The therapy session
An imagined exchange about gender that never took place
Does psychotherapy have value in the treatment of gender dysphoria? If it does have value, which I believe it does, what is that value exactly?
Some academics have argued that doing a psychosocial assessment for gender dysphoria is demeaning and oppressive. Assessment by itself isn’t the same as psychotherapy but it is an important part of a psychotherapeutic process. An assessment is about listening carefully before jumping into action. Because psychotherapy is only as good as the agreed upon goal. If your target is wrong, your intervention might be ineffectual or worse, harmful.
The stance of the health provider matters. If the provider is using the assessment process as a means to impose their own agenda, then yes, that could very well feel dismissive and demeaning.
But isn’t it also demeaning for a mental health provider to treat the gender dysphoric client as if their trans identity is untouchable? As if they are so fragile that to express curiosity about their underlying motivations is to threaten their entire identity? I don’t buy it.
Psychotherapy is valuable precisely because it is a space where the whole person is welcome. Together, client and clinician use the power of verbal and nonverbal communication to create opportunities for future thriving.
In the spirit of a thought experiment, I have conjured up an imaginary therapy session. One where the therapist does not have any pre-ordained outcome in mind other than to help the client make sense of their own life experience in a way that is coherent and truthful.
Is it demeaning or oppressive? Decide for yourself…
What brings you into therapy?
I think I might be trans.
I see. What does ‘being trans’ mean to you?
That I’m not a woman. I’m thinking about transitioning.
Medically?
Yes. And legally… socially...
And what do you see my role as being?
I don’t know. I guess I need an assessment letter for the hormones.
And you would like me to assess you?
Yes.
To determine if you are really trans?
I guess so.
That’s not something I can assess, unfortunately.
Why not?
Because trans is an identity, not a disease. You either identify with the identity or you don’t. That’s why I asked you what trans means to you.
Well what if I’m not sure if I actually am trans?
Then it seems like an identity that you might hold lightly.
I’m not sure what to do with that.
What do you want to do with it?
I wanted you to help me figure out if I should start hormones.
Ah. That’s a different question. I may be able to help you there.
How?
Well, I can’t tell you if you’re trans. But I can help you figure out for yourself how starting hormones might impact your life: Your relationships, your health, your future…
Well, I already know that it’ll probably be negative.
How so?
My parents are pretty old school. They won’t approve. I guarantee it.
Maybe that’s the point.
What do you mean?
Maybe it’s a way of differentiating yourself from them.
Maybe. We don’t get along anyway. This’ll just be the last straw.
Do you have any siblings?
Yeah, two sisters. They’ll probably be apathetic. We rarely speak now, so I don’t imagine much will change.
What about your friends? What’ll they think?
They already think I’m weird. I don’t think much will change there.
Do you have a romantic partner?
No. I only dated once, when I was 19. It wasn’t all that great. I don’t think he liked me very much. I don’t blame him. I was a mess.
Would you feel more confident dating if you started hormones?
I don’t know. I’m kind of useless with relationships. I don’t know if I’m dating material.
So to summarize: starting hormones will negatively impact your relationship with your parents, to whom you are not very close as it is. It won’t change much about your relationship to your sisters or your friends. And it may or may not improve your dating life. Did I get that right?
Yeah, I guess so.
What about your work life? How will that be impacted?
I’m at university now. I got my BA in English Lit a few years back but haven’t figured out what I want to do with my life. I’ve been bouncing from job to job. I suck at most things.
Really?
I mean, I’m OK as a writer, but I don’t really have the attention span to create anything meaningful. I’m not that creative. Besides, it’s hard to make a living in the arts.
What are you studying now that you’re back in university?
Human sexuality. I thought it might help me better understand myself.
Are you having a hard time understanding your sexuality?
You can say that. I guess I’m bisexual. I don’t really know what I am. I want to have a partner. I don’t really care what genitals they have. I just want them to love me back.
Loving and being loved back is a pretty fundamental human need.
But I don’t like my body. And the one time I did date, my boyfriend didn’t much like my body. Maybe if I changed it, I could make it look better.
How would hormones make your body look better?
I don’t know. I’d have more muscle. I’d be stronger.
Compared to now?
Yeah.
And if you were stronger, how would that improve your body?
I could protect myself more?
Do you need to protect yourself more?
I don’t know. I feel like I do, yeah.
