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Moving toward an expanded life

Post-Transition Therapy

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A few years ago, I wrote an article for a local queer newspaper in which I said that I thought transition was the most difficult, life-changing process a person could undertake willingly in life. A friend of mine read this article, and commented that she thought the decision to become a parent rivaled transition as a difficult, life-changing event. (She has two children, both now young adults) I’ve thought about this a great deal in the years since, and find I can’t disagree because I’m not a parent. On the other hand, my friend has never desired to transition. We now agree that neither of us can claim to “know” which is the more difficult or life-changing process as neither of us has undergone both, and such a claim is inherently subjective. We each said, however, that if the wording were changed to read: “the most difficult, life-changing process I’ve undergone,” we would absolutely agree.

What I have found in the years since I began hormones and had surgery, is that I felt in greater need of therapy about a year after surgery than at just about any other point in my transition process. Yet the current Harry Benjamin Standards of Care (SOC) stop at the point of having surgery, as if one is finished and everything is now perfect in life because of the transition. However, I have also seen statistics showing that some post-transition individuals commit suicide (I’ve seen varying statistics, ranging from 5% to 30%, but don’t know how reliable the numbers are). I don’t know to what extent these suicides are related to transition, but the rates would seem to be beyond that of the general population. Thus, there may be some correlation. Because of these statistics, my personal experience, and that of friends I observed transition before me, I have begun questioning the current SOC and how to apply them in my own practice as a therapist.

I had thought of adding various steps, further standards to extend mental health care beyond the point of surgery, but that felt inadequate. I finally realized my criticism of the current SOC did not lie in the steps outlined, but in the very paradigm under which the SOC were written. For some time now, I have been considering transition as a developmental process of emerging identity. (My friend’s comment about parenting as a life-changing event triggered this connection for me) Not coincidentally, this is how many parents view their job in raising children – providing a safe space in which this new human being’s identity can emerge and develop in a healthy manner into adulthood. This parallel is not coincidental if one views transition as allowing the “rebirth” of the person in the gender they consider more appropriate. Consider, then, what it would mean to have a “Standard of Care” for the process of having children, a parallel to the SOC in place for transition. It’s easy to imagine what the steps might look like:

(1) The pre-decision phase, in which the prospective parent(s) are required to undergo therapy to learn more about themselves, what residual childhood issues they may need to resolve in order to short-circuit some of the more destructive family patterns they learned from their own parents. In addition, prospective parents might be required to take some classes in human development, to learn how babies and children develop into functioning adults. Perhaps there might be some requirement that prospective parents volunteer at local daycare centers, to interact with babies so they might learn whether they have the patience, desire and temperament to raise a child.

(2) The action phase, in which the prospective parent(s) have decided to adopt or have a biological child and now begin the process. Adoption papers are filled out, or pregnancy ensues. At this point, the therapy would shift to support around existential fears of having made the right decision. If pregnancy is the mechanism, the woman might need counseling because of the hormone fluctuations she will experience. Group therapy might be the most logical setting at this point, to allow parents-to-be to compare their experiences and find they are not alone.

(3) Birth, or welcoming the adopted child home, would mark the next phase. The parent(s) would come home from the hospital, or adoption agency, with this new life in their arms. And then – all they have to do is raise the child to adulthood.

Is it logical to assume that this would mark the end of a “standard of care” for the process of having a child? That the parent(s) would be told, “Okay, you’ve received all the support you need. Now you have your child, everything is grand, have a great life”? Yet this is precisely how the SOC work around transition from one sex to another. If considered from a developmental perspective, this seems illogical. If one undergoes a life-transforming process, how can that process ever have an “end” as long as the person is still alive? There are always new situations to negotiate, new people to come out to, new relationships to develop, people from the past who reappear suddenly and must be told. It is impossible to divorce oneself from one’s past completely, and this makes transition a lifelong process.

Why is it, then, that the current SOC consider transition finished at the point of surgery, and do not address the rest of the person’s life? This situation arises largely because the SOC are not based in a developmental model of emerging identity, but in a medical model that views transsexualism as a psychological disorder. Viewed from this perspective, physical transition (hormone therapy and surgery) is considered the “cure” and once it is administered, the patient is no longer in need of treatment. (Of course, taking hormones is a lifelong treatment, but is viewed in the same light as a person taking thyroid supplement to correct an imbalance.)

