what a young transgender client needs from their therapist(s)

Emily Marie Williams, 2019-03-16
© 2019 Whole-Systems Enterprises, Inc.

Who I am: Credentials or Something?

I’m not a psychologist, not a social worker, not a medical doctor. In fact, I’m not a doctor of any kind. Just a highly intelligent and introspective citizen scientist. (Yes, I hold a baccalaureate).

Oh, and I happen to be transgender: Thirty-nine years living publicly as a man, approaching four years living publicly as a woman.

And I’ve studied the science of gender identity in exhaustive detail; I happen to be a scientist by trade.

And I’ve seen more therapists than I care to count.

First Define Therapeutic Goals

All Ages

Let’s first define therapeutic goals, appropriate for transgender clients of any age:

  • Client learns they are responsible for their own learning
  • Client learns suicide prevention and distress tolerance skills
  • Client learns how to respond emotionally and socially to harassment and bullying
  • Client learns how to respond emotionally and strategically to discrimination
  • Clients learn the correct language and choose what applies to them
    • “Transgender” vs. “transsexual” vs. “intersex” vs. “transvestite” vs. “cross-dresser” vs. “genderqueer” vs. “drag queen” vs. etc.
    • Gender identity vs. sexual orientation
    • “Trans” vs. “cis”
    • “Transwoman” vs. “transman”
      • E.g., a man who becomes a woman is a “transgender woman”, not a “transgender man”!
    • Why the “T” is included in “LGBT”
  • Existential health:
    • Client will not need a theologian or a philosopher to tell them they are right with the divine and/or the universe
      • Although I admit it helps emotionally!
    • Client will not need an evolutionary psychologist or an anthropologist to tell them they are right with society
      • Although I admit it helps emotionally!
    • Client experiences daily joy
  • Client understands that a gender transition (of any kind or degree) will not cure all their ills
    • We all still have death and taxes
  • Client knows their legal rights in their jurisdiction
  • Clients are appropriately guided toward biomedical interventions, where desired
  • Clients become aware that the transgender community exists and is networked
    • We have a history and mythology, e.g.,
      • The Stonewall Rebellion
        • This was just as much about gender variance as it was about non-heterosexuality, a fact that the “mainstream” queer movement swept under the rug until recently
      • Joan of Arc
      • The Rebecca Riots
      • Tiresias
    • We have a music community (e.g., G.L.O.S.S., Trap Girl, Axis Evil featuring Napalm Fatale, Against Me, and QTPi Xpress).
      • Disclosure: I am “Axis Evil featuring Napalm Fatale”.
    • We have legal advocacy groups and work closely with the ACLU

Youth and Their Parents

All of the above-stated goals apply to youth, but parents play a greater role in their success:

  • Parents learn they are responsible for their own learning
  • Parents learn how to affirm and validate their children
    • Including respect for desired names and pronouns
  • Parents learn suicide prevention and distress tolerance skills
    • For both themselves and all their children
  • Parents learn the correct language, and let their children choose what applies to them
    • “Transgender” vs. “transsexual” vs. “intersex” vs. “transvestite” vs. “cross-dresser” vs. “genderqueer” vs. “drag queen” vs. etc.
    • “Gender identity” vs. “sexual orientation”
    • “Trans” vs. “cis”
    • “Transwoman” vs. “transman”
      • E.g., a man who becomes a woman is a “transgender woman”, not a “transgender man”!
    • Why the “T” is included in “LGBT”
  • Parents learn how to work with schools to attenuate bullying
  • Parents learn about discrimination and systemic oppression. They must be “woken up”
  • If parents are spiritual and or religious, find a faith community that proves supportive
  • Parents must learn and model joy
  • Parents understand that gender-related care for their family will not cure all their ills
    • Again, we all still have death and taxes
  • Parents know their children’s legal rights in their jurisdiction
  • Parents understand the array of biomedical interventions available
    • And the time dependencies of these interventions with respect to the onset of puberty
  • Parents need to understand that the body of research regarding transgender youth is slim
    • Parents need to understand that an active effort within the research community regarding transgender youth is identifying the difference between “is it a phase?” and “is it clinical gender dysphoria?”

