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.