construct and seeing the person as an individual. People are messy and do not fit cleanly into boxes.

However, the theoretical constructs and scientific research matter also. There is a vast deal of difference in degree of scientific orientation among psychologists and therapists. One problem in psychology is that the academic community of research psychologists and the community of clinicians and therapists often don’t talk to each other. Some sections of the the clinical community are even actively anti-science. Some professors in my master’s program would use the term “evidence-based practice” almost as a swear word, like it meant un-evolved. The narrative is not the only thing that matters.

Nothing is pathological

Progressives are absolutely allergic to the idea of pathology and tend towards the idea that calling anything pathology is “stigmatizing”. So there are movements to talk about how everything from bipolar to schizophrenia is a healthy variation of human experience. Many even question the very idea of mental illness. They are quite correct that stigmazing causes harm. I think it is harmful to stigmatize people based on their conditions, however we should never lose track that some things are healthier than others. For me the question of whether something is healthy is not whether it is normal but rather whether it is functional. Even being functional in some environments is sufficient, that is just a matter of getting to the right environment.

I recently read the excellent book Buddha and the Borderline by Kiera Van Gelder. This book tells of a woman’s journey in healing from borderline personality disorder. She describes how much of her community as well as many of those therapists and psychologists that treated her did not want to give her the borderline label for the reason that it would be stigmatizing. She acknowledges that it can indeed be stigmatizing when she is labeled borderline by others, but it it is also helpful to acknowledge it as an illness and that helps her in working with it.

I think refusing to understand that there is a such thing as health and a such thing as pathology causes problems, especially if you are in a profession where you are supposed to be an agent of health. Pathology should not be mistaken for diversity.

The insider experience is the only one that matters

Progressive ideology centers the insider experience, and holds that the words of a member of a group are those that are valid about a group. For example, only trans people should speak about trans experience, only women should speak about women’s experience, only black people should speak about black experience etc. It is indeed quite true that people that don’t have a certain experience are likely to get things wrong about that experience. Women are likely to see things about their experience that men don’t see, etc. Problems arise when the people studying something are all of one group and they are studying a different group. This idea also intersects with the idea of priviledge/power, and so applies in a much larger way when it is a privileged class studying a marginalized class.

This is an important idea, and tremendous harm has been caused by the lack of representation of minority groups in health. It is a very good thing that their voices are being heard in respect to their own health. However, while it is true that the insider can see what the outsider cannot see, it is also true that the outsider can see what the insider cannot see. Fish can’t see water. How many times have you encountered someone who had some false idea about themselves that everyone but they could see? This is precisely why the outsider perspective is important also. It is best to see something from as many perspectives as possible. All groups whether marginalized or privileged are prone to cultural blind spots and groupthink. Particularly in the case of groupthink, an outsider perspective is precisely what is needed.


I have written quite a bit about my views on identity here, and here The identity politics wing of progressivism strongly encourages a focus on identity, both the importance of personal identity and an identification with particular groups and classes. In addition to the critiques I made earlier, one problem with identiarianism is that it exacerbates the kind of tribal thinking that clouds truth. Once people feel their group is threatened they focus on defending their group rather than truth. This is just hard-wired into human psychology.


The nature of tribalism, identity and ideology increase the difficultly of find scientific truth on trans issues. The tense nature of these discussions drive away many people who might be interested in working on these issues, and also causes harm to trans people, as they are deprived of scientific advances and the best possible care. Understanding these effects and working towards minimizing them can help to reduce the tension in the ongoing discussion and help us work towards a future where all those who are dealign with these issues receive the best possible care.

“regret rates” are not the sole measure of outcomes

I’ve seen the statement made many times that “the rate of regret for gender transition is very low”, generally quoted between 1 -3 % or so. This is used as evidence that we should not be so concerned with the problem of detransition. People identifying with a certain gender and wanting to transition is enough proof that transition is right for them, and therefore there is no need for any in-depth screening.If someone identifies with a certain gender and wants to transition then clearly that is the right thing, as evidenced by low regret rates. Also, there is no reason to look at different ways to deal with dysphoria, because we have this great treatment that already works.

