A clinician posted this inquiry in a group for mental health professionals:
Here are some of the responses.
“…a growing number of clinicians fight this by writing letters in the first session…”
Hmm. So, how does that work?
As a clinician, I have training, experience, and intuition. But I can’t imagine a scenario in which, upon meeting a client for the very first time, it would be a responsible course of action to jump to such a conclusion about the nature of the client’s problems and what the solutions should be.
A diagnosis is necessary in order to bill insurance. If it’s quite evident from history and symptoms that the client has a common condition such as Generalized Anxiety Disorder or an Adjustment Disorder, we can diagnose that and move forward helping the person with anxiety. If the client is interested in medication, we can refer them to an appropriate provider to discuss that with, such as their primary care physician or a psychiatrist.
Often, in the first session, if symptoms and etiology are not entirely clear, we give a provisional diagnosis. For instance, I see many people for trauma. It’s not always in the client’s best interest to spend the first session with a new therapist discussing their trauma symptoms in great detail. Since I can’t know right away whether they meet full criteria for Post-Traumatic Stress Disorder, I may give a provisional diagnosis of “Other trauma- and stressor-related disorder.” In the diagnostic criteria description, I will write a brief summary of the traumatic event(s) they have experienced and the symptoms they have reported so far, with a note that “Post-Traumatic Stress Disorder should be ruled out,” meaning that I will evaluate for PTSD over time and update the diagnosis as clinically appropriate.
I also can’t immediately ascertain the full nature of the client’s problems, their origins, and their solutions — and I’m a pretty intuitive clinician. Many clients feel that I “get” them right away, and that they make progress more rapidly with me than with previous therapists. So I do make a fair amount of guesses early on, which I check out with the client, so that they can affirm or correct my initial lens. Still, it may take time working together for us to discover how their anxiety is affected by various biological or social factors, such as their sleep or family dynamics. As we gain insights together, solutions become apparent.
It would be irresponsible of me to jump to premature certainty about what exactly is going on. Maybe in an anxious client’s initial description of their spouse, I have some concerns that their spouse may be narcissistic. If that were indeed the case, then over time, I would provide psychoeducation about narcissism and emotional abuse, and I may help the client find the motivation, courage, or skills to leave the relationship. If in the first session I learned the spouse was physically abusive and the client didn’t feel safe at home, I should definitely do my best help them get to safety as soon as possible. But barring such immediate danger, I should remain open to developing a nuanced view of the situation. Perhaps, for instance, we discover that the spouse has autism, not a personality disorder. Or perhaps we discover that the spouse is a normal, stressed-out person with flawed communication skills; the client’s previous family history makes them particularly sensitive to certain cues; and the two of them together have developed a hurtful dynamic that can improve with appropriate resources. In any case, my professional responsibility is to take time to understand the situation.
Humans are enormously complex. If they weren’t, then working as a therapist would not require years of training.
“The depression and/or functional impairments are very much a result of the transphobia, gatekeeping, and alienation that comes with wanting to transition.”
This is true sometimes. It is most likely to be true in cases where the trans person has felt this way consistently from a young age, and/or, they come from an unsupportive family or a conservative culture. However, I’m not sure we can assume that “alienation that comes with wanting to transition” is always going to be a factor in today’s society.
I live in Portland, Oregon. In my city as well as many other liberal cities — and perhaps more significantly, in a tremendous amount of places on the internet — being transgender may not come with alienation. Oftentimes the opposite is true: people who have felt alienated for much of their lives, due to issues that may have nothing to do with gender, finally feel that they are embraced, supported, encouraged, or stood up for when they adopt a trans identity.
