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Friday, September 20, 2013

Gender Dysphoria, Transphobia and Post Traumatic Stress Disorder

Having written on the topics of gender dysphoria, transphobia and posttraumatic stress disorder, I would like to explore how they all interact with each other to negatively impact the lives of transgender people.

 I have experienced my life as a transsexual woman, observed and facilitated the process of well over 450 trans people's experience as a therapist. I have worked with individuals across the developmental life span over quite a dynamic time in the lives of trans people from the late 1950's to this time in history. I have been afforded the opportunity to experience both my private experience, echoed in my clinical work with people who have sought me out to help them find their unique path in expressing their gender identity with a sense of congruence.

Most have transitioned socially; some have completed their goal of gender reassignment surgery, while others have found a middle ground that they can be comfortable with and a few chose not to transition at all, usually because of relationships that they cherish and are not willing to lose. Despite the pain of living in a compromised manner, they have found a place where they can be their true selves to a degree that is manageable.

There have been a few who could not transition at all, instead choosing to suffer secretly or they were not candidates to transition due to medical reasons. There are also a very few who have experienced gender identity conflicts that are not clearly transsexual and come to find that hormonal reassignment is not right for them nor would transitioning to a different gender social role bring them a sense of comfort and peace or be a solution for their lives.

In almost all cases of these individuals, myself included, the forces of institutionalized transphobia, internalized transphobia and social stigmatization have played a role in the marked emotional distress they have experienced. In most cases, these social and emotional forces have resulted in various degrees of Post Traumatic Stress Disorder. Some people's experiences of being traumatized have been mild and easily resolved through treatment with the use of medications and with psychotherapy, or by simply transitioning and  there are others  who were severely traumatized and have been left with life long significant impairment and disability in their social functioning despite their decision to transition.

I spent some time working with Viet Nam Veterans (God Bless you and thank you for serving our country at such great personal sacrifice in so many ways), learning from more experienced therapists in that field that one common predictor of how a combat veteran would fare psychologically had a great deal to do with their pre combat adjustment.

Soldiers who grew up in stable family environments with two parent households where the children were well cared for and free of physical, emotional, and sexual abuse and did not have addictions to alcohol or drugs fared much better than those where were victimized as children, had unstable households and came from broken homes. Now this is not true of any given individual situation. Some combat veterans were also biologically more resilient to extreme distress, but these factors have had a great deal of prognostic value in predicting outcomes. I believe that the same parameters operate in the lives of people with a cross gender identity as well.  These same parameters seem to have a great deal of value in determining who will experience greater trauma as a result of having a transsexual identity as opposed to those who will be able to manage the experience and have happier, better outcomes.

In Western cultures, we have seen a profound sea change in the degree that institutionalized and internalized transphobia has decreased over the past 50 years and particularly since the mid to late 1990s . In turn, I have seen better emotional and functional outcomes in young adults as opposed to people of my generation.

Indeed, the cultural changes we have experienced since then were instrumental in my own ability to come to terms with my own identity and complete my transition over the past 5 and a half years. I simply wasn't able to see a way through prior to the mid 1990's to become socially the girl and then the woman I have always experienced myself to be.

In the context of my culture's views of people like myself, which were internalized from the time of my recognition of my identity as a small child, this was simply unacceptable to myself and the culture I grew up in. Yes, there were a few people who were emotionally strong enough to do what I yearned to do from such a young age, but they were thought to be so rare that there was no way the majority of people like me could even comprehend becoming who we truly were, so I and most of my transsexual peers lived silent, tortured and desperate lives.

It is because of the process of stigmatization; the process of internalizing institutional (or cultural) transphobia that we have such high rates of suicide, addiction and alcoholism, as well as being victims of crime that we do in our community. The reason people resort to cope with drugs and alcohol place themselves in situations in which there is an increased risk of victimization and destroy themselves rather than continue to suffer in misery is because they have been traumatized and lack the coping skills to overcome their traumatization.

It is the result of internalizing societal messages that we are unacceptable as members of our society, as well as to ourselves and that we will never be able to participate in life as equals with others who have value and worth.

We come to internalize the idea that we are deviants and do not have the right to participate in life to become the best we can be and we are not worthy of loving others or being loved. As a result we become unable to love and accept ourselves and fall into a state of helplessness and hopelessness. It is a state of despair.  It can become a terminal condition when a person does not see a way to integrate her cross gender identity and see herself as a whole and healthy person worthy of loving and being loved, with value as a member of our culture. It is the result of having a guilt and shame based identity, so common in people with post traumatic stress disorder.

In the taxonomy of human problems that my chosen profession addresses, we have refined the definition of the problem at hand, not as a problem with having an identity that does not match the physical body, but it is that of the distress of the recognition that the physical body habitus is not congruent with our gender identity. (Keep in mind that the diagnostic categories we have created are partly reflections of cultural norms and values.) The problem is two fold. One is the biological conflict we experience psychologically from having a gendered body that is not congruent with our gender identity. The other problem is that we recognize that this is not a state of existence that our society considers within the norm and that we have internalized that value that as a result we are not "normal" and as a result, this recognition is traumatizing.

