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.

Erotic Imprinting – Overview

Erotic imprinting is a key component in transgender identity development. This is also a factor is cross-dressing, cross-dreaming and other cross-gender behavior as well. Unfortunately, psychology currently has no way of changing erotic imprinting. Particularly in natal males, it acquires a fixed character and once that happens it cannot be changed. However, the situation is not completely hopeless. Erotic imprinting can be managed, and sexual behavior is like any behavior it can be conditioned (for good or for ill).

There is a critical period for erotic imprinting. John Money suggested this occurs between ages 5-10, but no one is sure of the exact ages. In particular, we know that younger brains show more plasticity, so the imprint window might still be open in early puberty. Erotic imprinting is similar to other imprinting such as language acquisition, where there is an imprint window. This is why people who learn languages at a young age do not have accents, but those that learn them after the imprint window has closed do.

In particular trauma or any strong events in childhood can override erotic imprinting. This is what John Money referred to as a “vandalized love map” Such overwriting can be total, but is usually only partial. This creates a kind of dual sexuality where a person has a typical sexual imprint (hetero/homo/bisexual) as well as some fetishistic scenarios that turn them on. These dual sexual imprints compete. This if found in many other sexual imprints and is not specific to gender issues. There is also a dynamic competition which is life long. Fortunately, one does have some control in this scenario, and a person’s actions have some say in the relative strengths of these two imprints.

There is good reason to favor the original imprinting. One is that imprinting is like to be more functional in finding relationship partners. The function of sexuality is to connect us to others, and the original sexual imprinting is more likely to succeed at that. It is also more likely to be in harmony with one’s organic sexual needs. Your Brain on Porn suggests a way to determine what your organic needs are in case things are confused.

Also if one’s sexual imprinting has been corrupted through trauma, to allow that side to dominate is to allow the traumatizers to win. There is something empowering in choosing connection. It is also possible to find partners where one can connect to both sides of their sexuality at once, however this can limit one’s choice of partners.

We see this dual sexuality play out all of the time when MTF-spectrum people are struggling with gender. The cross-gender feelings can go away when one finds a new partner and come back after the limerance has passed. They also tend to increase in times of stress. If there is also a negative schema present, the erotic fantasy can act to discharge the tension caused by the schema (schema avoidance). This also strengthens the schema, creating a feedback loop. The fantasy is never enough, and there is risk of escalation.

If one has this dual sexuality, the side one feeds is strengthened. There are two traps in managing erotic imprinting. If one wishes to manage an erotic imprinting they do not wish to enact, it should neither be fed or repressed. Both of these give energy to it. Simple acceptance is best. An example of repression would be to attempt to suppress fantasy or deny it. These thoughts should be accepted with curiosity, as is described here

Neither should this side be fed. Feeding is seeking out ever increasingly intense porn or enacting the fantasies in compulsive ways with others. This will strengthen the fantasies and lead to the dopamine-based escalation we see in all porn addictions. Porn is like alcohol, gambling, or any vice, okay in moderation, but unhealthy if it fits a pattern of escalation. Unfortunately, today’s porn is very powerful and is more like meth than alcohol. Not only can it lead to wasting lots of time, it can shift sexual tastes. This is different than the imprinting I referenced earlier, this is conditioning. Conditioned responses will reverse if porn is stopped, but imprinted responses are permanent.

This is just an overview, and I will discuss more in future articles about methods for managing sexual imprinting.

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.

A three-part model of transgender identity development – Overview

Transgender issues are often framed as a question of essence. Some people have the “trans essence” and need to transition and express their true selves in order to be happy. Other people do not possess this essential nature and therefore it would be wrong for them to transition. Any detranstion is because the person was mistaken about their essence and “wasn’t really trans”. People who come out as trans describe it as “figuring out they were trans”, that they looked into themselves and discovered the trans essence. This framing is dangerous, because it leads people to believe they must transition to be “true to themselves” rather than it being in their best interest. It also leads to some confusion in thinking about these issues.

I frame this issue as three different components that interact with each other. These components are narratives/identity, schemas/trauma and erotic imprinting. Narratives are stories, they are high-level structures in the neo-cortex, and therefore are the most mutable. Schemas are lower-level structures, they contain non-verbal components and are felt viscerally. This makes them more resistant to change. Erotic imprinting has to do with the biological components of gender identity and tends to be the most unchangeable.