Many people fail to acknowledge that adopting a transgender or nonbinary identity is socially incentivized in many places. It’s difficult to underestimate the significance of our need for belonging. So, if someone is expressing distress and attributing it to gender, can we know for certain, upon meeting that person for the very first time, without knowing much else about their life, that the distress arises from being a trans person who has been discriminated against and alienated? Could it be possible, in some instances, that the person has felt alienated for a really long time, for any number of reasons (family dynamics, bullying, neurological atypicality, the list goes on), and that they have found hope in the popular idea that their pain can be attributed to, and alleviated by, addressing gender? What if that’s not all there is to it?
I also think it’s premature to jump to the conclusion that depression and functional impairments arise from these sources. Again, while that can certainly be the case, we really owe it to our clients to take time to understand the complexities of the biological, social, environmental, and psychological factors that are affecting their wellbeing.
It seems to me that this person might be at risk of making a very common mistake: overgeneralizing from their personal experiences and projecting them onto their clients. I have to watch out for my own tendency to do this all the time. We’re only human, and this is totally normal, but we have a professional responsibility, and a lot of power that we need to handle with care.
A therapist’s education includes training in transference and countertransference. Transference refers to the client’s feelings toward and experience of the therapist, while countertransference describes the therapist’s feelings toward and experience of the client. We develop skills for recognizing and interpreting both of these. Sometimes we need to discuss them with our supervisors and peer consultants. Sometimes it’s appropriate to discuss them with our clients, especially if we practice from a relational-psychodynamic standpoint, as I often do.
There are so many factors at play. Transference and countertransference can range from positive to negative, helpful to counterproductive, accurate to inaccurate. I could remind a client of her bossy older sister, her abandoning mother, her best friend, or her favorite teacher. That resemblance could be due to my personality, but it could also have more to do with my name, the shape of my face, or the sound of my voice. Similarly, a client could remind me of people from my past. I could write an entire article on this subject, but I think I’ve said enough for now. The point is that our personal experiences can be wonderful tools for understanding and establishing rapport with our clients, but they can also color our perceptions in ways that obscure our vision too. A good therapist recognizes her countertransference and explores it with curiosity and a bit of caution.
I feel concerned reading this. To recap, several therapists are taking the stance that when a client suffers from depression or another mood disorder (eg. bipolar disorder), or even psychosis, this shouldn’t inhibit or otherwise alter their trajectory toward significant medical interventions related to gender. This position is even supported by one person who has a psychotic sibling that experienced gender confusion as part of their psychosis. It sounds like the sibling did not go through medical treatments, thank goodness. I wonder if the commenter’s position would be any different had their sibling underwent medical procedures only to regret or reverse them.
Some clinicians also express a bias toward teenagers and against parents. They seem confident that they understand the teenagers better than the teens’ own parents do. Reading this commentary, I am reminded of myself as a younger clinician. As a more mature person and experienced clinician, I have a lot more respect for parents now, and more understanding of what kinds of salt grains I should take with the words of teenagers. I wonder about the age and life experiences of these commentators, and, as with what I wrote in the previous section, I also wonder how much they may be projecting their own inner teenager-parent dynamics onto their clients.
Overall, the lack of caution here is alarming.
Alright, let’s talk about “gatekeeping.” This term has seen a recent explosion in popular usage, often referring to the ways in which healthcare providers such as therapists and doctors are perceived as putting up barriers to access to care. The implication is that people who want a certain kind of treatment, whether it be hormone replacement therapy (HRT) or surgery, should be entitled to it as quickly as possible, with no holds barred, and that it is unethical for healthcare providers to deny or delay their access.
This witch-hunting tantrum in which grown adults point their fingers and shout “gatekeeper!” while demanding that skilled professionals cower unquestioningly to their immediate demands displays a lack of maturity that is so unbecoming for adult professionals to endorse that I feel vicariously embarrassed. It displays a sense of entitlement backed by righteous indignation; a disregard for knowledge; a lack of impulse control; a condescending and demanding attitude toward hard-working and highly skilled healthcare providers.
