Detransitioner and author of this wonderful blog Maria Catt very generously agreed to write a guest post about the mental health care she wished she had received as she was going through her transition. Thank you for your brave words, Maria!
Update: Maria’s letter is getting a huge number of views. Evidently, this is striking a chord. If you are a detransitioned person and would like to submit an open letter to therapists and other professionals, please feel free to contact us. We welcome submissions.
The main thing I wish were different about the therapy I received before and during my transition is I wish my therapists had been trauma competent.
I was in therapy right after my college rape. I was in therapy for the many years I was wondering if I was some kind of trans. I was in therapy when I decided I was trans and needed to get my letters for hormones and surgery.
All three therapists knew about my college rape. All three therapists knew about my stressful childhood in a home with daily violence. The second two therapists knew about me going through an experience of being virally hated on on the internet. Looking back, knowing about dissociative states, it’s crystal clear that was a traumatic experience I had classic trauma reactions to- dissociation, depression, anxiety, avoidance. We talked over my rape. We talked over my childhood. We talked over a pack of strangers hating me on the internet. We talked and talked and talked.
Talking does exactly NOTHING to reset the human body’s stress reactions after trauma. A massage will do more than sitting in a room and talking. The first responders who were traumatized after 9/11 found massage and yoga more effective than talk therapy. I highly recommend the book “The Body Keeps the Score” by Bessel van der Kolk about the limits of talk therapy and the need for embodiment work after trauma.
So why didn’t any of these therapists teach me about cortisol and the other physiological facets of a prolonged stress reaction? Why didn’t we talk about the altered states of consciousness that are part and parcel of untreated trauma? Why didn’t anyone say anything to me about dissociation?
The first time anyone acknowledged that the circumstances I was talking about in therapy- humiliating, coerced sex (otherwise known as rape, my first therapist let me call it “coerced sex” the entire time),a stressful childhood in a violent home, the amorphous threat of a lot of men on the internet calling me terrible names and also knowing where I was performing- constituted trauma, was actually at a medical appointment. I told the doctor I couldn’t concentrate and was crying a lot. I also said I had been raped in college. I was given a prozac prescription and the doctor wrote down on my chart that I had PTSD. My therapists up to that point had not mentioned PTSD to me. Once I had what I took as permission to apply PTSD to myself, a lot of the way my brain worked made more sense. Extreme trouble concentrating. Racing, obsessive thoughts. Lots of crying. Getting triggered at comedy shows by all the rape jokes. Nightmares.
But no one said anything to me about dissociation.
No one said, hey do you ever feel like you’re an outside observer of your thoughts and actions? Do you ever feel like you’re outside your body? Do you ever feel numb for weeks at a time? Do parts of your body feel unreal to you?
This is the best link I could find describing the DSM 5 criteria for depersonalization/derealization disorder.
I believe my experience of constructing a fantasy, non-woman persona was somewhere between a depersonalization/derealization disorder and a dissociative identity disorder. The obsessive thoughts of how my life would be different if people could see the “real,” non-woman, no boobs or butt having me, were all day, every day, for years. I’ve had obsessive thoughts about being really more like a boy since before puberty. There have been points in my life when I would catch myself in a window or mirror and see a boy briefly. My breasts and thighs and butt have felt unreal to me for a long time. Since long before my college rape. Pretty much as soon as they came in it’s felt to me like there has got to be a zipper for this exaggeratedly sexual body suit I’m wearing.
Now, let’s be kind to my old therapists and acknowledge differential diagnosis is a tricky skill set.
Here are the criteria for gender dysphoria in the DSM 5:
- Noticeable incongruence between the gender that the patient sees themselves are, and what their classified gender assignment
- An intense need to do away with his or her primary or secondary sex features (or, in the case of young teenagers, to avert the maturity of the likely secondary features)
- An intense desire to have the primary or secondary sex features of the other gender
- A deep desire to transform into another gender
- A profound need for society to treat them as another gender
- A powerful assurance of having the characteristic feelings and responses of the other gender
- The second necessity is that the condition should be connected with clinically important distress, or affects the individual significantly socially, at work, and in other import areas of life.
To get diagnosed with gender dysphoria you need two of these criteria for at least 6 months. Absolutely I had every one of these criteria for years. I had “an intense need to do away with my primary or secondary sex features” from ages 13 to 31. I had “a noticeable incongruence between the gender that the patient sees themselves as and their classified gender assignment” from ages 13 to 31. I had a “powerful assurance of having the characteristic feelings and responses of the other gender” from 26 to 31- once I was in a queer scene and knew about non-binary identities.