However, there are several problems with this which are:

  • The reported measures of regret rates don’t actually measure regret rates.
  • Regret rates are not the sole measure of good / bad outcomes.
  • The demographics of transitioners today are not the same as those in the past.
  • Gender transition improving people’s quality of life, doesn’t mean there aren’t less invasive ways to get the same improvement.

The reported measures of regret rates don’t actually measure regret rates

An example of a study that shows transgender regret rates is here. This study shows a “regret rate” of 2.2%. However what are they actually measuring? What they are actually measuring is the rate of “legal detransition”. They measure what percentage of people who undergo a legal name and gender change then undergo a second legal name and gender change. They don’t measure people who have regrets but don’t detransition legally, or don’t detransition at all. It is also possible to detransition and not regret the original transition.

Regret rates are not the sole measure of good / bad outcomes

Indeed, regret is an important component of good outcomes. Regret is part of a poor outcome, and satisfaction is part of a good outcome. However, it is not the totality of good outcomes. Good outcomes include social adjustment, economic well-being, mental health, and other measures of health. There hasn’t been any research that I know of on long-term outcomes of gender transition (20+ years), partly because most long-term transitioners are lost to follow up.

Because I transitioned 20 years ago, I know many MTF transitioners that were in my cohort or even 5-10 years before. What I see is concerning. I am the only one out of them that has detransitioned, and most of them would not say that they regret their transition and continue to go by feminine pronouns and feminine names. In terms of life outcomes, I would say economically they are mostly doing well. However, socially they are struggling. Most of them are alone. I see a lot of social anxiety, people being unwilling to leave the house. In addition, they still continue to deal with dysphoria and have emotional difficulties.

This is not a good thing, some people would say these difficulties are due to oppression and by reducing this oppression it would reduce or eliminate these difficulties. I definitely believe that oppression is a large factor in some of the things that are awful about being transgender. I oppose those that intend to make the world worse for trans people. However, I do not think it is the sole source of these difficulties.

The demographics of transitioners today are not the same as in the past

These studies of regret rates are often used as reasons that we don’t need to be too concerned about people with cross-gender identities regretting transition. This is combined with the idea that people have a fixed and essential gender identity and aren’t wrong about it. So, if someone identifies as transgender, then they are transgender, and that can’t be changed.

In particular we should be concerned about two groups, adolescent / young adult FTM transitioners and transitioning children. Historically, the ratio of MTF : FTM transitioners was around 3:1. A recent study showed that FTM transitioners are now exceeding MTF transitioners, a large change. Also, there is a recent
showing that many of these are young women dealing with typical adolescent identity issues as seen here. I wrote about this in more detail here There are already more and more female detransitioners and people who take testosterone for a while and then stop. The trouble is we don’t know how to distinguish between the people that are going to be happy with their transitions in the long term and those who won’t. This is a topic that is in great need of further study, and we should proceed with caution until we have it, to make sure we aren’t giving a permanent solution to a temporary problem.

We should also be concerned about transitioning children, as historically 75-90% of children with gender identity issues desisted at puberty. I believe that children that have gender dysphoria that persists into adolescence should be given access to transgender services. I don’t think this point is particularly controversial in the field. However, desistance rates have been declining. This has been celebrated as vindication for the use of puberty blockers, but it seems to me that this is evidence that the experience of puberty itself leads to desistance, and therefore it is important to have these children experience at least some of their natal puberty in order to determine whether they will desist or not.

The wrinkle in all of this is that if someone is to undergo gender transition it is better for them to experience as little of their natal puberty as possible, both for the emotional effects of their puberty, and better physical results from transition. This is one of the things that makes it tricky. I think it would be best to try to figure out how much of the natal puberty they need to experience to determine if they would desist or persist, I don’t know what the answer to this question is.