As Long as I Can Remember

For perspective:  As soon as I realized there was a difference between boys and girls, I wanted to be a girl. Maybe two or three years old?

The feeling didn’t stop with puberty. Didn’t stop when I registered for Selective Service. Didn’t ever stop.

Where Seeing More than One Therapists is Appropriate

Having a client see more than one therapist at the same time is controversial, but I do it. Here is why it is practical:

Therapists who specialize in transgender issues are scarce and generally clustered around major cities. Therefore, it is totally reasonable for a client to see a “regular” therapist on say a weekly basis and see a specialist on a monthly (or longer) basis. Seeing a specialist at least occasionally is vital, as they have access to the latest clinical practice information and are one of the key gatekeepers for obtaining biomedical interventions such as hormone replacement therapy.

The “regular” therapist I referred to in the above paragraph can work on matters like distress tolerance, suicide prevention, family dynamics, etc.

Suicide Prevention and Distress Tolerance

The suicide rate is extremely high in the transgender population. (I don’t know how this breaks out between youth and adults—a later edition of this text will provide those details if they exist). Therefore, it is imperative that transgender youth, their parents, and transgender adults learn suicide prevention skills. “Skills” is the correct word here; we are talking about a set of learnable behaviors that save lives.

Distress tolerance skills are also vital; saying that living transgender proves distressing is an understatement! I’ve found Dialectical Behavioral Therapy (DBT) the best approach for myself and would recommend it to anybody. DBT is all about skills development.

Family Therapy

Family therapy proves vital as well, as poor family dynamics and abuse (if it is present) will not help anybody.

Also, parents may carry undue guilt that their child expresses gender identity issues—as if they were bad parents or something. While my research shows a possible heritable element of gender dysphoria, the same research supports a hypothesis of biological origin of the condition.

Murder Prevention

The murder rate among transgender individuals is high, especially for transgender women of color. A therapist and a transgender child’s parents must ensure the client knows how to protect themselves.

I carry a hunting knife in my purse and know how to disable an attacker by hand.

Affirmation and Validation

Through various channels (social, parental, religious, etc.), transgender children can get the message that their feelings are either “not real” or “bad”. This needs to be countered by therapists, and parents must be taught by therapists how to counter these ideas as well.

What a Therapist Should Watch For

While it is perfectly possible for a client to be both schizophrenic and transgender, the schizophrenia must be treated first, as it might be a source of gender confusion. For example, and forgive my shallow understanding of schizophrenia, a schizophrenic individual might have one or more feminine-identified “insides” and one or more masculine-identified “insides”.

Additionally, there are some homosexuals who are so homophobic that they would rather change their sex than accept their sexual orientation. Here the problem is acceptance, not gender dysphoria, and gender transition is not a clinically appropriate treatment. I can see this scenario playing out in a teenager raised in a fundamentalist environment. Interestingly, Iran forces homosexual men to become woman, as it is okay with transsexuality but not homosexuality. This probably does a lot of damage to these individuals’ psyches.

Adolescent Sexuality

All adolescents struggle with sexuality, but I think it is worse for transgender individuals. Therapists must be understanding of this.

One of the most confusing issues I faced in my youth was that for me as a teenager, I became sexually aroused when I wore women’s clothing. So, I couldn’t tell if I was expressing a fetish or something more fundamental to my core identity. Now that I am an adult and wear women’s clothing full time, this arousal no longer happens. In other words, my desired to cross gender lines cannot be explained by fetish alone.

A minor psychological theory that some practitioners still refer to, though it has largely been discredited, is “auto-gynephilia”. This model defines men who express transgender thinking as simply being sexually attracted to the idea of themselves as a woman (and female)—basically a “meta-fetish”. The idea has been used by hostile parents in court cases to prevent children from receiving appropriate transgender care. The major proponent of this idea—I forget who—is still alive and working for a major research hospital (I think; I’ll check on this detail later and update this document accordingly).

