05/11/2022
Answers to questions from Genspect Webinar. Supporting Gender Questioning Students on Campus
a webinar with university counsellors
1. What do you see as the best way for campus therapists to screen for trauma as the cause of gender dysphoria? Is it possible to screen for trauma without a family history or family involvement?
Depends on your way of working. Always take a personal and family history to get an idea of family dynamics and personality structure. You want to get to know the person behind the presentation. Who are they, what do they like what do they struggle with? If they are defensive and push you away. I would observe that seems very closed down. They may be suspicious that you want to impose your agenda on them. We also come from a position with over 18s that they have to decide how to live their lives. It's their decision. But important decisions about the body and mental health benefit from a thorough exploration of what's going on for the individual. What do they hope the transition will achieve? What's the transition about. We need to understand who they are. And interest the individual in themselves and the way their mind works. The way they think. The therapist is thinking about the broader focus on who the person is and where they come from. It may be that the narrow focus on gender gets the individual away from thinking about themselves and their relationship with themselves. Perfectionism and self-hatred are a common presentation in young people presenting with gender confusion. Also, tendency to look for concrete physical solutions to psychological problems.
2. On my campus, we see trans students who appear to be thriving during their transition. Does it matter if their GD is brought on by trauma or another cause if transitioning helps address their mental health issues?
We all have to find a way of living with trauma, and some may go on to transition. In the short term, there is often a feeling of euphoria that they have found a solution to their problem by distancing themselves from a troublesome aspect of themselves, like the woman who experienced neglect or abuse in childhood, search for an identity that functions like an external carapace that could protect them from future mistreatment. Testosterone is often felt to give that induvial the feeling of invincibility. The man with an aggressive father may wish to distance himself from masculinity by taking oestrogen and thinking of sexual reassignment surgery. It's as if he could remove all traces of the masculinity he associated with his father. However, longer term, the mind is like the tax man. You can delay paying for a time, but eventually, the tax man comes knocking. The process of repressing and pushing back into history is normal and natural. However, if you try to get rid of a problem by splitting it off and pushing it away, it tends to come back to haunt you. The aim is not about whether the transition helps them 'thrive' (which might be a defence) but when they come to you for counselling, focus on why they've come to see you. The difficulties will need addressing irrespective of their gender identity. Are there other ways of addressing their problems.
3. Do underlying conditions such as ASD and ADHD make it more likely that a person will experience trauma? Do these conditions make it more likely that trauma will lead to gender dysphoria?
We usually think first about the structure of the individual's personality. A fragile structure. That can either mean being prone to fragmentation and falling to pieces or being rigid and inaccessible. Comorbid problems should be seen as part of the whole. And different parts of the personality interact with one another. For example, someone on the autistic spectrum and prone to black-and-white thinking and trying to manage their psychological state is very attracted to the black-and-white thinking behind gender ideology. Getting rid of one troublesome aspect of their personality might feel extremely attractive as it appears to give them more control removing conflict and anxiety. You have to think of the person as a whole. The trauma for many with ASD is that there is a growing awareness for them that they often struggle to fit in or feel part of the group. Sometimes they have experienced many friendship splits – intense and then over etc.
4. What are some ways that you recommend for female patients with body issues (re being female and sexual abuse) to come to reconcile with their femaleness when it feels so scary?
First, start from the view that, in the end, adults have to decide how best they live their lives. But before making big decisions with long-term consequences, it's worth trying to understand what's going on. Try to understand the defences in the first instance. Understand that they may feel vulnerable, and they develop an understandable view that concretely if they take testosterone which gives the individual a sense of strength and gets them away from feelings of vulnerability and distance themselves from femininity which they might in a rigid stereotypical way identify with vulnerability, then they feel defended. However, the cost is high. These solutions are short-term gains with long-term costs. Also, see that this is a concrete solution but only one of the ways of thinking about the problem. Can their view of themselves be opened up for exploration and examination? Trans is also a difficult way of living. We have also heard from detransitioners that identifying as male tens to put them more in the company of men and more open to a sense of threat – both that they are male and the often-constant fear of being exposed or not passing. It can be exhausting for many.
5. Could the unacceptance of someone being transgender cause trauma instead of the other way around?
Rejections, exclusions, or traumas are experienced differently by different people. In many ways, you have to look at the trauma in relation to the individual. What does it mean to them in particular. Also, you have to look at the capacity of the personality to digest and work through the trauma. Some people who have experienced abuse in early life go on to repress the trauma, allowing them to get on with their lives. Others may be traumatised by a sibling's birth and find this difficult to recover from. The problem emerges in later life, at the point of puberty (representing the transition to adulthood) or separation from the family home.
The fragility of the personality is often represented in the individual's relationship with others. Fragile individuals often want to control how they are seen because they are also trying to control how they see themselves. The control of the other and what the other thinks is often a reflection of the wish to control their own emotional state. When we feel under threat, we tend to search for certainty and doubts are seen as the enemy. This creates a rather rigid state of mind and flexibility of thought is seen as a weakness rather than an attribute. Mature thinking is based more on an ability to look at things from different points of view, looking at the downside of decisions and whether there are alternative ways of thinking about the issue.
