Post Traumatic Stress Disorder and the Transsexual Experience

One of the most frequent features of the vast majority of transsexuals I have worked with in my experience is the extremely high rate of Post Traumatic Stress Disorder symptoms that are common to the vast majority of us. It is also probably the most often overlooked and underdiagnosed problem that is not a focus of treatment. This is an often important aspect of gender dysphoria that has been mostly overlooked. It is not well represented in the literature, nor does it seem to be a frequent consideration for treatment.

Consider the diagnostic criteria of PTSD in DSM V

Criterion A: stressor

The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (1 required)

1. Direct exposure.
2. Witnessing, in person.
3. Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental.
4. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.

Criterion B: intrusion symptoms

The traumatic event is persistently re-experienced in the following way(s): (1 required)

1. Recurrent, involuntary, and intrusive memories. Note: Children older than 6 may express this symptom in repetitive play.
2. Traumatic nightmares. Note: Children may have frightening dreams without content related to the trauma(s).
3. Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. Note: Children may reenact the event in play.
4. Intense or prolonged distress after exposure to traumatic reminders.
5. Marked physiologic reactivity after exposure to trauma-related stimuli.

Criterion C: avoidance

Persistent effortful avoidance of distressing trauma-related stimuli after the event: (1 required)

1. Trauma-related thoughts or feelings.
2. Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).

Criterion D: negative alterations in cognitions and mood

Negative alterations in cognitions and mood that began or worsened after the traumatic event: (2 required)

1. Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol or drugs).
2. Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous.").
3. Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
4. Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt or shame).
5. Markedly diminished interest in (pre-traumatic) significant activities.
6. Feeling alienated from others (e.g., detachment or estrangement).
7. Constricted affect: persistent inability to experience positive emotions.

Criterion E: alterations in arousal and reactivity

Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (2 required)

1. Irritable or aggressive behavior.
2. Self-destructive or reckless behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems in concentration.
6. Sleep disturbance.

Criterion F: duration

Persistence of symptoms (in Criteria B, C, D and E) for more than one month.

Criterion G: functional significance

Significant symptom-related distress or functional impairment (e.g., social, occupational).

Criterion H: attribution

Disturbance is not due to medication, substance use, or other illness.

Specify if: With dissociative symptoms.

In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli:

1. Depersonalization: experience of being an outside observer of or detached from oneself (e.g., feeling as if "this is not happening to me" or one were in a dream).
2. Derealization: experience of unreality, distance, or distortion (e.g., "things are not real").

Specify if: With delayed expression.

Full diagnosis is not met until at least 6 months after the trauma(s), although onset of symptoms may occur immediately.

Of the over 400 gender dysphoria patients I have seen personally, the majority of them exhibit enough symptoms to justify a diagnosis of PTSD. It is empirical from my practice experience that from the time one realizes one's body's sex does not match their gender identity, this is going to become a severely traumatizing event and the effects of this trauma can have the potential to be profound as a result of not being addressed early in life when the realization of this incongruence manifests itself. The mediating factor in the severity of PTSD appears to be the resiliency of the individual; some people appear to be extremely debilitated by their trauma symptoms and some individuals appear to cope better and minimize to some degree the impact of the trauma of gender dysphoria on their overall quality of life.

DSM V is a major improvement in the conceptualization of what is the focus of treatment in the transsexual individual. The DSM IV- TR diagnosis of Gender Identity Disorder wrongfully conceptualized having a cross gender identityas being a psychological pathology. In fact, it isn't the identity that is pathological at all: its the intense distress at having a cross gender identity. To improve conceptualizing the problem and to this end, DSM V now has the Diagnosis of Gender Dysphoria and I have listed the new criteria here.

Here are the proposed criteria for adults and teenagers for the upcoming DSM-V.

Gender Dysphoria
A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by 2 or more of the following indicators:

1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics) [13, 16]
2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) [17]
3. A strong desire for the primary and/or secondary sex characteristics of the other gender
4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning,  or with a significantly increased risk of suffering, such as distress or disability**
Subtypes

• With a disorder of sex development [14]
• Without a disorder of sex development

Specifier
Post-transition, i.e., the individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is undergoing) at least one cross-sex medical procedure or treatment regimen, namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in a natal male, mastectomy, phalloplasty in a natal female).