Also there are those that claim desistance is equivalent to persistence as long as they are well-adjusted. I disagree with this strongly, even if they become well-adjusted trans people. If they could have been well adjusted without this treatment as well that is still a loss. Infertility and a lifetime of dependence on hormone treatment should not be treated lightly. Of course if the choice is between being a well-adjusted trans person and non well-adjusted cis person, we should prefer the well-adjusted trans person.

Gender transition improving people’s quality of life, doesn’t mean there aren’t less invasive ways to get the same improvement.

The research shows that gender transition improves the quality of life of some transitioners, and I do not advocate for eliminating it, or denying access to those who need it. However, this does not mean we shouldn’t continue to look for better ways to work on these issues at the same time. Even though transition does indeed improve people’s quality of life, this is still a community under significant distress. Attempts to help people work on these issues without transition should not be denounced as “conversion therapy”. It is not evil to want people to find better ways to deal with their issues.

Narcissism Pt. 2 – Antidotes to Narcissism

In the previous post I talked about Narcissism. In this post, I will talk about some of the antidotes to narcissism. Severe narcissism such as in full-blown Narcissitic Personality Disorder is notoriously difficult to treat with psychotherapy, however, more mild forms of narcissism can be worked with. Really, it depends on how much access the person has to their true self. The paradox of narcissism is that healing requires that the true self be loved and accepted, and the narcissist so identifies with the image they have created that they reject any love given to the true self. They feel intense shame and vulnerability when the true self is even seen. However, sometimes narcissism can partially or totally remit on its own.

Narcissism sometimes remits when the person reaches their 40s. Also spontaneous remission of Narcisstic Personality Disorder sometime occurs in response to an immenant threat to life itself. The direct experience of one’s own mortality, can bring one into the real, in a way that nothing else can. I suspect the reason that remission sometimes occurs in mid-life is that mid-life also brings the realization of mortality. Narcissism is in part a choice to deny the visscitudes of life, mortality, aging and impermance in favor of an immortal image. Also, of course, one can meet the recognition of mortality with denial, which brings the classic mid-life crisis, the attempt to remain young forever. This is especially prevalent in Western culture, which glorifies youth.

That brings us to the first antidote to narcissism, mortality.


My own recognition of my mortality is what first knocked loose my transgender identity and eventually led to the opening that enabled me to heal. When I was 30, I was diagnosed with Stage IV cancer. Fortunately, it was one of the more curable kinds of cancer, but I was given only a 50:50 chance to live. The knowledge that I could be about to die paradoxically made me much happier than I had been. It released me from the relentless pressure to be perfect, and I just played for the first time. A few months later, still not knowing whether I would live or die, I found myself reading Jung. In particular, I encounter some of Jung’s writing on “anima possession”, where a man is taken over by his anima. . In reading this, I felt my body unwind and that there was truth in it, that I had become possessed by a false self. I still could not let of go of this female identity for ten more years, as there was so many things to work through. The encounter with mortality opened the door, and enabled me to begin truly working on my healing.


One of my favorite exchanges in Game of Thrones is the Bravosi greeting. They say “Valar Morgulis” – All men must die. The expected response is “Valar Doheris” – All men must serve. This is because service to something greater than oneself is a healthy response to mortality, and ultimately what is most fulfilling. I first noticed that there was something wrong when I was in my mid 20s and I became involved in groups where there was some emphasis on service. People would volunteer with relish and might even spend their entire festival working in the kitchen. I noticed they had an access to a happiness that I did not. I thought I would try to emulate that, and volunteer, but I didn’t really feel anything. Being wrapped up in the fantasy self acts as a barrier to the human feelings underneath. One of the great joys of working through these issues is the ability to feel the joy of doing something good for another in deeper and deeper ways. This is a much more nutritious food than the more shallow food of attention and validation. What matters here is not the magnitude of the service, but the intention behind it. Indeed narcissists sometimes perform quite valuable acts of service in service to their egos, but that is not what will create healing.