Narratives / Identities

Narratives and identities are stories we tell about ourselves and use to explain ourselves to others. These are abstract concepts that by necessity are incomplete. They help us to say, I am like this group and I am not like that group. Narratives are also culturally-specific and cannot be innate.

It is not possible to identify as trans in a culture that does not have a concept of trans identity. It is possible to engage in cross-gender behavior in any culture. Likewise gay identity is recent Western concept, but same-sex attraction and sex have occurred in every culture.

Cultural narratives interact with personal narratives and influence cross-gender expression. Many cultures have cross-gender roles, but only in Western culture is there the idea that one can actually become a member of the other sex. Other cultures with cross-gender roles consider people in those roles as a member of a third category,and their roles often have characteristics of both gender roles.

It is because of this Western conception that being trans in our culture often means attempting to convince people that one is a natal member of the sex associated with their gender identity, rather than merely expressing oneself in ways typical of their gender identity. Further, self-expression and individuality are highly valued in Western culture, and therefore it is considered important that a person be true to themselves and express themselves fully.

The way cultural narratives interact with personal narratives can be seen in recent shifts in queer culture. There has been a large explosion since the mid-2000s of people identifying as FTM or genderqueer identities. This is because the queer cultural narratives have shifted. People who might have identified as a butch lesbian in the 1980s might now identify as trans men in the 2010s. They might have the same feelings, but become exposed to different cultural ideas of what their feelings and experiences mean.

Finally narratives can be arbitrary. Healthy narratives are connected to lower-level functions in the psyche as well as the material world. However this is not required. If the material world is unsafe or harmful in some way, an arbitrary narrative can be a great escape. This process can be clearly seen in some of tumblr queer culture. This is not to say that narratives are unreal, they have tremendous influence. People have died by the millions in fights over which narratives are true, just look at the Crusades.

Trauma / Schemas

The second component of my model is Trauma and Schemas. Unlike narratives which are verbal constructs made up of words, traumatic memories contain pre-verbal components and include feelings and body sensations. Such memories are undigested, and when an event happens that reminds someone of the traumatic memory, they will get triggered, which means it will feel as if the traumatic memory is occurring in the present. These traumatic memories can even be completely disconnected from any verbal components and the person may have no idea what the original event was. A person that is triggered may dissociate, have flashbacks, feel intense body sensations and intense feelings. Once triggered it often takes time to come back as a person cannot simply decide to not be triggered.

Schemas are rigidly held patterns that often originate in childhood. They are formed over time and also have non-verbal components. Schemas tend to act as filters and shift our perception of the world, emphasizing events that fit the schema and discounting events that do not fit the schema.

Az Hakeem, a researcher and psychotherapist that works on trans issues, identified rigid gender schemas as being common among transgender people. Further, he found that transition does nothing to change these schemas.

Common schemas I have seen with trans people, include “Men= bad, Women=good”, “Men = unsafe, Women = safe”, or schemas involving inadequacy as a man for MTFs.

It is important to note that these schemas can be disconnected from the rational mind, and often hold a child’s view of the world. A person can have a quite sophisticated view of gender in their rational mind, and simultaneously be imprinted with one of these rigid schemas. Even if their rational mind disagrees with that imprinting. One of the schemas I had to work through comes from the bullying I suffered as a child which I associated with being male. So I had a schema that being a man in the world was unsafe, while being a woman in the world was safe. Even though this did not make sense to me rationally, certainly as an adult that lived as a woman, it was still a visceral feeling that I had. I simultaneously held the schema that men were evil and did not want to identify with them. Letting go of these two schemas was crucial to my healing.

Schemas and trauma can be worked with through therapy although they are resistant to change.

Erotic Imprinting

The third component is erotic imprinting. This includes biologically hard-wired attractions, primitive sexual instincts, sexual orientation, turn-ons, and how we like to have sex. These operate quite differently in natal males and females, and this component creates the differences we see in MTFs and FTMs. I believe the first two components function similarly, but this component functions differently.

Erotic imprinting is not necessarily genetic, and trauma can play a role in erotic imprinting, however in adulthood it is generally unchangeable, although a lot of research shows that females have more fluidity in this area than males do.

Some of what is called sex dysphoria fits into this category, although trauma and schemas play a role in that as well.

This is just a basic overview of my ideas, I hope to have a series of posts on each of these three components and how they interact. Some of these things are changeable and some are not. Breaking things down can help expand options for people dealing with gender dysphoria. I do believe transition in a valid option, but it is not the only option, and not always the best option.