Over the years, I, as a mental health professional, and as someone who is a transsexual have struggled with the proper place of transsexualism and gender dysphoria in the pantheon of mental health disorders. To my way of thinking, anything that creates as much distress as the incongruence of one's gender identity being in conflict with one's physical sex rightfully has some place in the DSM and is worthy of being addressed in a manner to relieve that distress. I am also of the mind that it is not one's gender identity that is disordered and that is why I like the move to change the diagnostic nomenclature to Gender Dysphoria. It implies that it is environmental factors, not an innate etiology, that is responsible for our distress, much like the diagnostic category Adjustment Disorder.

This seems straightforward enough and also provides a mechanism to get the services we need to successfully transition. I know that there are many who don't like that descriptor either, but I think it is a step in the right direction and for a condition as obscure as ours, it will take many more years before this is correctly sorted out.

I have come to believe that perhaps many if not all of the symptoms we experience from having a gender identity that does not match our physical body habitus can be better accounted for with the diagnosis of PTSD and that the criteria should be expanded to include symptoms of gender dysphoria. As is true of the degree of gender dysphoria we experience, ranging from mild to severe, so the relative degree of PTSD affects a person differently due to a number of biopsychosocial factors.

I think that one's earliest recognition that their gender identity does not match their physical sex is extremely traumatic and that the experiences we have along the way in attempting to reconcile this most often contribute to life long traumas being experienced for much, if not all of one's life until they are able to facilitate a successful transition. Some people experience this in profound ways which is why there is such a high rate of attempted suicide and addiction as well as other negative outcomes in the members of our population. Even in successful post transitioners, PTSD symptoms can remain debilitating and are a potential point of intervention.

Including symptoms of gender dysphoria under the diagnosis of PTSD will resolve the problems we face trying to get insurance coverage for the services we need to improve our quality of life as PTSD is an accepted diagnosis by the health insurance industry.

Critics may argue that no reference to any gender disorder should be included in the DSM and that it is stigmatizing to individuals. I disagree based on my clinical experience. I have not met anyone who was not distressed by their conflict between their identity and their physical body and have not been helped by facilitating a process in which they can decide and obtain what is necessary to have a quality of life each and every one of us should have.

Some people do not experience any dysphoria over their gender identity and they should not be diagnosed as having a problem that does not exist for them. They are best served by being offered case management to inform them of options available to them for gender transition and to plan for, link to and serve as a coordinator to help the person who is ready to complete their transition or by simply identifying resources to explore on their own.

Whether transgender individuals in emotional distress would be better served with a stand alone diagnosis or whether gender dysphoria should be subsumed under Post Traumatic Stress Disorder is a debate worth having.

What do you think?

Choosing the Right Therapist For You (It's Not As Hard As You Might Think)

Finding the right therapist for someone who is transgendered is not an easy task, as most of you know already. Many trans people would prefer that their therapist not only be well versed in providing transgender care, but also be transgender themselves. As difficult as it is to find a therapist who is well experienced in this area to begin with, the therapist who is transsexual, such as myself, is an even more rare thing to find. As many of you know, my practice is in a rural health care system in the heart of the Shenandoah Valley. I am the only therapist for over a three hour's drive radius who practices transgender care and there are no other therapists who do practice in this area who are transgendered themselves to the best of my knowledge. I do know most of the therapists in Virginia who provide this type of therapy. So when I went searching for my own therapist, I had to find someone who although had no experience specifically in transgender care and wasn't transgendered, yet would be able to provide me with competent care to the best of her abilities.

I did a quick survey of the top 40 graduate programs in my own discipline of Social Work. Of the handful I surveyed, only two had practice course work that had the keyword transgender in the course title. The program I attended at the School of Social Work at the University of Alabama had no courses in this area when I attended (NO! I will NOT tell you the year I graduated!! A lady NEVER reveals her age!!!!).

A therapist who has herself as a patient is a fool. Someone asked me me why I don't do my own therapy in all seriousness and it was a fair question to ask. It's because I lack the objectivity that one would get from a therapist when it comes to myself. The decision to transition is one of the most important ones of my life and I have only one chance to do it right). This might seem like it would be impossible to find someone who could get the job done, but that isn't true. My own therapist has never worked with a transgendered person before me and she has done an excellent job. At this point I would recommend her to anyone seeking transgender care. She has some characteristics that ensured that she would be competent to do the job, and I knew this when I selected her to be my therapist at the beginning of my own care. I want to share with you how I was able to find someone to help me. It isn't that hard when you know how to go about it.