Medical prescriptions and procedures have always required a medical process, and some require a psychiatric process as well. I don’t call my optometrist a “gatekeeper” of my contact lenses, my psychiatrist a “gatekeeper” of my Ritalin, or my dentist a “gatekeeper” of my fillings. I respect that healthcare providers are usually quite conscientious people, know a lot of things that I don’t, and have a job to do that I don’t fully understand yet nonetheless benefit from. While I am the one experiencing my vision, mind, and mouth, these professionals have tools for understanding the nature of what I need help with, and the best course of action.
I have severe, chronic dry eye. This means that I am a poor candidate for laser eye surgery. My best course of action is to engage in the self-care techniques that experts have advised me to do at home (warm compresses, fish oil supplements, preservative free eyedrops), and the correct prescription for me is a type of contact lens that helps protect moisture in my eyes. If I were to pursue laser eye surgery, I would encounter “gatekeepers,” e.g., highly trained medical professionals. After thoroughly evaluating my eye health, they would not allow me to proceed with surgery. Thank goodness. The last thing I want is to permanently ruin my eyeballs.
“Gender affirmation is suicide prevention.”
Yes and no. There’s a lot to unpack here. You’d be hard pressed to find anyone who disagrees with the notion that we should be careful when it comes to the topic of suicide. I don’t think this statement, as it currently stands, is adequately careful. For anyone wanting to understand this popular claim and what data does or does not support it, I recommend The End of Gender by Deborah Soh.
“Mental health issues always improve with transitioning.”
“Always” and “never” statements are another area of caution for the wise. Simply put, this is untrue. There’s a lot to consider here.
Transitioning can certainly help some people, but it can also harm others. A person who has been depressed for a long time and has hope that medical interventions will fix their problems can be at risk for even worse hopelessness if and when this turns out to not be the case. Furthermore, people who transition and regret it, who may or may not choose to detransition, suffer a lot in the process. It can be very depressing, if not downright traumatizing, to make permanently life-altering decisions when you are young and then face having to live with the consequences. Where is our care and consideration for the girls who detransition and then suffer the humiliation of having to fess up to their community that they made a mistake, and stare down the barrel of a future in which they will never again have the feminine voices that their natural genetic and hormonal makeup would have otherwise bestowed them with? These people are suffering too. Ideas like these ones only contribute to the harm.
“Cis people should have no right to gatekeep at all.”
Let’s revisit some of the analogies I used in my response to the notion of “gatekeeping.”
Should an optometrist have no right to prevent me from having laser eye surgery if she herself has never had myopia?
Should a psychiatrist have no right to prevent me from taking a medication that is contraindicated for my physiology if she herself does not have ADHD?
This comment’s sentiment hearkens back to the popular notion of “lived experience.” While shared lived experience can indeed help some patients feel more comfortable with their providers, it is not the only factor that affects the efficacy of treatment, nor is lived experience a substitute for professional expertise. Furthermore, following from my earlier discussion of the caution we should have around projection, overgeneralization, and countertransference, lived experience sometimes poses the risk of obscuring a clinician’s judgment.
“Cis people” are a whole lot of people. The vast majority, in fact. It’s hard to find transgender medical professionals. A patient should seek care from providers who are available, have the proper training and qualifications, and help them feel comfortable. If this means they would prefer to work with transgender providers, that’s totally up to them, just like a woman seeking therapy might prefer to see me over a male therapist. But it’s not helpful to instill in gender-atypical or questioning patients an unnecessary fear toward cis people, and I think that this sort of sentiment can have that affect. The truth is, they will always live in a world full of cis people. Cultivating distrust and paranoia toward the vast majority of people is not good for anyone’s mental health. Mental health providers shouldn’t encourage or endorse this kind of attitude. Instead, we should help people feel more at ease in the world, and learn to put their fear instincts in their proper place, helping protect them from real harms, not imaginary ones.
As for “the right to gatekeep?” Again, trained medical professionals should be “gatekeepers” who ensure that those who pass through said gates are in the proper condition to do so. I am more concerned about the potential for harm posed by untrained activists who insist on tearing down such gates without any concern for the unintended consequences that could result.