The problem is not with auto-gynophilic sexual fantasies, which I’ll admit even I have from time to time, but with the idea that that model alone fully explains male-to-female transgenderism. To put it in personal terms, when sexual arousal and activity is the farthest thing from my mind, I still want to be called “Emily” and “she”, and I still want to interact socially as a woman.

Feminism and Young Adults

Most feminists support us, but there is a small and vocal subset that severely opposes transgender individuals and their demand for rights. A young woman thinking of transitioning to manhood can easily be dissuaded by these ideas. This is okay if the individual decides so; but most members of this small, vocal subset of feminism are bullies and need to be taken through that lens. (We call them TERFs, for “trans-exclusive radical feminists”). TERFs often refer to female-to-male transitioning as “testosterone poisoning”, among other things. I won’t even begin to tell you what they say about women like me, because it is out of scope for this document.

A good therapist needs to be aware of TERF thinking and influence, especially when working with young adults attending a university.

I’ll Add More Later…

I’m sure I’ll think of more to add to this document as time passes.

on love

Thought it time to write an essay (of sorts) on the nature of love:

Here I specifically mean Romantic love, partnership love; not other kinds. I won’t throw Greek words at you to differentiate between the types of love as many writers do (e.g. C.S. Lewis), except I thought I’d decide to use the term “eros” at some point, but didn’t. I’m going to use the imprecise English word and we’ll make its meaning clear from deconstruction and context. We are talking about the love that drives madness and rock songs. We are also talking about the love that, when steered wisely, channels into successful marriages.

Why am I writing this? Not entirely sure. I’ve spent much of my non-child life in a state of unrequited love and, being rather introspective, have consequently thought about the subject a good deal. Moreover, I remained in an abusive relationship for 14 years (seven of which in marriage) and stayed primarily due to my choice to continue loving, rather than out of fear or insecurity. Naturally, I’ve thought deeply about that choice, both during those years and after the divorce.

Furthermore, roughly 2.5 years ago I publicly became a woman (I’m biologically male) and having been living and loving as such since then. Among the intelligentsia where gender is considered a social construction this matter may not seem to pertain much to a discussion of love, but I can now tell you from personal encounters that an individual’s experience of romantic love is shaped by patriarchy and heterosexism, no matter what that individual’s gender identity and sexual orientation.

I’ve also written seven love songs in the last two years. So take the intellectual out of me and I’ll still sing about the matter.

Two Basics

When I tell someone I love them for the first or second or tenth time, I really mean two things:

  • I love them.
  • I’m in love with them.

Note the difference: The second is a state of the brain caused by heightened dopamine receptor activity. It is transitory. It fades. This is why couples often complain about the “spark” disappearing in their relationships (if they don’t nurture the first item on the above list).

The first uses love as a verb. It is something you do. It is a choice you make. It is a gift that you give. But you have to commit and continually recommit to this verb form of romantic love to achieve benefit from it. And of course in this form of partnership love, unlike the dopamine receptor form, both parties share the benefit and pain, where as the psychological state of being “in love” is actually quite selfish—driven by the lover’s desire for benefit and, for lack of a better word, acquisition.

The verb form leans altruistic. Consider lyrics from my song “Waste”:

This hope seeks recognition, connection, resolution.
And its more about the love I wanted to give,
than that I wanted to receive

Admittedly the first line could apply to either form, but the second two lines clearly apply to a desire to give love. An activity. A decision. A verb. Not entirely altruistic though, because one hopes to receive the verb form of love just as much as they might desire to give it.

Madness and Estrogen

Here we return to a discussion of romantic love as elevated dopamine receptor activity. All feels well and good until the rejection or the breakup. Then one’s brain chemistry walks through the depths of Hell. In my case, due to bipolar disorder, I go just plain “mad”—engage in reckless behavior and become dangerously suicidal. This condition might last years over one incident of heartbreak. Not a good thing.

