This question has been debated for years within the organization WPATH (World Professional Association of Transgender Health) which I have been a member of for almost 20 years. This organization is comprised of general practitioners, endocrinologists, surgeons, speech pathologists, mental health providers, educators, and parents and allies of transgender youth. It is this group that is responsible for writing the Standards of Care which most health care providers and mental health providers follow in working with transgender adults and youth as well as gender-variant children and adults. So, for example if you were seeking hormones or gender reassignment surgery, there are guidelines in place to help the provider and the patient understand what should take place. It really is a case by case situation and varies by provider. The guidelines help the surgeons who are performing the gender reassignment surgeries to have a basic understanding of the whole patient. The doctors obviously need to prepare the patient medically. I have found over the years that having a therapist is so helpful in almost every case. Most of the therapists in our field understand that our roles are more of unconditional support, guidance, and hope. Many times, the person having gender reassignment surgery lose support from loved ones. Their family and friends have abandoned them and they may have some friends but in many cases, they are on their own. On many occasions, I am the one that visits my patients in the hospital making sure they are comfortable and being treated with dignity and respect. I will speak with their surgeon to find out how surgery went and what is the time frame before the patient can go home, were there any complications and anything else they think I should know. My experience has been that the surgeons are grateful for our roles overall. Some medical providers don’t see our value and believe that they are better equipped to support their patients. I believe in many of these cases they don’t completely understand what the patient goes through emotionally after anesthesia or how having gender reassignment surgery can be anti-climatic. I work diligently with my patients to prepare them for the highs and lows that can occur for the first several months after surgery. It’s usually an emotional roller-coaster.
There have been many times when I contact the surgeons myself advocating for my patients. These calls help me get to know the doctors in the field and it also gives them information about the person that will be having the surgery. The doctors i work with appreciate the involvement I take in helping everything run smoothly. Having a therapist to support their patients with their fears, anxieties, expectations, hopes and dreams can be invaluable.
I do appreciate that WPATH has been instrumental in the removal of Gender Identity Disorder from the Diagnositical and Statistical Manual of Mental Disorders, Fifth Edition. Providers refer to it as the DSM-5. According to the DSM-5, gender dysphoria refers to the distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender. It goes on to say that although not all individuals will experience distress as a result of such incongruence, many are distressed if the desired physical interventions by means of hormones and/ or surgery are not available.
Anne Vitale, Ph.D. describes dysphoria this way, “when people inquire about my services or come to see me for the 1st time, either their lives are in ruin or if their condition were to become known, they would loose so much. High anxiety and deep depression and suicide ideation is common. These people are not unhappy, they are miserable.” I can say with certainty that this is occurs in my office often.
It is my belief that in seeking a therapist, it’s a mutual selection process. Many patients think it’s entirely up to them but that’s not the case. If I feel that it’s not a good match or out of my scope of practice, I will refer the patient to others. To me, the relationship between the therapist and the patient is more important than a therapist’s theoretical orientation or how many letters they have after their name. I believe that the relationship in the room is the underlying healing. If we are exploring gender dysphoria, gender therapists must remain unbias. I know that sounds contrary but we must leave our own opinions elsewhere. We need to be good listeners, provide good sound information, refer patients to the best doctors, the best providers, and help them find good support groups or other places to interact with others. It is crucial that our patients feel supported realizing that they are not alone and that others feel the same way. Transitioning can be isolative, lonely, scary, and suicidal at times. A good provider can help the patient understand their gender dysphoria and help them answer for themselves where they want to go. Is this a phase, a fetish or something that has been a part of their life forever?
Many of my patients are in their 30s, 40s, 50s, 60’s and even 70’s. Many of them have lived good lives, enjoyed their families but always knew something deep inside was missing. They say things are good but they still experience anxiety. They are doing as they say, “the right thing” and still feel trapped either in their bodies or in their situations. Coming to therapy pretty quickly helps the patient deal with their anxiety and for many, I have been the very first person they have told. That in itself can be freeing. Knowing that every word is confidential and that I respect them and support them goes a long way. Anne Vitale, PhD. says it so well when she says, “it is the therapist’s role to help their clients find a way to make their life work. For many, they are overwhelmed by anxiety due to obsessive cross-gender thoughts.”
It is not my goal to decide for my patients if they are or if they are not something. I believe that my role is to make the patient comfortable, safe and supported so that they will feel empowered to talk about themselves and their struggles. It is my role to talk about the impact transitioning will have professionally and personally as well as helping build their self-esteem as people can be cruel and judgmental. I believe that confidence takes time and feeling good about making this change is a personal decision and I am there to help process their thoughts and feelings. Together, things get figured out pretty quickly and then we are able to come up with a treatment plan and a time line. This has worked very well in my practice and I will continue to provide services this way. I am honored to do the work I do and to help my patients move into the life they feel comfortable with.