The secret in finding the right therapist for you is really simple: You are hiring someone to do a job for you and you need to do your homework up front, just as you would if you were hiring an electrician or a plumber. There are things you can do to make sure the person you hire is competent to do the job, just as hiring anyone else. Remember, the therapist works for you and you are interviewing candidates to fill the position, just like any other job. This can be an intimidating prospect for most people because they don't have the same knowlege base as the therapist and they don't feel like they can pick someone who will be competent, so they make appointments with someone and see if it works. That can get expensive, especially if you see two or three before finding THE ONE. Plan on interviewing three or four, if at all possible. It's nice to have a number of options.
If a therapist isn't willing to spend 15 to 30 minutes speaking with you on the phone about what your needs are, then he or she will not be a good candidate for you to contract with. When you are interviewing, it isn't so important that you completely understand the answers to some of the questions you ask, just write them down. You can look up some things afterward on the internet which will help you make an informed decision on who to pick for your therapist.

The first thing you will want to do is look in the yellow pages and see if anyone uses the term "gender and sexuality" in their advertisement. That one key phrase brought me tremendous numbers of trans patients when I had my private practice. The other resource was people who found information about me on the internet. A number of websites provide lists of therapists who are competent in gender therapy.

More and more insurance companies are paying for transgender therapy. The easiest way to find out if you will be covered is to call your insurance company or the mental health managed care entity who handles this for your insurance and ask them if the the  DSM IV- TR diagnostic code 302.85 is covered under you insurance policy. Almost every insurance company I am a provider for, with the notable exception of Coventry administered by Southern Health and their mental health managed care company MhNet cover this therapy and that includes Virginia Medicaid and Medicare.

When you are speaking on the phone interview you will want to ask the following questions:

1. Do you accept my insurance plan and what are your rates? If my plan doesn't cover this service, what is your fee for service? (If there are valid reasons that you can't pay the full rate) Do you have a sliding scale?

2. What is your theoretical orientation? There are many theoretical schools of psychotherapy. Some of the major ones are:  Behaviorism and it's derivitives, Cognitive Behavioral Therapy and Rational Emotive Therapy; Humanism; Gestalt; Transactional Analysis; Psychoanalysis and it's derivitive, Object Relations and Feminist Therapy.

My undergraduate education was strongly rooted in Behaviorism and I practice mostly Cognitive Behavioral therapy and Rational Emotive Therapy. I am well versed Humanistic therapy, Gestalt and Transactional Analysis and have a working knowlege of Psychoanalysis and Object Relations, though I only use them to conceptualize therapeutic issues when I find it useful and do not practice their techniques as I have not been supervised to practice in that area.

Over the years I have been concerned when I hear that a therapist describes their therapy as "eclectic". Too often that means that a therapist has not mastered any particular school of psychotherapy and just draws techniques to use in their practice because they feel right to them for the situation. They often can't articulate why the selected a particular intervention and the theory base behind it. Not all therapists who say they are "eclectic" though don't operate without a philosophical underpinning it is just important to know they understand why they select their interventions.

After you have interviewed the therapists you have selected, it's time to hit the internet and look up the information they provided you. You can then decide which therapists' theoretical orientation seem to be in tune with your own belief system and make a wiser choice in your decision.

3. If they have no transgender treatment experience, then enquire if they have worked to any extent with gay and lesbian individuals. If they have experience with them, they are more likely able to be helpful to you. While our issues are not identical to their's, they do overlap to some degree. This was the deciding factor in my choice for my own therapist.

If they do have transgender experience, ask them if they are a member of the World Professional Association of Transgender Health. If they are a member of WPATH, that is the gold standard for transgender care. If they are not, ask them if they are familiar with the new seventh version of the WPATH standards of care. If they are knowlegable of them or the prior version, then you know they are at least well enough acquainted with transgender care that they are likely to be able to provide you with quality treatment.

If they don't, but have other experiences that place them into serious consideration to become your therapist, then ask them to what degree they are willing to educate themselves to be able to help you. Are they willing to dig up resources and learn on their own? If so, you will most likely find a good therapist to help you, though they might be inclined to follow the standards of care more to the letter of the law. That can be frustrating. We all want what we want when we want it in terms of our gender issues and transition and I am no different in that respect, but someone who is going to be careful before signing off on your hormones and surgery rather than just going along with what you want may just be what is best. At least you will be sure they erred on the side of caution, if they erred at all.

Too many of us have rushed into decisions they knew were right for them without consideration how they will support themselves, who will be supportive of them and who will abandon them merely because they are differently gendered. Too many times thre have been disasterous outcomes. Our community has about an 800% higher rate of attempted suicide than the general population and an astronomically higher rate of substance abuse and addiction as well.

I hope that these thoughts and strategies will help those of you who are looking for a therapist. If anyone has any other ideas that will help my viewers, please do contribute your thoughts to the discussion.