I’d even call it addictive. Idolatry.

Estrogen made this experience far worse for me soon after I started taking it. Before then I could channel my reckless behavior into socially acceptable activities. But I lost this ability (for a considerable period of time) once I started taking the hormone, as the hormone drove my emotions to far wider extremes than anything I’d ever experienced before.

Fortunately, I’ve now become accustomed to estrogen’s impact on my emotions, and now make better decisions.

What I’m trying to say though is:  We should never underestimate the damage long-term unrequited love can inflict on one’s spirit.

Back to the Good Stuff

And now back to discussing love as a verb:

When I love someone I do everything I can to ensure they know their intrinsic value. Not their value to me as a lover or potential lover, but their value in the universe, their value for simply being human. To be clear, I also express their value to me, especially when a rich friendship underlies whatever else we might create, but that is a secondary activity. Its their intrinsic value that matters, not my valuation. Another way of saying this: I’m fleeting—we must promote valuation in light of things eternal.

Currently, there are three women in my life I would take a bullet for. Two have been cruel to me (one extremely so)—and neither of these two will have anything to do with me. But I still actively love them (verb form) in the only ways I can, through radical forgiveness and continued prayer for their well-being. Furthermore I keep the door open to them at all times.

Authenticity and Self-Expression

Anyone who knows me knows that concern for authenticity in all things drives me. That explains why I present romantic love divided into the two distinct forms discussed above. Doing so enables clarity—allows me to demonstrate to a partner or potential partner exactly what they are getting when I say I love them. Authenticity resides in the understanding transmitted—my beloved realizes that I’ve thought deeply about the meaning of love and therefore am trustworthy with regard to that dangerous word.

Self-expression matters too. I can’t be anyone other than the stylish femme I project to the world. One has to live according to their soul to love successfully. Sure one can suppress themselves to pay for the short-term dopamine high, but to sustain the commitment of verb-form love throughout all the challenges it brings one must practice alignment (and continual realignment) with their core identity. In other words, the strength generated by a quality relationship flows both from the genuine within and from the genuine in the beloved.

This mandate plays out too for one’s treatment of their beloved: One commits to loving them for who they are, knowing they will evolve and, if nurtured, grow. While conflict comes inevitably and must be worked through faithfully, trying to fundamentally change one’s beloved is a fool’s errand. Besides, their spirit holds intrinsic value as it is and one can easily lose good love by neglecting that truth. The exception of course regards abusive situations, where change on both sides proves necessary. (Not just the abuser must change, the other party must learn not to participate in the dynamic).

Control

A lot of this comes down to control, and the choice to cede it to positive vulnerability. Note that we are not talking about ceding discernment here.

As my narrative above indicates, the dopamine high-driven form of romantic love often involves perilous loss of self-control. I frankly become a slave to my passions. Bitch owns my heart.

But the verb form of love retains control; the decision to give love, to support and promote a quality relationship, is exactly that: A decision. Good decisions only emit from a position of self-control.

And good, well-grounded decisions to love actively enable wholehearted surrender to positive vulnerability, the state where things really blossom in a relationship.

Patriarchy and Heterosexism

Now that I’m a woman, I feel a pressure to date men that I can’t put my finger on. I do like men, and occasionally engage in romantic behavior with them, but I don’t like the subtle nagging feeling that that is the way things are “supposed” to be.

I watched “Sex and the City, the Movie” last night, which I absolutely loved for the fashions presented. But the story made me feel inadequate for not being in a heterosexual relationship (or any relationship for that matter!). It made me feel that my excitement for highly expressive dresses and my bisexuality stand at odds, as if a stylish girl like me should be guy crazy and exclusively so. The movie also reinforced the patriarchal model that a woman’s path to economic prosperity is through a relationship with a man.

Now I’ve experienced a few nights of passion with men, and enjoyed them thoroughly, but these experiences lived out the most base of the dopamine-high form of romantic love. If pressed by social expectation to only commit to verb-form love with men, I leave out a whole segment of the population that I resonate highly with. This is intolerable. To give love one must stand free to give love.