What the first commenter says is so simple and reasonable.
The second commenter says, “the way you are talking about transgender people is harmful.” Here we see another common instance of the woke community’s quickness to vilify any dissenting perspective as “harmful.” In doing so, they instill a sense of guilt in reasonable people, and refuse to engage in meaningful, nuanced dialogue.
The first comment is not harmful.
“It is never a therapist’s job to decide whether another person is going to regret their autonomously made decisions regarding their own life.”
I agree. We can have our opinions, and we can keep them to ourselves, or share them; but no one can ever really know how they themselves are going to feel in the future, what to speak of knowing how someone else will feel.
We can advise, inform, and express concerns. We can offer our assistance helping people understand themselves, their situations, and their options.
But there’s a logical error here. This commenter seems to be suggesting that since a therapist cannot predict the future or control a client’s decisions, they are also obligated to encourage and facilitate a client’s intended plans. That’s not correct. While we have no legal or ethical right to stop anyone from acting out of their own free will, we are under no legal or ethical obligation to help people do things that we think are ill-advised or poorly thought out according to our professional judgment and our knowledge of the client. If the client wants to seek a different opinion from a different therapist, they are free to do so.
Oof. For some reason, this one hits me in the feels.
On the one hand, it’s so true. The word “trans” is an unnecessary qualifier: people have a right to make their own mistakes, regardless of gender. But again, it is not our obligation to help others make decisions we are concerned could be harmful to them. We can say, “I’m sorry, I don’t think it’s a good idea for you to go through with this. You are free to seek a different opinion, but based on my understanding, I cannot honestly recommend proceeding with this choice, and will not play an active role in making it happen.” This might be a response in a range of situations, personal and professional: as a therapist of a distressed individual, a sibling of a reckless driver, or an academic advisor of an at-risk youth, just to name a few examples.
More significantly though, what really gets to me about this is the lack of sensitivity for what people actually go through when they do make a mistake. There are a lot of young people who are really hurting, and struggling to figure out what to do about their pain. Gender transitioning is not the right choice for all of them. Some will regret it, and may suffer for the rest of their lives as a result. Do they have the right to make their own mistakes? Technically, yes. But this doesn’t warrant such insensitivity to how our hasty encouragement of life-altering medical procedures can contribute to mistakes that will only worsen their suffering. What seems especially tragic to me is that many of these young people without adequate role models and professional supports blame themselves for their mistakes and live with tremendous shame as a result, when really the onus should have been on the adults around them to help them make decisions more carefully. In this article, I expressed how my heart went out to Ryan for that very reason.
More haste, ad nauseum.
I find it bewildering that many of the same people who make these kinds of comments in these groups — about how we shouldn’t “pathologize” gender “expression” as a “mental disorder” — are equally quick to defend other “mental disorders,” such as ADHD, as legitimate handicaps that warrant awareness-building, accommodations, and treatment options. The logic isn’t consistent.
Anyway, I don’t think anyone is pathologizing gender expression. Has this person read the DSM? Clinically significant distress or impairment is necessary to warrant a diagnosis. People are free to express their gender however they would like. Many critics of hasty, reactionary trans activism are not gender-typical themselves. Deborah Soh and Heather Heying are two outspoken women who both identify as having many traits that are not considered female-typical. I would put myself in this category, if on its perimeter — perhaps roughly half gender-typical and half not. I am sensitive, nurturing, aesthetic, verbal, musical, sensual, holistic in my thought process, and heterosexual. I feel most comfortable with long hair, flowy clothing, and a bit of makeup and jewelry. But I also cannot stand high heels, have no interest in tweezing my eyebrows, and feel dread at the thought of feeling pressured to adopt stereotypically hyperfeminine vocal patterns or social behaviors. I would rather find my fingers caked with garden soil than nail polish, rather kayak than shoe shop, rather watch a sci-fi movie than a rom-com. I probably score lower on agreeableness than the average woman, and won’t shy from a good debate. To me, none of these traits make me any less of a woman. But enough about me. The point is, it’s 2021, and anyone can dress or behave however they want, as long as they are not hurting others. Boys can wear pink, girls can play sports — who cares? What makes gender dysphoria a disorder is when it causes distress or impairment, warranting clinical or medical interventions. Anyone who knows the first thing about the healthcare system is that one must have a diagnosis in order to be treated. Otherwise, there is nothing to treat.