If an individual is fragile, they tend to search for agreement from those around them, need to have everyone in agreement with their way of thinking with no doubts or questions or thoughts of their own and feel threatened by anyone who wants to think around the issue. The therapist needs to empathise with the fact that exploration and thought maybe experienced as intrusive and threatening. The therapist has to titrate the things they say with the level of threat experienced by the individual they are seeing.
6. More and more laws in the US being passed banning treatment for minors, which could be traumatic for teens with gender dysphoria. Students already want to start transitioning as soon as they get to college and are very eager to move quickly. What is your recommendation for dealing with this student population who have had to delay gender-affirming treatment?
Moving from the family environment to college symbolically represents a movement from being a child as part of a family in transition to being an adult in the outside world. What equipment do they have to cope with anxieties and conflicts questions about the adult world? How do they feel about sexual relationships finding a partner, work who will employ them? What do they feel about the responsibility of making their own decisions? Will they take drugs and get involved with the wrong people? Will anyone like them? Are they going to have a family. All of these issues are questions that the adult world has for them. College is the gateway to the adult world. You thought your parents were repressive and crap and you could always hold them responsible, but now it's down to you. In other words, the transition from childhood to adulthood is anxiety-provoking. In some ways focusing on one narrow issue called gender can feel more manageable than the big questions about how prepared they are for the adult world. Occasionally there can be a kind of over-exited, almost manic sense of being free from parental controls, which can be part of the 'rush'. Try to help the person develop an understanding of their internal world – not always projecting blame/grievance at parents may – but the combination of being allowed to express the difficulties but also think about themselves in relation to their expanding world, to develop their own sense of self – otherwise they might remain in an aggrieved state of mind.
7. What are your thoughts on the announcement last week about the Tavistock changing course on treating minors with gender dysphoria? Our students are older, but this guidance seems to go against the WPATH standards that we use at my school.
Many experienced people believe that WPATH is a captured organisation more driven by political ideology than clinical evidence. Our government appointed the Hilary Cass ex-president of the royal college of Paediatricians to look at this. She said there isn't evidence to send these kids on a medical pathway. Political ideology has captured the whole area rather than clinical research debate discussion. She argues for holistic care with all aspects of the child being assessed. Finland and Sweden have come to the same conclusion.
8. We are beginning to see some detransitioners at my school. Do you have any recommendations for clinic staff regarding how to support students who may be considering detransitioning or are in the process of detransitioning?
Understand that relinquishing a belief system is like mourning the death of someone. You invest in an idea for a good reason. You believe that it will help you manage things for the better. You usually exclude doubts and may have upset people who love and care for you. To relinquish that idea and take back your investment takes courage. You have to say I was wrong. I feel guilty that I might have upset people I love. I have to question my own judgment. I may have to experience the shame of realising I misunderstood the problem. It's a climb down. They may lose the support of a group that championed them they may have to face their parents, who always said they thought this was a big mistake. And they now have to reshuffle their identity and view of themselves. As we say, it's like a mourning process.
A few after points.
Important to remember that the individual may see the counsellor as a controlling parental figure on the one hand or a careless libertine on the other. The therapist is often in a position where they are pushed into being either for or against them. We also try to start by identifying with the individual point of view. Where are they coming from. Then try to introduce and interest the individual in our point of view as a therapist who is interested in opening things out and thinking about the person as a hole. This is difficult work, but you don’t need to be a specialist. Its just like other developmental issues such as eating disorders self-harm. We try to concentrate more on the issue of the individuals struggle to find their own identity than a narrow preoccupation with gender.
Also, important to recognise the therapist’s conflict between the need to investigate risks and thought about plans to transition. This is an active approach more akin to a mental state examination in which the clinician is assessing risk and competence to make decisions. The individual may experience this as intrusive. This approach conflicts with the receptive approach employed in therapeutic encounters. Both have a place in clinical work and the clinician may move from one approach to the other depending on their role the setting and the clinical presentation. E.g., if the individual mentions suicidal thoughts. The clinician might switch from a receptive stance of following the patients and trying to understand the meaning of the patient’s communication to an active approach in which they try to assess the level of suicidality.
The projection of confusion and doubts into the therapist or other figures of authority. This can provoke the therapist to try and push questions back into the individual. This can make the individual feel worse as the projection of doubt and confusion about identity is the individual feel more in control. Letting these doubts and confusions back in would threaten their sense of coherence. We usually try to understand why the individual is defending themselves what is the underlying anxiety. Then try to find points of concern and chinks in the defensive armour.
The capacity for reflection in the individual is likely to increase when they feel they are with someone who understands where they are coming from. Reflectivity increases when the individual feels supported and their underlying anxieties are understood. When the individual feels threatened they are likely to feel they have to defend themselves.
Marcus Evans & Susan Evans
