therapy

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.

The problem with gatekeeping

It might be surprising that as someone who is concerned about unnecessary gender transitions, I also oppose the gatekeeping system as it currently stands. For those who are unaware, the “gatekeeping system” is the process by which letters from therapists are required for transgender people to proceed with hormone therapy, or genital surgery. This process has become steadily more relaxed in recent years, as the “informed consent” model has become more popular, at least for hormone therapy. This system causes more harm than good for several reasons:

There is no gate to keep

There is no point in guarding a gate when there is a large hole in the wall next to it. There are always going to be therapists that are willing to write letters to anyone, and doctors that are willing to prescribe hormones to people without therapist letters. People can simply find out about these providers through word of mouth, and go to them if they want, at least in most major cities.

There are no evidence-based criteria for gatekeeping

The ostensible function of gatekeeping is to determine whether a person is an appropriate candidate for treatment, and to prevent those who are inappropriate candidates from having treatment. When I went to see a therapist about these issues, I was prescribed hormone therapy after just 2 sessions! Years later I was quite angry about that, as I thought of it as malpractice, and that my problems could have been avoided if it wasn’t for that. Then when I began to study to become a therapist, I was shocked to discover these criteria don’t exist at all! I attended four different trainings on therapy for trans people, and there were no criteria for evaluation discussed! There was a lot of discussion on cultural competence, and the issues that commonly arise, which is good, but no criteria for evaluation. Neither the DSM-V or the WPATH standards of care contain such criteria. The DSM-V criteria essentially state that someone has to be uncomfortable with their gender for at least 6 months, and the new WPATH standards expressly state that “Psychotherapy is not an absolute requirement for hormone therapy and surgery”. This means that therapists either use no criteria, or arbitrary criteria, both of which are problematic.

The use of no criteria or arbitrary criteria are both problematic

The use of no criteria is problematic, because it creates a kind of false endorsement of a person’s trans identity. I have heard several people argue to unsympathetic family members that they are “really trans” because their therapist has “diagnosed them with GID / Gender Dysphoria”. I used the same argument with my family when I first transitioned. This can choose to erase doubts in people’s minds about their gender and help to push them into transition. When as mentioned above, the diagnosis of Gender Dysphoria only means that one is distressed by some aspect of their gender, which they already knew, or they wouldn’t be seeing this therapist at all! If we lack diagnostic criteria, we should neither endorse nor oppose transgender identity and be honest about that fact.

The use of arbitrary criteria is also problematic. These arbitrary criteria are often based on gender stereotypes. Some criteria that were used in the past for MTF transsexualism include whether the person was exclusively attracted to men, or wore dresses and skirts. There were even male therapists that chose to determine whether their clients were “really women” based on whether the therapist was sexually attracted to her!

These arbitrary criteria lead clients that want treatment to simply lie about fitting these arbitrary criteria in order to get what they want. Besides being wasteful and unnecessary, this undermines any potential therapeutic relationship as the clients don’t feel safe in telling the truth to their therapists. Fortunately, this is happening less and less.

Gatekeeping creates a dual relationship which prevents healing

Dual relationships (when a therapist has to play multiple roles with the same client) are frowned upon in psychotherapy, although it is recognized they are sometimes unavoidable. When the therapist has to play the role of the gatekeeper it creates an immediate conflict. As gatekeeper, the therapist should be playing an evaluatory role, while as therapist they should be playing a healing role. In order to create a good therapeutic relationship conductive to healing, the client should feel safe, open and free to express what is on their mind. If the client wants something from the therapist, this will not occur, and the client will censor themselves acting as an impediment to healing.

This is doubly important in the case of trauma, where the client’s being in control is part of the healing. Part of trauma is not being in control of what happens to you, so being in control of the pace and the choice of whether to explore the trauma is important to healing. The gatekeeper relationship creates another situation where the client does not control things and this can add to the trauma rather than heal the trauma. People might disagree as to whether trauma plays a role in transgender identity formation, but almost everyone would agree that there is a lot of trauma in the community, and people in need of healing.

Many in the transgender community distrust the therapeutic community in part because of this issue. This prevents people from getting the healing they need, instead they see the therapist as an obstacle in the way of what they want.

Possible alternatives

The movement towards pure informed consent also creates problems and may lead to unnecessary transitions. A possible alternative would be to include a therapy requirement for transition, but allow the client free choice to participate in hormone or surgical treatment after therapy. This would prevent some of the problems with the gatekeeping system. However, even this would be difficult to implement because there really is no more gate as referenced above.

Applying general psychological principles to gender issues

One of the problems that contribute to unclear psychological thinking on gender issues, is that it is treated as a special case of psychology. For whatever reason, general psychological thinking goes out the window when dealing with gender issues. There is already well-established thinking on issues such as identity, trauma, dysphoria, narratives, and sexuality. Many of the ideas I will present are derived from taking a step back and applying these general ideas to the issue of gender dysphoria. What is healthy for those without gender issues is also healthy for those with gender issues. General principles of psychological health must be applied to these issues. All of these things are interconnected.

This often does not happen in the case of gender issues. Gender dysphoria is seen as a specialized field in the world of psychology. This means that people dealing with these issues are referred to specialized gender therapists. Gender therapists are generally very thoughtful and caring people. However, the gender issues are generally treated as separate from other issues. In particular, trauma seems to be correlated with transgender identity formation, yet trauma is often seen as having nothing to do with gender identity, both by gender therapists and the trans community. Many people that have retransitioned have cited trauma as a key factor in their transition and felt their gender therapist did not see it as relevant. It is not as simple as trauma causes gender dysphoria, but it does play a role. Biological and cultural factors seem to play a role as well.

In the psychology series on this blog I will expand upon these topics further. By working through my trauma and studying psychology I was eventually able to reclaim a male identity, which was not a possibility expressed by anyone during my transition journey. I am not against transition, as I do think it is right for some people. I also think there are people who transition and don’t need to, and that the psychological community is contributing to this. It is a complicated issue.