Therefore, in reality, gender dysphoria is a symptom of having been traumatized. Gender dysphoria is not a disorder; it is a symptom of post traumatic stress disorder. In our next iteration of categorizing and diagnosing mental disorders, we need to find a way of capturing gender dysphoria as a symptom of post traumatic stress disorder and not keep it as a stand alone diagnosis, though we must preserve a way of keeping it as a legitimately recognized source of distress that is a focus of treatment and also a treatment that is reimbursed by health care insurance.

There may be those who object to this being categorized as a symptom of post traumatic stress disorder, but the only other alternative diagnostic category would be under the classification of adjustment disorders.

The migration of these diagnostic categories from a stand alone gender disorder to recognizing it as a trauma disorder or adjustment disorder will be predicated on mitigating institutionalized transphobia and the process of stigmatization that results in internalized transphobia. This will result as our evolving society becomes more and more accepting of transsexuals and other transgendered people.

We have seen this happen with increasing speed in society and as these changes in accepting trans people have come about we have witnessed the changing conceptualizations of how to identify and help people with gender dysphoria in the iterations of the DSM over the years. As society changes, we will continue to see this reflected in future DSM volumes. We will see people markedly less distressed about having a cross gender identity and they will be able to participate fully in the dominant culture without being stigmatized or internalizing a stigmatized identity in our society's future.


  1. I know what the definition of transsexual is and I realize that I have been transsexual all along, even before I began my transition. But still, it is hard for me to visualize someone as transsexual or accept them as such, if they still cling to all or part of a male life. This is even if they are part time and on hormones. Transgender might be a term I would more freely use for someone in that situation even though transgender is used to describe everything from crossdressers to full time post op transsexuals. In stating this, I realize that many people that have not been to therapy or begun some form of transition may be transsexual and not even realize it. I am sure they know something is very different about themselves but I don't imagine that many of them identify as TS or if they do, I am not sure how it would be perceived. "Hi, I am Jim and I am transsexual, I have always felt like a girl inside but I have a wife and three kids and sometimes when my wife is out of town I sneak and wear her clothes..." Just does not equate with me in the same way with those of us who make life altering changes in order to be ourselves. From a therapist' perspective this might make sense, but from my own practical perspective in relating to those I meet in the tg community, transsexuals do not have to be on the road to SRS, but they do need have come out and left any semblance of male life behind....

  2. Hi Tammy, thanks for contributing to the conversation. My opinion is that the definition of a transition isn't predicated on behavior but it is about identity. The reason I think this is that in this day and age it is much easier to decide to transition than it was when people like me were growing up; the majority of my patients are becoming younger and younger and I see many more people in their late teens and 20's. They have a much easier time transitioning than people my age do because our culture has become more accepting of transsexuals. Still it appears from my observations that young F2M transsexuals have a much easier time coming out than young M2F transsexuals because it is still almost universal that all cultures value the masculine over feminine. It remains much more difficult for mid life transitioners to come out and transition than young people today and the difficulty that older transsexuals face cannot be discounted. It is so much easier as a young person to "lose everything" and rebuild a happy life than it is for someone who is in their 40's, 50's or even older. This has everything to do with institutionalized transphobia and the cultural stigmatization of transsexuals which in turn is internalized, that which I refer to as internalized transphobia. This is the process of the formation of a stigmatized identity. I would refer my readers to the writings of Erving Goffman, particularly his book, "Stigma: Management of the Spoiled Identity" (1963).

    I think it is unfortunate that the concept of the "transgender community" exists and that transsexuals are included in a group with fetishists, crossdressers and transvestites who have very different identities and very different purposes in expressing crossgender behavior. The concept of this community really exists only for sociopolitical purposes and the "T" in LGBT exists only to serve the political purposes of the gay political movement. The inclusion of Transsexuals and Transgender people is solely to advance the political goals of the gay community. Whatever benefit that we receive has been as an after thought. I base this opinion on the many times Transsexuals have been thrown overboard when legislative policy has been advanced when including transsexual people would thwart the political goals and aspirations of the gay community.

    I would also add that expressing a transsexual identity publically (or even privately with a few select people) is a developmental process. Those who have not been able to accomplish leaving that semblance of a male life behind may at some point or one day be able to do so in the future as their individual circumstances change. Some may not be able to due to the risk of losing so much physically, emotionally, and spiritually that they may not be able to survive that process. These unfortunate folks are severely traumatized by this inability to transition. It is the basis of the high rates of depression, anxiety, addiction and suicide we see in our society and a large contributing factor why so many of us become vulnerable to becoming victims of violent acts.

    In my experience, the people I have worked with are pretty clear on their identity and whether they are transsexual, crossdressers, transvestites or fetishists. It does in my opinion come down to one's identity and not necessarily based on behaviors.