Could you get stronger without using hormones?
I hate working out. I hate having other people watch me work out.
You feel judged?
Yeah. Big time.
Hormones alone are unlikely to make you stronger. You’d still need to work out.
Yeah I know. But it’d be easier to build muscle. Faster too.
I imagine you’re right about that. If you were to start hormones tomorrow, what is the thing you’d most look forward to?
Stopping getting my period.
Yeah?
Yeah absolutely. It’s fucking gross. I can’t believe people put up with it every month. It’s disgusting. And painful. I hate it.
Some females go on birth control to manage it, if their period is very disruptive. Have you considered that?
No. I heard birth control makes people really moody. I’m already too moody as it is.
Are you?
Yeah. And my friend who started testosterone said it mellowed him out.
You’re hoping it’ll do the same for you?
Hell yeah!
Have you told anyone else that you think you might be trans?
Mostly online.
Online?
Yeah, I joined some forums for trans people. I tend to avoid too much interaction though. I just lurk. Sometimes it’s kind of depressing though.
How so?
So many trans guys post about how they’re getting divorced because their partner no longer wants to be with them. Luckily I’m not in a relationship so I guess I don’t have to worry about that. It just seems like very few trans guys are in happy longterm relationships.
You’re worried that transitioning will narrow your dating options?
I guess I am yeah. I already have a hard time connecting with people.
Seems like connecting with people is something that’s very important to you.
Well yeah. I’ve been pretty alone all my life. I don’t want to die alone.
Do you think about that a lot - dying alone?
Oh yeah. I’ve always had a complicated relationship with death.
How so?
Well you know, growing up, my dad was very sick. Always on the verge of dying. That does a number on you, when you’re a kid. I guess you could say I became obsessed with death and dying. I was depressed by the age of 12. And I’ve been like that ever since.
Been like what? Depressed?
When I was a kid and not sufficiently obedient, my mother would accuse me of killing my father with my bad behaviour. I knew it wasn’t true, but I guess part of me worried that I was causing him stress which was indirectly causing him to weaken. I felt a lot of guilt about that. Like I was a bad person. Like I deserved to die.
How is your dad’s health now?
Not great. He’s probably not going to live much longer. Then again, my mom’s been saying that for most of my life.
What’s it been like, living with the uncertainty of him dying? I imagine it’s been difficult.
I don’t know. It’s just what it’s always been. I guess it just feels normal. It just feels numb.
You feel numb?
Yeah. A lot of the time. Half the time I don’t even know what I’m feeling.
What about the other half?
What?
You said half the time you don’t know what you’re feeling. What about the half when you do know what you’re feeling?
I feel angry a lot. Not angry. Rage.
Do you feel it now?
Not really.
When’s the last time you felt it?
Whenever I get an email from my mother telling me what a bad daughter I am.
She tells you you’re a bad daughter? Why?
Oh yeah. All the time. She’s pretty much cut me off from my father. She checks his email account. She answers the phone. I can’t talk to him without it going through her.
She doesn’t want you to talk to him?
I told him I didn’t want to have a relationship with her anymore. So the only way she can force me to talk to her is by gatekeeping my relationship with my father.
Something bad must have happened for you to decide you no longer wanted to talk to her at all anymore. Something more than the usual negative emails you’ve gotten used to getting from her. What led you to that point?
She’d send me awful emails telling me what a disappointment I was to her and my father, how selfish I am. I just got tired of it. Then on the same day I found out about one of my close friends dying, my mother sent me another email telling me how selfish I am. I just couldn’t anymore.
Why did she call you selfish?
I don’t know. I’ve been having a hard time finding my own way. I haven’t always made the best decisions.
About what?
When I finished university the last time, she wanted me to come home, to come live with them again. I declined. She didn’t like that. She said I was a bad daughter.
Do you think you’re a bad daughter?
Well, I guess it’s not easy having a kid like me.
How so?
You know, constantly depressed. Kind of lost. Not really contributing anything. It is kind of selfish.
Is that how you see yourself?
Yeah, pretty much. I don’t think I bring much to the table. I have no special talents, no skills really.
Sounds like you believe the things your mother says about you.
Well, she’s not completely wrong.
So starting hormones, that’s a way for you to break out of the mould of being the bad daughter?
I mean, I don’t know about that. But maybe it’s a chance to start over.