And yet, my “powerful assurance of having the characteristic feelings and responses of the other gender” was an incorrect powerful assurance. I am now powerfully assured if by some medical miracle surgeons actually were able to transform a bottom heavy woman into the David Duchovny lookalike that I obsessed about being since puberty, that transformation would have ended with me profoundly unhappy. (Surgeons can’t do that by the way. I had big delusions about what surgeons would be able to transform my body into. Realizing I was deluded about that resulted in a half a year of profound, suicidal despair.) If you get triggered by rape jokes at comedy shows you will constantly be triggered by how men talk to other men about the women around them. It would cause me significant, clinically important distress, which would affect me socially, at work, and in other important areas of life, to be regarded as a man by other men. My transition was always bound to fall apart, because what I actually have is a body with a stress response that is all bent out of whack from sustained, untreated, repeated trauma.
Ok, so how are mental health providers supposed to parse out who should be labeled with “gender dysphoria” and who should be labeled with a decades long dissociative disorder that is manifesting itself with gendered fantasy?
Good luck answering that. The DSM is a frustrating document because it attempts to categorize human misery along lines of potential treatment. This means that the treatments the psychiatric community and the patient communities like to have happen end up reflexively creating the diagnostic categories. The authors of the DSM 5 acknowledged that leaving the door open for insurance companies to pay for transgender medical interventions was a major consideration in how they reworked the criteria of “gender identity disorder” into “gender dysphoria disorder.” Here’s the fact sheet the APA put out explicitly acknowledging that.
I needed mental health care that would steer me towards constructing a daily life that works with my exaggerated cortisol responses, so that I can ease up off of the obsessive thoughts. Here are the lifestyle changes that have actually helped me with my “intense need to do away with my primary or secondary sex features” and my “profound need to have society treat me as another gender.”
1) Making reducing stress the number one goal of my life- reducing stress about money, reducing stress about bodily safety, reducing stress about accomplishments, reducing stress by separating myself from stressful people
2) Hot yoga
3) Getting enough sleep
4) Reducing use of marijuana and alcohol. Pot absolutely increases my risk of having an episode of dysphoric feelings, both while I’m high and the next day. I relied on marijuana so much while I was trans for stress reduction, and as a result felt like life was unreal, that my body was unreal, that I was living in a creepy movie, for 2 years.
If there was a pill I could take to help me with this dissociation I struggle with, I would take it in a heartbeat. My grasp on my symptoms when life gets stressful is sometimes tenuous. Getting care for dissociation is very challenging. Heck, getting care even for ADHD is really challenging- testosterone was way easier for me to get a prescription for than my ADHD meds.
I wish I had had a therapist talk to me about sustained stress. I wish I had had a therapist talk to me about cortisol. I wish I had had a therapist talk to me about embodiment work. I wish I had had a therapist who talked to me about trauma.
I also wish I had more answers for mental health providers. In the current political climate, responding to a patient who wants a letter for hormones or surgery with a line of questions about trauma symptoms is verboten. I think if MH providers felt ok about talking to each other about the traumatic histories they are seeing walk in with their trans patients, they could come up with better ways to encourage trans-identifying patients to hang out in a discernment period for awhile. Treating trauma symptoms is also something that people who should transition deserve. I believe there are people for whom living as another gender is the best outcome. I believe the people in that category also deserve education about trauma and embodiment. If only so that every decision the patient makes about the medical interventions they pursue are coming from a clear, relaxed, realistic about how their bodies can be transformed state of mind. People deserve to make life changing decisions when they are thinking clearly and are realistic about the future lives they’re constructing. People with untreated trauma are in long term altered states and should not make life changing decisions.
I’ve talked to therapists who specialize in trans care and I know this is already a concern for a lot of them. The political climate makes them nervous to speak openly about it. They need the voices of detransitioned people talking about trauma to create a climate where they can talk about trauma. More transitioned people being willing to speak openly about the role of trauma in their gender dysphoria would help a lot too. We are so constrained by this “brain gender” narrative. The political emphasis on sticking to that story, and editing life stories to affirm that narrative, ends up hurting trans people. At the end of the day, people get to transition because of their human right to autonomy. Part of respecting people’s autonomy is creating therapeutic contexts where they are making these big decisions with their most relaxed, calm, realistic mind. Therapists who treat trans people incorporating trauma education and treatment into their practices is a base level necessity to fulfill the ethical requirement of respecting their patients’ autonomy.