Psychotherapy for gender dysphoria

Is psychotherapy the solution to our gender affirming care crisis?

Photo by Greg Rosenke on Unsplash

Recently I have been reading the HHS report on gender affirming care for minors. Since the report essentially advocates for psychotherapy as a first-line treatment for gender dysphoria in minors, I have been reflecting on my own experiences with the mental health system; what I have found helpful and what I have found less helpful.

In the past, I have said that I was misdiagnosed with what used to be called gender identity disorder (GID), now gender dysphoria — but that is not entirely accurate. To be misdiagnosed one must first undergo a diagnostic process, and while I thought that was what I was accessing, I now know that no such process occurred. My self-report was sufficient to land me the label of GID. Next steps were assumed - that what I wanted and needed was a medical pathway to social transition. No other options were seriously discussed.

While at the time of my ‘diagnosis', psychotherapy was offered, it was offered only as an adjunct to starting cross sex hormones and surgery, which were described as the primary treatments for GID. We did not discuss what GID actually was nor did we discuss that for some it dissipates without medical intervention. We also did not talk about the high complication rates of medical procedures or how a medical transition might impact on social interactions, relationships, or longterm health.

Granted, back in 2003, much of what we now know about gender dysphoria was not as widely discussed (e.g. high rates of autism/ADHD/neurodiversity), but as I remember it, very little time was spent discussing what remained unknown. The psychological assessment also involved minimal examination of the ways that gender dysphoria might show up for same-sex attracted individuals. Nowhere in the process did we discuss the possibility that the gender dysphoria could dissipate without medical interventions.

I was an adult when I was diagnosed with GID. I did not receive adequate information on what I was signing up for. I was also not informed that gender identity shifts can occur post transition, and that some people choose to detransition. Granted, at the time, the 1% myth was still widely held up as fact. Today, minors are accessing medical interventions and they are still lied to about what is known and not known. It remains common practice to hear clinicians make claims that puberty blockers are reversible, for example. This quite simply is not true.

My interaction with the mental health system did not begin with my diagnosis of GID. Growing up, I had a lot of difficulties with anxiety. As a child, little things would lead me to spiral — like social interactions with my peers (I feared judgement), or going to the toilet (I feared being sucked down when I flushed). I was something of a germophobe and would do things like brush my teeth until my gums were raw or wash my hands until the skin peeled off.

These unusual tendencies did not go unnoticed, particularly since my father was a psychiatrist himself. I credit him for helping me through some of these anxieties. Unfortunately, as his physical health deteriorated, my mental health issues increased. At 16, I engaged in problematic eating behaviours, restricting my food intake and refusing to eat dinner with the rest of the family. My parents had me consult with a neurologist, who I saw for one session and then never again. I briefly worked with a dietician to develop a meal plan, and remember seeing her a few times to monitor my weight.

Around the same time, my father also started bringing home antidepressant samples that the pharmacist reps dropped off at his office. My mother watched over me to ensure I was taking them. No one discussed with me why I was taking them or what they were supposed to do for me. I remember feeling out of control on them, not like myself at all. I eventually refused to take them, to my parents’ chagrin.

At 18, I left home to go to university. I thought leaving my parents behind would feel good, but starting over in a new city did not assuage my social anxiety. I became suicidally depressed. I reached out to the university’s counselling centre and worked with a talented therapist who helped me a lot. For one thing he seemed to care about my wellbeing. And he seemed worried about me. Given that by this point my biological family was understandably fatigued with my mental health challenges, and more focused on my dad’s physical health challenges (which were considerable), this therapist’s caring felt unfamiliar but good. I worked with him for as long as I could but the number of sessions I was allowed was limited and he eventually had to refer me out to someone else.

For the next three years, I worked with a psychodynamic therapist in private practice who was also a psychiatrist. She prescribed me a generous cocktail of psychotropic drugs including Citalopram, Ativan, Zyprexa and Wellbutrin to complement our talk therapy sessions. While I liked that she did not seem to tell me what to do, I also felt frustrated that she did not seem to have much in the way of solutions for how to lessen my anxiety and depression. She made vague comments about the ways my family’s dynamics contributed to my mental health challenges but did not offer me skills nor much insight.