To give love one must stand free to give love.

Heterosexism and the patriarchy constrain that requisite freedom.

Giving God the “Finger”

When unrequited love drove me to madness roughly 1.5 years ago, I wrote a song about giving God the “finger” to express my angst. No regrets! Here is the song, titled “Prayer (Say Nothing Again)”:

See Also

the currency of love

radical forgiveness (video)

the pedagogy of love

how to validate someone who won’t talk with you

taking abuse for not being “ladylike” enough

I expect that many women receive abuse from their loved ones for not being “feminine” enough, by which these loved ones mean not being “ladylike” enough.

I received such abuse for the first time in my life last night, from a mentor and dear friend. He is a keen observer of woman and generally a wise man, so I rely on him for advice about my presentation. He also loves me greatly.

Something masculine in my behavior really lit a fuse with him yesterday though, and he sent an extremely abusive e-mail detailing his dissatisfaction. I won’t post it here. He obviously holds some deep insecurity that came out in that moment.

But I will post my response; it demonstrates how I’ve learned not to accept abuse but still can reach out with complete love, forgiveness, and compassion. I’m setting an example for others.

The lesson in this for me is that I need to refrain from oppressing myself. I place a lot of pressure on myself to become the “perfect lady”, but to me this is fun. As long as I maintain that perspective, and keep things real, things are alright. In my response (below), I observe how it is far more important for me to exhibit stereotypically feminine characteristics of empathy and kindness than, for example, manage how I walk or gesture.

And why do I consider the pressure I place on myself to become the “perfect lady” fun?  Because I am claiming the oppression and re-spinning it for my own ends. I accepted this oppression upon becoming a woman and decided to make a game out of it. This is punk.

And the fact that I’m now receiving the oppression from someone else shows how successful at feminine assimilation I’ve become.

Two days ago at a restaurant I observed a woman with the perfect presentation: Elegant gestures, graceful stance, etc. Then she slapped her kid. Disgusting. Poise without compassion is meaningless.

Anyway, here is my reply to my mentor:

——,

I am a lady, and therefore expect better treatment than you presented in your last e-mail to me. I expect an apology. I forgive you whether or not you give that apology.

I also know you wrote this out of both love and frustration. I am empathic to that. But ask yourself: Why the insecurity?

In my recent feminization work, I’ve pursued becoming a great “woman” over becoming the perfect “lady” (for now). So I’ve been maximizing my empathy and kindness.

I’ve also asked you before never to bring up my weight. Never do that again!

While I’m not perfect, please remember how far I’ve come! When one is acculturated as a man (think guzzling beer for instance), one cannot expect to change habits overnight.

Again, I’m focusing on the “woman” side of the coin right now, versus the “lady” side. So I’m studying fundamental examples of Christian women. Perhaps you noticed that the last time you were angry around me (about the PBS series on Viet Nam), I gently comforted you. That is the femininity I am concentrating on building right now.

I value your coaching tremendously, and appreciate stern correction. But your last e-mail was abusive. You are better than that.

With absolute love and complete forgiveness,

Emily

Update One Minute After Publishing This

About 1.5 years after my public transition, an emerging transwoman leaned on me for support. We had coffee together.

She is extremely tall, and carried a purse not much larger than her hand. I advised her that having a large purse would prove more appropriate to her body frame. Really stressed this when she resisted. (She likely resisted due to anxiety about having to spend money or anxiety about shopping as a woman).

I told her it would make a difference in how well she passed.

The thing is:  Saying it once was fine. But the fact that I persisted reveals some anxiety I was carrying at the moment. I fake nobility and rationalize that I was concerned for her safety, but I was actually really anxious because her look was incongruent. As if it reflected on me. As if it “outed” me.

I’m sure my mentor feels the same way, that my incongruencies reflect badly on him. As if it “outs” him as trans-friendly.