Breaking the testosterone/dysphoria cycle

In Anne Vitale’s T-Note #15 entitled ”Testosterone Toxicity Implicated in Male-To-Female Transsexuals: Some Thoughts”, she speculates on the role of testosterone in causing gender dysphoria in natal males. She talks about how some MTF people try to detransition, and then attempt to take testosterone and their gender dysphoria returns. She presents two case studies where two post-op MTF people have detransitioned, but could not take testosterone without overwhelming feelings to retransition returning. One eventually retransitioned and the other did not go on testosterone.

Note that I generally agree with Anne Vitale only in her descriptions of phenomena, not in her descriptions of the reasons why they happen.

Also note that these people were both okay with presenting as male as long there was no testosterone present. Suggesting that there is not some essential identity involved. This is one of the things that I am critical about in our conceptualization of these issues. I can definitely find plausible the existence of a condition that makes one function better on cross-gender hormones. I also think cross-gender expression can be healthy. However, I cannot find plausible the idea of a medical condition that requires someone to have their cross-gender identity constantly validated by others in order to feel okay with themselves. It was noticing the difference between how hurtful it was when someone did not validate my gender identity, versus how little it hurt when people didn’t validate aspects of myself I was comfortable with that contributed to my questioning of the whole thing. In the first case it was because deep down I didn’t believe in my female identity myself, precisely why it was so threatening when it was challenged.

However, I still faced the challenge that Anne Vitale addresses in this article. As I talked about before when I escaped from this female identity and got off estrogen I felt more connected to my body and enjoyed the absence of social anxiety and better mental functioning. I still had issues with fatigue and apathy and so decided to try testosterone. I felt amazing in the first 2 months of testosterone, a very great euphoria. However this was only temporary. I soon felt there was a part of me that wanted to return to presenting as a woman as well as erotic fantasies. I felt this pressure within my psyche and resisted it. However after a couple more months I found I couldn’t resist it and so went off of testosterone and went back on estrogen. This relieved that pressure but again it was clear to me my mind wasn’t functioning properly and I felt dissociated. Now I was in real trouble because I felt like I couldn’t go forward and couldn’t go back. Then I tried T again and the same thing happened, then I went back off it again.

By this time I was aware of role of trauma in this process and had a good intellectual understanding of what was going on, but that was insufficient to solve the problem. I went to two different counselors that I had worked with in the past to do work on this issue. I discovered the root of my “female self” was in feelings of profound unsafety around being myself and presenting male. In other words there were vital aspects of myself that I couldn’t express as a male without being subject to violence, much like the violence I suffered in childhood. Through the use of EMDR and IFS I was able to work through this. When that happened it felt like this idea of a female self dissolved and I have since been able to be on testosterone without difficulty. It has been over 2 years now and the feelings have not come back, of course I can’t be 100% sure they won’t come back again, but it felt like something permanently shifted in that moment and there is no pressure in my psyche. It is important to note the fantasies still exist, but they only exist as fantasies and I understand them for what they are. I don’t think the existence of the fantasies itself is changeable, at least not with our current knowledge.

This is why I conceive of this as a psychological process in a feedback loop with an erotic imprint (at least for those in Anne Vitale’s “group 3”) This also fits what I observe in others. People can have the erotic imprint without the psychology (i.e. cross dressers). I think the difference between cross dreamers/crossdressers and those that go onto transition is that they have the same erotic imprinting (they like the same fantasies) but have different psychological responses to it. Also eliminating testosterone does not eliminate the psychology but does reduce the fantasy component. I disagree with her that the developmental process she describes is inevitable, but I do think it reaches a point where it is quite difficult to reverse.

So, the what can you do if you want to halt this cycle and do not want to transition? I have written about some of the psychological issues here, here and here. Intellectual understanding is insufficient for this psychological work, it is a visceral, experiential understanding that is required, and it is probably best done with supportive others.

However, this says nothing about the erotic component which I think behaves more or less like other erotic imprint issues. Unfortunately, most of the psychological treatments have high relapse rates and are not very effective. A couple of examples include aversion therapy, and orgasmic reconditioning. The use of porn exacerbates these problems as overtime it requires more and more stimulation for the same effect. Other things that have shown promise are the use of mindfulness to insert a gap between stimulus and response, and values-oriented living as this problem tends to exacerbated by loneliness, stress and anxiety (and people often transition in response to a life crisis of some kind).

One thing I have learned is that having shame about fantasies makes them worse, and you have to accept them. Lots of people have erotic fantasies that don’t correspond to what is healthy for them to do in their lives. No one would suggest that women with rape fantasies live them in the real world in order to be their “true selves”. It is not any different for people with feminization fantasies or other fantasies. Porn doesn’t tell you who you are! They are things one can perhaps act out with a consenting partner, but they aren’t life maps.

If the fantasies are too powerful and acquire a compulsive quality, there are pharmaceutical treatments that are known to be effective. Of course anti-androgens are helpful for testosterone driven behavior (and if anti-androgens or estrogen improves your well being I think that is great) , however transitioning is a separate decision. Anti-depressents, particularly at higher doses are known to be effective for stopping this compulsive sexual behavior, but the response is highly individualized and that is something that should be done working with a doctor.

Sometimes cross-dressing and other cross-gender behavior has been connected with OCD, and in that case working on the OCD itself may stop things. Treatments that have worked for OCD include cognitive-behavioral therapy, exposure-reponse prevention and again high-dose anti-depressants.

This stuff is very complicated, and I really wish more mental health people were really digging into these things instead of saying “oh you have gender issues, therefore you have gender dysphoria, here have some hormones” Not all gender therapists are doing this, but the ones who see people for one session and write letters for them definitely are, that’s not enough time to diagnose anything.