The field of Positive Psychology studies human flourishing. Most of clinical psychology is concerned with pathology, and relieving pathology. One of the findings of positive psychology is the development of character strengths and living in accordance with these values. Each person has their own particular strengths. These strengths specify the ways in which people are most fulfilled in serving the world. However, at first they exist as potentials only, and must be cultivated. Positive psychologists have identified 24 character strengths, and created a test to see which ones resonate with you the most. This value-orientation is very different than the identity-orientation, because it requires action. The identity-orientation says that you are what you perceive yourself to be, no action required. The value-orientation is not just something you are, but also something you do. This orientation to life goes as far back as Aristotle, who defined virtues as habits that were built over time. Who you are is your character, and is based on what you do and what habits you develop, not on how you think of yourself.


Embodiment is being in one’s body and being connected to our own instinctual processes. One of the problems I had with living in my fantasy self was that I was disconnected from my body and usually in state of dissociation. I didn’t even know what dissociation was because it was just my normal existence. My body had a lot of tension. My body is also how I came to know what was real and what was not, because in my head I could be absolutely anyone, but that was not true in my body.


One of the largest determinants of happiness is the quality and depth of human relationships. Having deep intimacy, seeing another and being seen by them, is one of the great joys of life. Narcissism impedes this, because having another see your image is not the same as having another truly see you. It also hard to truly see another if you are fixated on your own image. One of the reasons I let go of my transgender identity was because it interfered with my being present for another, this was particularly true as I began to see clients as a therapist.

Empathy / Universality

Narcissism arises from the belief that one has to be unique and special to be loved. The best medicine for narcissism is to receive empathy, and empathy for the real self. Empathy is not based on what is unique about us, but on what is common about us. We share certain things with all humans, certain things with only some humans, and certain things are unique to us. It is the common things that allow us to put ourselves into the shoes of the other. We all have feelings, we all have pain and pleasure, we all grow old and die. What is unique about us is important also, but does not generate empathy. A person who feels they can only be loved for their specialness is disconnected from our common shared humanity which is the source of empathy.

I see my journey of returning to male as being a letting go of fantasy and returning to what is real, and working to let go of narcissism. I do not mean to imply that all transgender people suffer from narcissism. The research does show elevated rates of narcissism particularly with MTF folk, but does not show that all MTF or FTM folk have problems with pathological narcissism. It is just that since the essence of narcissism is identifying with a grandiose or fantasy self, if narcissism is present as well, it seems possible the two are related. They certainly were in my case.

Don Draper, Superheroes and Narcissism

Spoiler Warning: Contains Spoilers for Mad Men.

I recently finished watching Mad Men, one of my favorite shows. The story of Don Draper is the story of narcissism, set to the back drop of the 1960s. I find it easy to identify with him as my own journey was really only secondarily about gender, and first about healing from narcissism. I have never seen such a good portrait of narcissism, particularly from the point of view of the narcissist, as in this show.

The defining characteristic of narcissism from a psychological perspective is feeling that who you are is unacceptable in some way, then constructing a persona and totally identifying with that persona to the point of mistaking it for your complete self. This is due to feeling a great deal of shame around the real self and therefore wanting to bury it completely. It also has its roots in conditional love. A child that feels they cannot be loved unconditionally and can only be loved due to their achievements or certain traits can develop this dynamic. They build the false self in order to receive love. However, conditional love is not real love, it is only an approximation. The tragedy is that this conditional love can never completely nourish all the time. It is like eating a diet of junk food all the time, yes it might keep you alive, but will not allow for flourishing.

