When I suggest that it might be appropriate to do a thorough assessment of trans identifying youth before sending them down the road to become life-long medical patients, I am often told that such an approach would be tantamount to conversion therapy. In doing so, I would be committing the same sin that mental health providers committed for years in attempting to “cure” homosexuals of their same sex attraction. Though this may appear at first to be a valid analogy, the two things are very different.
Homosexuality is not a mental health diagnosis. Gender dysphoria is.
Tragically, it is true that for too long of a time, homosexuality was viewed as a mental health diagnosis which required treatment and cure. Today, we know this isn’t true. I have had the honor of treating a number of young people who were in the process of coming out. I offered them support as they told friends and family. Together we explored internalized homophobia. In one case, I advocated for the patient with her mother. I did not need to assess whether these patients were in fact gay or lesbian, because being gay or lesbian is not a mental health disorder, and therefore no treatment is indicated or sought. My role was merely to offer support and a place to process a variety of feelings these young people had as they came out.
Transgenderism is not a mental health diagnosis either. It is an identity that is adopted as a means of managing the acute distress that can accompany gender dysphoria. Gender dysphoria is a mental health diagnosis. Like many conditions, there can be many causes of dysphoria, and there are several possible treatments for it. Some of those with dysphoria have found relief with interventions such as somatic psychotherapy; embodiment practices such as yoga; talk therapy; and medications, especially SSRI’s. Adopting a transgender identity is one way of managing gender dysphoria. Medical transition, which can involve cross sex hormones and/or surgery is the most invasive treatment possible for gender dysphoria, and therefore should be the treatment of last resort after others have failed.
Put another way, a person presenting to a therapist with gender dysphoria is there to get treatment and relief for the discomfort he feels in his body. The patient’s self-reported distress is the presenting problem, so of course it is appropriate to assess and explore it. In the case of a gay or lesbian, society sadly assigned pathology to the fact of being same sex attracted (by pathology, I mean something like “there is a problem that needs to be fixed or addressed”). In the case of someone with gender dysphoria, it is the patient himself that is telling us that there is something wrong with him that needs to be addressed. If the symptom is same sex attraction, then that doesn’t require treatment. If the symptom is feelings of profound distress, well that does require some kind of treatment.
When someone presents to a psychotherapist with symptoms that may require invasive treatment, it is the therapist’s job first of all to do a thorough assessment in order to determine whether the patient meets the diagnostic criteria for the disorder for which he or she is seeking treatment. Appropriate support and interventions should be offered, reserving the most invasive treatment only as a last resort.
For example, many people arrive at a therapist’s office saying something like, “I’m depressed.” Depression is used colloquially to indicate that we are feeling sad, however, it also has a specific clinical meaning. If someone came to me and said they were depressed and wanted electroconvulsive therapy (ECT), sending the patient to the hospital to undergo this procedure would be reckless and inappropriate. The first thing I would do would be to ask them to describe for me their depressed feelings. At some point, I would run through the list of symptoms that indicate whether one is suffering from major depressive disorder. I would ask: How are you sleeping? How is your appetite? How is your mood? Sex drive? Weight? Do you do anything that you find pleasurable? Do you have thoughts of suicide? From these and other questions, I would begin to get a sense of whether the person qualified for a diagnosis of depression.
I would also need to know many more things before I could make a treatment recommendation. For example, is there a family history of depression? Are there other symptoms that might indicate something else is going on? Perhaps the person has an eating disorder, or is feeling depressed sometimes, but is manic at other times. All of these factors might change the intervention that would be most appropriate. I would want to know whether the person had suffered a recent loss. If their spouse had died recently, then the diagnosis of depression wouldn’t be exactly right. I would want the person to know that the deep feelings of sadness, the hopelessness, and sleeplessness would be a normal — if painful — part of the human condition.
Before deciding upon any treatment, therefore, I would need to confirm the diagnosis, to complete a differential diagnosis to rule out other causes, and to ascertain the severity and duration of the illness.
Depression can be serious. Ninety percent of those who kill themselves have depression or another mental health disorder. It is appropriate to take depression very seriously. It is considered best practice to begin treatment with those interventions whose adverse effects are least serious and permanent. For example, most of the first line medications for depression such as SSRI’s tend to be well tolerated and have mostly non-serious side effects. Talk therapy can be effective in treating depression and generally does not have adverse side effects. Some people do not respond well to these medications or therapy, however. In these cases, doctors may prescribe a variety of medications, some of which carry more risks.
For those patients who have debilitating depression and severe suicidality, and who have failed every other treatment, psychiatrists will often prescribe “shock therapy,” or ECT. ECT can be very effective, but it is considered a treatment of last resort since it can result in permanent memory loss. Most people with depression will avoid ECT as long as they can. Most patients are not even considered for ECT until they have failed out of every other treatment.
Back to gender dysphoria. Someone arriving at a therapist’s office seeking medical transition is there because he or she is suffering from a mental health diagnosis known as gender dysphoria. Just as in the case of depression, a good therapist ought to do a thorough evaluation to confirm the diagnosis; complete a differential diagnosis to understand what other mental health issues might be going on; and get a sense of the severity and duration of the dysphoria. Only then ought a treatment plan be devised. As is the case for depression — or any other physical or mental health issue, for that matter — the least invasive treatment with the fewest long-term side effects ought to be tried first. Indeed, insurance companies often require that mental health and substance abuse patients “fail out” of lower levels of care before they will pay for more expensive, extensive treatments.
Gender dysphoric young people ought first to be offered therapy and perhaps anti-depressants. Not to “cure” them of being trans, but to address the distress for which they are seeking treatment — in this case, gender dysphoria. Such therapy might include support and exploration. Only if the young person fails all other treatments ought drugs which induce permanent changes and carry a high risk of adverse side effects to be prescribed.
Part of the confusion around the matter of “conversion therapy” with trans identified youth is that many do not see medical transition as a treatment for a mental health disorder. They view transgenderism as a normal variant of human experience. This may in fact be the case. However, according to this view, those seeking medical transition are therefore choosing to undergo a medical procedure without a medical indication. This is certainly something that we have a place for in our culture. We allow adults to modify their bodies with cosmetic surgery. To have breast implants, face lifts, etc, we do not require a mental health diagnosis or any kind of psychological assessment. Adults are free to do as they wish with their own bodies, and we consider such procedures ethical as long as patients have been fully informed of the risks.
It may be that as a society, we evolve to think of medical transition in the same way that we currently think of cosmetic surgery. In this case, it is not a treatment for a mental health diagnosis. No assessment and diagnosis would need to be made. It would become just like any other fact about a person in therapy — something that could be explored and discussed if the patient wished.
However, if medical transition is not a treatment for a mental health diagnosis and is therefore non-medically necessary, then it should not be performed on children and young people. Ever.
Currently, medical transition is considered to be a treatment for a mental health disorder. Advocates are lobbying for policies that will require insurance companies to cover transition costs because these are deemed to be medically necessary. When treating a mental health disorder, it is always appropriate to do a full assessment and to offer those treatments that are least invasive.
To imply that therapists who complete a thorough assessment of a young person presenting with gender dysphoria are somehow not practicing appropriately is fallacious. In fact, omitting such an assessment and rushing to affirm a transgender identity is not competent or ethical.