The consequence was that I looked elsewhere for answers for what was wrong with me. I looked to the internet, and to the people around me. One of those people was a university friend who herself was planning to start testosterone following a GID diagnosis. Listening to her speak of her experience opened up a pathway I had not, to that point, considered. While I had always been gender nonconforming in appearance and demeanour, I did not think of myself as a man. But looking at her, I was more masculine than she was. She liked feminine clothes on some days and more masculine clothes on others. In today’s parlance, she might be called genderfluid.

In my naive way of thinking at the time, I considered that if she was receiving treatment for her gender dysphoria and her dysphoria was less intense than mine, then maybe I should receive treatment too. Armed with this new theory of what was wrong with me, I returned to my own therapist and told her that I thought I was trans. Given that she did not have much experience with trans patients, she referred me to a gender specialist. The gender specialist diagnosed me with GID - high intensity. Once I was equipped with a GID diagnosis, I was able to get a hormone prescription from an endocrinologist, and so my medical gender journey began.

But what if the gender specialist had said “yes you are experiencing gender dysphoria” and then had proceeded to explain that many cisgender people also experience gender dysphoria and a lot of butch lesbians in particular? What if that gender specialist had then explained that very little is as of yet understood of the causal mechanism behind gender dysphoria and that research is still in its infancy on the best treatment for it. What if that gender specialist had then suggested that I continue with psychotherapy to better understand the ways that gender dysphoria has presented itself in my life and to enumerate the ways that I had learned to cope with it? What if that gender specialist had worked with me to develop skills on how to deal with it psychologically and to focus on other areas of my life that were a struggle too?

For example, he could have helped me to address my social anxiety around my peers. He could have role played with me ways that I could respond to workplace bullying. He could have taught me ways of developing an internal locus of control, to learn to not let my happiness be dependent on the external validation of others. He could have talked to me about the ways my place in my family system had contributed to me feeling like an outsider and what it had been like to grow up with a father who suffered from chronic illnesses. He could have equipped me with ways of interrupting my perfectionistic, and ruminative thought patterns.

But these interventions would have required time and effort. They would have required me taking a long hard look at myself and how I was relating to the world around me. They would have required someone caring enough about me to want to put in the effort to work with me. While I think he cared about me well enough, I also don’t think he truly understood what I was struggling with. How could he have? He saw me for one 90 minute session before labelling me with GID. And I didn’t know enough to ask questions.

When I started hormones, I stopped taking the cocktail of psychotropic drugs my psychiatrist had prescribed me. The testosterone levelled out my mood and temporarily gave me a sense of confidence I could not remember having ever felt. That gender euphoria lasted maybe two years. By 2007 I was again having thoughts of suicide. No one, least of all me, brought up that hormones did not seem to be having the desired effect on my mental health. In 2008 I went ahead with a double mastectomy. In 2010 I had my uterus and cervix removed. By 2013 I was again seeing a therapist for suicidal thoughts. I was lonely, directionless, and lost. But I didn't question my gender transition.

Not until COVID hit did I begin to seriously reconsider my gender trajectory. By this point, I had gone back to school, started a new career and gotten married. My life felt meaningful for what felt like the first time. I credit my relationship for a lot of the improvements I experienced in my mental health. My work as a mental health counsellor also provided me with a sense of purpose and direction.

In my clinical practice, I listened and learned from my clients, some of whom had ambivalent feelings about their gender transitions. In my personal life, a handful of my friends chose to detransition. Others who continued to identify as trans saw their mental health deteriorate. As I revisited key moments in my own life, I recognized that my reasons for transitioning had not come from believing I was the opposite sex, but from my not knowing how to interact with the world around me as a gender nonconforming female.

With doubts increasing, I sought out a counsellor in private practice to talk through my thoughts, my ambivalences and my regrets. That therapist, steeped in the gender affirming therapy approach, was no help at all. He simply could not understand why I was questioning any of it. You pass, he said. As if that was all that mattered.

All this to say that psychotherapy is an umbrella term for a lot of different types of psychological interventions, with sometimes wildly divergent and even contradictory underlying assumptions. To date there are more than 500 different psychotherapy models out there. While the research is pretty solid that psychotherapy benefits mental health, what is less clear is how to optimize it for different populations.

I have experienced both the benefits of good psychotherapy, and the harms of it when poorly practiced. If reports like the Cass Review and the HHS report are going to advise psychotherapy as the appropriate response to gender dysphoria, I think we also need to talk about what therapy can realistically offer and not offer to clients. We need to clarify what we mean by psychotherapy.