The classic portrayal of the narcissist is of an arrogant man who manipulates others and is abusive and self-centered. This is really just one type of narcissist. Narcissists come in lots of different flavors depending on the particular persona that is constructed. They can be quite self-effacing in fact. What is common is the creation and identification with a persona. I was never a classic narcissist, but the woman I was living as was a character I created, even if I wasn’t consciously aware of it.

Our ability to create a persona is not in and of itself a problem. Indeed it is vital to functioning in different social contexts and part of being a healthy person. A person might go to work and put on one persona in the workplace, and then a different persona with friends, and a third with family etc. The persona is a mask that enables one to take on a role and helps others to recognize that is your role. A doctor might adopt the persona of the doctor when in office, and then take it off when with friends. The mask is like a filter for the self-expression, certain aspects are emphasized and certain aspects are de-emphasized. A persona is not purely constructed, people have personas they resonate with more or less depending on their nature.

The difference between a healthy persona and a pathological one is if the person can take it off and put it on. A friend once observed that you can see this difference looking at superhero stories. The superhero dons their super persona in order to perform acts of heroism and then goes back to the mundane world where they have an ordinary identity and an ordinary life. They are part of the community and have friends, love and connection.

The supervillian is not part of the community and cannot take their mask off. They have no true friends, only subordinates or superiors. Both superhero and supervillian gain their powers in response to an extraordinary, often traumatic event. It is their response to the event that determines which way they go.

Returning to Mad Men and Don Draper: Don Draper was born Dick Whitman, to a poor family. He enlisted in the Korean War and eventually killed his CO, taking on his identity. He used his new background as an officer as part of his rise in social status, eventually becoming a powerful man in advertising. On the outside he is very successful, rich, handsome, powerful and a ladies’ man. However on the inside things are very different. He struggles with his past and his knowledge that on some level that he is fake. He drinks heavily, and bounces from unsatisifying relationship to unsatisfying relationship, always grasping for what is real. He has more and more success in his career, and makes more and more money. One point I get from the show is that while it very fun to watch Don Draper, and it might be fun to have a fling with Don Draper, it is terrible to actually be Don Draper.

The last season he almost totally breaks down. One day he goes into a meeting and just can’t take it any more. He gets in a car and just starts driving. He doesn’t know where he is going but just knows that he needs to get away from things. He confesses what he did to his CO to a group of veterans. He goes to a retreat center and has a moment of human connection. The next to last scene shows him in a group at the retreat center meditating when a smile crosses his face.

You might think he then leaves the advertising world forever, but he doesn’t. The last scene shows a classic coke commercial from the 70s, implying that he created it. That is because his advertising gift was part of his realness, that is the thing about the false self, it contains truth. It is not completely fake, rather it is the best the person can do. It is created as an attempt to avoid unbearable pain. It is the best attempt you can make at the time to be yourself. It is a lot like being a method actor, but being unable to let go of the role you are playing.

There are large cost to this. One of the main ones is that on some level you don’t really believe the persona is you, not completely, and so it requires validation to maintain it. Any challenge to the reality of the persona will bring back all of the toxic shame that led to the creation of the persona in the first place. People don’t have intense emotional reactions to being invalidated about traits they feel secure about, that is easy to brush off. If you mistake the persona for yourself, a threat to the persona is a threat to your very existence. So, there is this endless seeking of validation, which is sometimes called narcissistic supply and every time the persona is validated it feels good, but never enough. Every time the persona is not validated it feels so very painful.

The persona also prevents true unconditional love from reaching the heart, which is precisely what is needed for healing. This is what makes severe narcissism so difficult to treat in therapy. Narcissism is on a spectrum, so there is hope for some. However in some cases all we can do is help the person live the best they can under the constraints of the persona they have created, and maybe help them to not cause harm to others. If the persona they put forth is loved, that love doesn’t truly reach them, because again on some level the person knows it isn’t really them. ”If they really knew me, they wouldn’t actually love me”

Indeed, I think narcissism is the pathology of our age, not full-blown NPD, but a milder kind of narcissism that has become so prevalent that is almost the water we swim in, at least in 21st century America.

