When an assessment isn't one
When I first went to a psychologist for an assessment for Gender Identity Disorder/Gender Dysphoria I was operating with the belief that there was some way to tell, objectively speaking, whether I was gender dysphoric or something else. I thought that the psychologist would have some criteria with which to determine whether such a diagnosis was appropriate and that once I was diagnosed, we would have clarity over what the next steps would be.
I do love clarity.
I now realize that where I went wrong (or at least one of the places where I went wrong), was to think that what I was experiencing was actually a diagnostic assessment. I later discovered that the psychologist wasn’t really diagnosing me. The word assessment might have led to my confusion. I now realize that assessment can mean different things to different people: Assessment can mean diagnosis, based on the DSM (the manual of mental disorders psychiatrists and psychologists use); assessment can also mean cognitive evaluation, or a process for determining whether someone is competent to make an informed decision. Finally, assessment can refer to a bio-psycho-social assessment, which is a process for looking at the medical, social and psychological context and needs of a client to determine what the contributing factors are that are to be addressed for a favourable outcome.
The psychologist who assessed me diagnosed me with a DSM label of Gender Identity Disorder, based somewhat on my history of gender nonconformity but mainly on my say-so. People who know who they are — it’s a refrain often expressed in trans activist circles. Except when they don’t. I had a lot of identity issues and part of why gender transition was so appealing was that I thought it would give me a more solid identity.
While he asked questions in line with what you would ask during a bio-psycho-social assessment and I shared with him a history of depression and anxiety, he chose to conveniently leave out these diagnoses in his report. I can only speculate as to why. My best guess? He believed that GID/gender dysphoria was causing the depression/anxiety I was experiencing and that those conditions would go away once my GID was treated. But based on what evidence?
To a man with a hammer everything looks like a nail.
Had he spent more than a 90 minute session with me, he would have learned that I was highly sensitive to noise and touch. He may have learned that i was socially awkward and struggled to make friends. He might have learned that I had been gender nonconforming as a child but had not felt like I wanted to be a boy. He may also have learned that I was bisexual and that I was uncomfortable with my sexuality. He would have learned that puberty was a very difficult time for my physically and socially.
But he didn’t seem to see these issues as relevant. He cared about assigning me a label so that he could pass me on to the next doctor on the conveyer belt of what made up gender affirming care — the endocrinologist who would start me on hormones.
But can I fault him?
As a mental health clinician myself, I know how easy it can be, to think you know what is up with a client, only to learn later that you only had a small sliver of the story. Psychotherapy often deals in uncertainty and most of the time we can’t really know whether what our clients are telling us is the truth. But that’s OK because psychotherapy deals in subjective experience. We seek to identify the patterns that govern the way clients interpret the world, and then we ask: is this way of seeing, of believing, useful in living a meaningful, purposeful life? Or is there a more effective, more reality-based way of navigating decisions?
Interventions such as the ever-popular cognitive behaviour therapy has as one of its central tenets that our suffering is often caused by the way we interpret events around us rather than the events themselves. Thought distortions like catastrophizing, all-or-nothing thinking, or minimizing can muddy the waters and lead us to misinterpret life stimuli. With training, we can change our thoughts, our beliefs about ourselves, others and the world around us. And when we change those thoughts to match reality more effectively, our suffering grows less.
For this to work, though, requires a commitment to reality as it is.
The psychologist who assessed me wasn’t interested in helping me come to terms with reality. He was not in the business of challenging my thoughts, let alone understanding them within a larger context of family dysfunction and mental health challenges.
As a mental health clinician I sometimes work as part of an interdisciplinary team, collaborating with psychologists and psychiatrists to best support my clients. I see how often clients are sent to psychiatrists for a diagnostic assessment, and the psychiatrist speaks with them for little more than 20 minutes before announcing one medication or another for them to try. This is informed by a medical model of mental health issues. Some clients go along with this approach without hesitation, believing that the doctors are the experts. Others are more skeptical, and sometimes shocked at how quickly they are labelled and prescribed serious drugs. Rarely do psychiatrists suggest that clients could improve without medication. And few psychiatrists practice psychotherapy.
While therapy has gained traction in mainstream culture, it is a term that has many different meanings to practitioners and clients alike. Say the word therapy and you might conjure an image of a client lying on a couch while the therapist sits quietly in a chair scribbling notes. You might imagine a long, drawn-out process of years. Others imagine that therapy is about venting for an hour while a therapist merely validates you. But therapy, good therapy, is so much more. It is a process that invites you to become more self-aware. Sometimes, it can be a difficult process where you are invited to challenge your deepest-held interpretations about yourself and others. The good news is that it doesn’t have to be a years-long process. Many brief forms of therapy exist that have demonstrable benefits for clients.
What all therapies have in common, however, is that they involve looking at yourself, your thoughts, emotions, actions and beliefs more closely, and bringing curiosity to bear on them. In the process shifts occur, beliefs change — and so, too, do actions.
No one offered me psychotherapy as a possible way of managing my gender dysphoria. In fact, these days some claim that offering psychotherapy for gender dysphoria is tantamount to ‘conversion therapy’. I find it so odd, that to seek to help someone resolve their difficulties with their body through talk therapy is considered conversion therapy, but to remove healthy body parts and organs is considered ‘affirming’. What an upside down world.
When I was offered the label of GID it was a relief. I felt legitimized. I wasn’t crazy or making up my suffering. There was a name for it. There were other people who had it. I was no longer alone, awash in the shame of suffering for no reason. But labels can become traps - they can lock you into an identity from which it can become difficult to escape. This is especially true in the mental health field. Surely people are more than the labels they carry. Labels come and go.
Had someone explained to me that GD was a condition that might go away on its own, I might’ve listened but probably not, who knows. The label carried with it a treatment already laid out for me and that was enticing to someone like me, who was desperate for a cure to my misery.
At first I resisted transitioning. I thought maybe I could just be an androgynous in-betweener. But it’s hard living in that in-between space. I have memories of a child staring at me and running up to his mother to ask: ‘is that a boy or a girl’? I remember the deep, deep shame. Or the time I went into the women’s washroom at the airport and was chased out of it by the female cleaner, angrily shaking her broomstick at me. All this before I’d transitioned, or even thought of doing so. Just by being me, i was an outcast, a monster, a freak. Having a medical label seemed like a ticket out of that monstrosity.
I recently looked up the psychologist who assessed me, thinking I might reach out to him for a follow-up conversation. What I found was his obituary. I would have liked to have had a chance to look him in the eyes and tell him of the harm he caused. I would have liked to tell him that despite the damage he and his gender affirming colleagues set in motion, I found my way out of my misery.
I will never have the life I could have had, but out of the ruins I have built a place for myself — a sense of self built on a foundation of reality. It’s the hardest, best thing I’ve ever done. No thanks to him.