I don’t think this person understands the meaning of the word normative. Traditionally, this has been a scientific term referring to what is most common — that is, what falls under the middle part of the bell curve of the distribution of any particular trait. It can also be interpreted as a standard for what is considered correct or should be aspired for. So either this commenter is suggesting that gender minorities are the majority, which, by definition, they are obviously not; or, they are suggesting that being a gender minority is something one should ideally aim for, which seems like a pretty bizarre value system.
There’s nothing discriminatory about acknowledging the reality that being a gender minority is not normative in either sense of the word. It’s not the most common condition, and it doesn’t make any sense that we should uphold it as a standard to aspire to when it’s frankly a difficult position to be in, from a medical standpoint even if nothing else. If one can be comfortable in their own skin without complicated, costly medical interventions, I think that’s preferable to the alternative. Those interventions should be reserved for the people who really need them, not prescribed carte blanche.
“It’s important to always affirm the client.”
This is a conflation of two concepts that our professional training should give us the skills to differentiate: support and agreement. Or, stated differently, validating a person’s pain, and endorsing their narrative about that pain.
For instance, if someone is experiencing anxious distress, their distress is real. We can affirm that experience and demonstrate care. That doesn’t mean, however, that we should automatically assume their view of reality is accurate. Let’s say, for instance, that they have an irrational and persistent phobia of elevators, in the absence of any real trauma history about elevators. Does showing our care and support mean that we confirm the viewpoint that elevators are indeed an unsafe thing they should be afraid of? No, of course not. Agreeing in this case isn’t going to make their life any better. The best course of action is to affirm the reality of their distress, express empathy for how hard it must be to fear elevators, and then help them learn how to not be so afraid of elevators, so that they can live happier lives.
“I can guarantee the client has been thinking about this for years.”
No, you can’t. If that statement were true, there would be no such thing as Rapid Onset Gender Dysphoria.
I don’t understand why so few clinicians are curious about the exponential rise in cases of gender dysphoria we have seen in the past several years and what all could be compelling it. It is ancient news that adolescent girls are extremely susceptible to peer pressure, contagion, insecurity, and a longing to fit in. Everyone knows that part of adolescence involves uncertainty and experimentation with identity, group membership, and aesthetic expression, as well as curiosity and experimentation with sexuality. Nor is it a surprise to anyone that the current generation of teens and young adults is experiencing unprecedented rates of anxiety and depression, for myriad reasons. We know teen brains have not yet developed impulse control and long term decision making skills. Why on earth are we just taking this entire social trend at face value?
There are certainly people who have experienced since early childhood a clear sense that they were born into the wrong body. This has always been the case and has generally been found in a fraction of a percent of young boys. That doesn’t account for everyone, though. Not all gender dysphoria has the same etiology or prognosis.
Mental health clinicians, we can do better. We are intelligent, caring, highly trained people. Let’s not succumb to social pressure to throw that all away. I get that we want to do right by people, but this trend cannot last. More and more, we are seeing the long term impacts, as I wrote about in this article.
Where do you want to find yourself several years from now? This kind of behavior could lead to remorse and humiliation as you realize that in your self-righteous eagerness to point a finger at others for causing alleged “harm,” you yourself were participating in a form of witch-hunting groupthink that led to way more harm than you ever thought you could cause. Please be careful. Think for yourself.