Some great things to read about narcissism:

Alice Miller is probably the most well known author on narcissism, in particular her book Drama of the Gifted Child is amazing.

The Last Psychiatrist talks a lot about narcissism and has a fascinating take on many issues.

Sam Vaknin who identifies as a narcissist, has a great site talking about his own experience and ideas about narcissism.

“Trans women are women” and RFT

When people say “trans women are women” what are they trying to say? Why does it matter? A lot of arguments around these issues have people going back and forth about whether trans women are women or men. People argue that “trans women are women” because identity, or perhaps brain sex and people argue that “trans women are men” because socialization, or physiology or biology etc.

First, we can talk about what gender identity isn’t. Looking at the gender bread person, a common model used by queer theorists to delineate the different components of gender we can see all of the things that it is not. First, it is not biological sex. It does not have to do with chromosomes, or breasts, or vaginas, or penises, or hormones. Second it is not sexual orientation. It does not have to do with who you are attracted to. Third, it is not gender expression. It has nothing to do with whether one’s behaviors are stereotypical of males or females or anything in between. It is indeed nothing to do with behaviors at all! So, it has nothing to do with your body, or your attractions, or your behaviors. Then what is left?

What is left is the concept of “woman” itself. So, when someone is saying their gender identity is that of a woman; they are saying that their self-concept is that of a woman. More concisely, “me = woman”. Likewise by saying “trans women are women”, they are saying “trans woman = woman”. What is going on here is the equating of two concepts. This is what it means to identify with something in general; you could say “me = American”, or “me = Democrat” etc. Other writers have noticed similar things and ridiculed gender identity as being essentially meaningless because it just has to do with a concept. However, it is not trivial at all. That is why people on all sides of the debate are so interested in arguing whether “trans women are women” is true or false. Why is this question so important to both trans people and their detractors? This question reveals something fundamental about human psychology, as is explained by a theoretical model known as “Relational Frame Theory (RFT)”.

Unfortunately most of the writing about RFT tends to be rather obtuse and academic. If you are a psychology nerd, I recommend the following video series on RFT by psychologist Joseph Rhinewine. Here are another two articles.

RFT is also the theoretical framework underlying ACT, and ACT is more accessible. This same psychologist has some great videos about ACT as well, and you can also read more about it here and here

Fortunately, we only need a few concepts from RFT in order to understand why it can be so important for someone to equate themselves with the concept of woman (or man) even when it has nothing to do with behaviors or bodies.

Arbitrary vs. non-arbitrary properties

The first of these concepts is “arbitrary vs. non-arbitrary properties” An example of a non-arbitrary property would be size. Some objects are smaller than other objects, and some objects are larger than others. This is a non-arbitrary property because it is universal. Everyone would agree that one object was larger than the other, if they measured accurately. It is also possible for an object to have arbitrary properties assigned to it. Take the example of a nickel. It has the non-arbitrary properties of being round, being made of metal and a certain size. It also has the arbitrary property of being worth 5 cents. People of all cultures would see the nickel as being round, mental and of its size. Only those that learn the meaning of the nickel being worth 5 cents would assign that value to it.

A dime has the arbitrary property of being worth 10 cents yet is smaller than a nickel. If you ask a young child which is more valuable, he will say the nickel is more valuable. Only when he learns the concept of value, and has achieved the level of maturity to understand such concepts will he see the dime as more valuable than the nickel. This ability is something that enables humans to create culture and all of the advances of civilization.

When I talk about objects I am not talking just about physical objects, I am also talking about words, sounds, concepts and ideas.

One property that is very important to understand is that the psyche does not treat arbitrary properties and non-arbitrary properties differently. They have the same psychological value.