An FTM I met in 2001 put it quite well in an e-mail to me:

“Since being trans is seen as a pathology with a “cure,” it leaves out the whole rest of your life, in which you are suddenly trying to negotiate life as a gender you probably weren’t socialized as. And regardless of whether you ever “felt” like your birth gender, no one taught you the rules of the “other” one. Guys have a whole bizarre amazing language and strange mores that I just don’t know, and have had to pick up on the fly. And then mostly realize that they don’t much work for me anyway. So I had to look for atypical guys to observe. But no one talks about that and you can’t really prepare for it. To think that a person could just jump into the opposite gender pool without any of those floatie things is a strange concept all the way around. For myself, I found I REALLY needed the therapy after the initial three months for hormones and 6 for surgery. Imagine having surgery, a pretty invasive and freaky thing in general, and then not expecting to need to talk to someone about it.”

One could make the argument that any post-transition person is free to pick up the phone and call the therapist they saw during their pre-transition stage, get back into therapy. However, if that were happening consistently, it is my belief I would not be writing this article, as therapists would have recognized long ago the need to address this phenomenon in the SOC. A few years ago, I ran into my pre-transition therapist at a social event and told her I was about to enter graduate school to become a therapist myself. She said, “I’m really glad to talk with you. Most of the time, I never see my clients again after they transition and I never learn how or what they are doing with the rest of their lives.” Now that I am a therapist, I’ve experienced this same phenomenon with clients (non-trans, for the most part). I see them for a period of time, they move on after resolving whatever issue brought them into therapy in the first place (or quit coming if the therapy approaches an issue they aren’t ready to deal with), and I never hear the end of the story. If I were not trans myself, I doubt that I would realize the great need for post-transition therapy.

Why is it, then, that trans clients often don’t go back into therapy after surgery, if it truly is a lifelong developmental process? To explain this, I need to delve further into the developmental process of trans children.

Being born gender dissonant results in an early awareness of being “different” from other children. I put the word “different” in quotes because for many trans people, that’s the best description they have for how they felt. Many were not able to pin down the difference to use the words, “I should have been born a girl instead of a boy,” or vice versa. Whether consciously aware of the nature of the difference or not, feeling gender dissonant colors the entire developmental process. Those clients who knew the nature of the problem very young tend to report having had constant fantasies and dreams of suddenly waking one morning to find a Pinocchio-like transformation has taken place and they are suddenly “real boys” (or “real girls”). Those who didn’t know why they felt different nevertheless can often pinpoint distinct memories of discomfort around gendered situations (bathrooms, locker rooms, being forced into frilly dresses or suits and ties). These children grow up with a heightened consciousness about gender as a social reality that is foreign to non-trans children.

The trans child cannot help but absorb some gender socialization, albeit reluctantly, if only for self-protection; a boy who consistently acts out the female gender role is going to receive very hostile reactions from adults and children alike. There is more latitude given “girls” who act out a male gender role – they are labeled tomboys, but rarely punished or discouraged from such behavior. Thus, I believe that a budding FTM will suffer less psychological “damage” during pre-adolescent development than a budding MTF. Whether FTM or MTF, the trans child grows up with a degree of self-consciousness and unhappiness around gender identity that is foreign to the non-trans experience.

At varying points in their lives, transsexuals reach a decision point, “I just can’t live like this any longer.” At that point, they begin the process of figuring out how to rectify the situation. Whether through research on the internet or at their local library, the trans person bumps up against the SOC. While many may recognize that they could use therapy to help themselves feel better about who they are, most are put off by the tone of the SOC –that they need a professional to give a “stamp of approval” for their interpretation of their identity. The implication (as the trans client sees it) is, “I know better than you do who you are because I’m a professional mental health care expert.” Thus, the trans client often walks through the door viewing the therapist as a gatekeeper and not an ally, regardless of how the therapist views their role.

If the therapist does not address this likely scenario from the beginning of therapy, it will be very difficult to establish a true therapeutic alliance. The client is likely to have the feeling, “I know a lot more about this condition and about myself than this therapist ever will, so I’m paying my therapist in order to educate them. I’m not getting anything out of this.” Which of course will probably become a self-fulfilling prophecy. Given this situation, where’s the incentive for the client to return to therapy post-transition, when they probably feel in need of it but don’t believe their former therapist can help them?

So what is to be done? As with any new idea or paradigm shift, the first step for any therapist is to accept the need for change, and to take a good long look at their own beliefs about transition and gender dissonance. Changing one’s view of gender dissonance from psychological pathology to developmental process is not a huge leap, but does require some inner work on the part of the therapist.

The next step would be for the therapist to talk with their trans clients frankly about the role therapy plays in the client’s life. While the client will be able to resonate with the concept of gender transition as a developmental process (after all, they are living it), they may not be familiar with the terminology or the idea that models of human development already exist and offer parallels to transition. This can be a comforting thought to the trans person, putting their experience in the context of human development rather than the context of the DSM. It may also make it easier for the therapist to broach the idea that the need for therapy doesn’t end with the scalpel, but may in fact feel more necessary as the client faces the “now what and what next?” stage of transition, the rest of their lives.

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