Relational frames

All of these objects are related to each other through relational frames. Relational frames describe how two different objects are related to each other across various dimensions. An example of a relational frame is the “relational frame of comparison”, which ranks objects according to a certain dimension. We can say a nickel is greater than a dime in the dimension of size. We can also say that a dime is greater than a nickel in the dimension of monetary value. Another important relational frame is the relational frame of equivalence, which says two objects are equivalent, in English this is denoted by “being verbs”.(is, am, are)

Derived stimulus functions

One uniquely human capability is derived stimulus functions. This means that we automatically derive new relationships based on existing relationships. For example, if someone had never seen a quarter, and I were to tell them a quarter was worth more than a dime, they would also know that a quarter was worth more than a nickel. I would not have to teach them that. Looking at the relational frame of equivalence, when an object is equivalent to another object, we automatically derive that it is equivalent to all other objects that object is equivalent to.

The transformation of stimulus functions

The transformation of stimulus functions means that any psychological association with a given stimulus will also be carried over to any related stimulus. For example, say a person loves to eat ice cream. A natural response to a food that someone likes is to salivate. This person will also have a similar reaction to imagining ice cream or even potentially the words “ice cream”. Say this person hears the words “uachtar reoite”. This will likely have no effect, unless the person speaks Irish and knows those are the words for ice cream. Later, if the person learns this association, these words can acquire the salivating response.

These associations are not always conscious

Another thing that is important about these associations is that they are not always conscious. They might be unknown to the person that has them. A clever test that psychologists have come up with to test these associations is the Implicit Association Test This test measures these associations by comparing reaction times to different paired concepts. For example, a person with implicit racism will have a longer reaction time if they have to pair images of black people with positive words, than if they pair images of black people with negative words. These tests show that implicit racism is rampant even for those that don’t have conscious racism.

how does this apply to trans issues?

Lets return to the statement “trans women are women”. In terms of relational frames, this is saying that “trans woman = woman”. Here we are talking about the concept of trans woman and the concept of woman, we are not talking about bodies or behaviors. So all this is saying is that the concept of “trans woman’ is equivalent to the concept of “woman”. On the surface, this seems like a meaningless statement, however it has profound implications both in the psyche of people dealing with gender issues, and in how trans people end being treated.

First, looking at the identity component, if “me = trans woman” and “trans woman = woman” then “me = woman”. Why this matters is that because of derived stimulus functions, if “me = woman”, then “me” is also equivalent to every other concept that is equal to woman. So if someone has the association “woman = caring” or “woman = good”, then if “me = woman” then “me = caring” and “me = good”. Also due to the transformation of stimulus functions, the person’s self-concept then acquires all psychological associations with those concepts as well. Also, if one has the common association “woman is opposite of man”, then they acquire the inverse of all psychological associations with the concept of “man” as well. So if “me = woman”, and “man = brutal”, then “me = not brutal” etc. Some people identify as non-binary or gender-queer, which is saying “me = not woman” and “me = not man” or in some cases “me = woman” and “me = man”.

These networks also interact with rule-based behavior. People internalize various rules, which can be expressed in an if..then format. These are “shoulds” and “oughts”. For example, “before bed, you should brush your teeth”. These rules can also pertain to particular classes, “men should not show their feelings”, “women should be sweet and submissive” etc. Not following your “shoulds” causes psychological distress, and if they conflict with your impulses that will be a source of tension. It is important to note that these rules can also be held unconsciously and contradict with conscious beliefs. For example, a person can believe that it is okay for men to show their feelings, but simultaneously have an internalized sense that is wrong for a man to do that. This is very common.

If one holds the rule “men should not show their feelings”, this rule only applies if you also hold “me = man”. There are two ways to eliminate this association (actually three but we will get to the third one at the end). The first ways is to eliminate the rule “men should not show their feelings”. The second way to eliminate the association “me = man”.

Not only does this matter in terms of sense of self, it also matters in terms of treatment from others as well. People who hold the association “trans woman = woman” will act differently to a trans woman than those that hold the association “trans woman = man”. It is possible to hold either association, because here we are dealing with concepts which are arbitrary objects, and not non-arbitrary objects like breasts, penises, hormones, chromosomes and vaginas. It is important to see this, because if you hold one of these associations strongly, the other is likely to seem ridiculous or offensive.

Again, the psyche treats the non-arbitrary objects and arbitrary objects the same way. Also, even though the concepts of man and woman are arbitrary objects, they are almost certain to be associated with the non-arbitrary objects like breasts, penises, hormones and vaginas. Most people hold the association “woman = vagina” and “man = penis” also. Even those who consciously hold the belief that “trans woman = woman” and that woman is about identity and not bodies, are also likely to still hold the “woman = vagina” association unconsciously as well. Not, to mention that these associations also interact with low-level instincts which have a lot to do with bodies. This can lead to dissonance, as the remaining masculine characteristics of the body (in the case of trans women) contradict the identity me = woman. This causes dysphoria and distress and leads to the desire to change the body and eradicate those characteristics. However as this is not completely possible, it is likely that dysphoria will remain. In addition, the person is likely to seek validation for “me = woman” in order to affirm that side of the contradiction. However, like the body changes, this validation does not remove the basic conflict it only serves as a temporary salve.

This was my experience of transition, the dysphoria did not end because this basic conflict remained. There was never any peace, and it was so primally important that I be validated as a woman, and it was never enough. Likewise, I was still uncomfortable with my body because it still contained masculine characteristics, and there was no amount of surgery that would fix that either. In fact, it is the adoption of the trans identity itself that greatly increases dysphoria for this reason, even as it simultaneously solves other issues.

how to apply these ideas

There a few ways to apply these ideas in order to reduce dysphoria and the suffering from dysphoria. When I was describing some of the various associations, such as “me = woman”. I was careful to use “me” rather than “I”. That is because there is a hidden additional association there, which is “I = me”. Meaning the association of the being self “I” with the conceptual self “me”. This association is not essential, and indeed causes numerous problems. The practice of mindfulness makes it possible to weaken this association, and see that the being self “I” is indeed distinct from the conceptual self “me”.

ACT identifies mistaking the conceptual self “me” for the self as a source of psychological difficulties. By practicing mindfulness and defusion exercises it is possible to reduce this association. It is not surprising that many detransitioners who are are still dealing with dysphoria report meditation as being beneficial. A couple examples of these exercises are here and here A good ACT self-help book is “The Happiness Trap” by Dr. Russ Harris.

Another way to reduce distress is by uncovering and eliminating some of the rules (shoulds, oughts, and musts) that you hold about gender. These absolutist shoulds are known to cause distress in all domains, and gender is no exception. A form of cognitive-behavioral therapy known as REBT (Rational Emotive Behavioral Therapy) takes this as one of its core principles. There is a great book called “Three Minute Therapy” that describes some of these ideas in a self-help way.

A third way is to relax some of the psychological associations with gender. I have talked about this in ”relaxing gender schemas” and also here and here Men and women are both diverse. Men are cruel and kind, oppressive and gentle, nurturing and cold. The same is true of women. If you are holding a deep psychological association such as “men = bullies” or “men = unemotional”, it is helpful to meditate upon examples of men that have the opposite characteristics. Having friendships with such men is helpful as well. Something experiential is best, whether visualization or experiences of real life people. Men range in diversity from Martin Luther King to Stalin and everything in between.


Nothing I am saying here about trans identity is special to trans people. The things I am saying are about identity in general and psychology in general. Transgender and gender dysphoria are very human conditions. I am definitely not saying that trans identities are different than other identities and therefore are pathological. I am saying they are a human response to a human condition. The point I am trying to make is that transition is not the only solution to these difficulties, not to eliminate it as a solution entirely.