Gender-Affirming Care Breaks Psychotherapy

I've seen more than my fair share of psychologists and psychiatrists.

As a transgender woman, much of my life was experienced through a clouded window of gender dysphoria. The journey to polish the window has been treacherous, yet in two and a half years of gender transition, I made major strides in mental health - almost unwittingly.

First, I struggled to believe I am worthy of transition. Persisting, I dissolved calcified gender norms in the weak acid of social transition. Finally, I found perennial peace within gender-affirming surgery.

The previous cheap, bubbly glass of enforced social norms has vanished. In its place, a clear perspective on existence.

Last week, a conversation with my current psychologist demonstrated I am suddenly capable of "normal" human existence. As if by magic, gender-affirming care bestowed a superpower.

All I did was release who I am into the world. All I did was become. And in becoming, I became self-aware - aware of my Self and my limitations.

In becoming, I have broken psychotherapy.

Descent

I met my first psychologist in 1990, at my then-girlfriend's demand. I was 20 years old, and Phil's therapy was offered by the University of California, San Diego Student Health Services.

After listening carefully, Phil informed me I merely had a fetish. I didn't want to wear women's undergarments, I had a fixation on them. I could manage my symptoms (and please the girlfriend) simply by denial.

Unfortunately, modern psychology had no cure for a fetish. But with careful self-denial of identity, Phil assured me I could still live a (mostly) normal life.

I failed.

In graduate school, insurance enabled me to find a private therapist - several, really. None was able to pinpoint my affliction, although the general consensus was Multiple Personality Disorder.

I regularly - and unknowingly - harmed myself with a razor blade. I seemed incapable of managing when Selina - my feminine counterpart - manifested. But psychology wasn't fussed enough to try to help.

After all, I was in a steady - and heterosexual - romantic relationship. I was successfully attending graduate school in Chemistry.

People with my symptoms simply didn't do that, so I must be in pretty good shape. Just…keep me away from razor blades and problem solved.

Nadir

At 35 years old, I finally hurt myself badly enough to warrant a trip to a hospital psychiatric ward. The apparent success that left me previously ignored by psychologists was irrelevant when I could also wield a butcher knife and turn it on myself.

For the first time, my symptoms were taken seriously, and I began a regimen of medications. Over the next six years, my symptoms abated - more or less. Mostly, I was dopey enough not to get in much trouble.

But in 2011, our son was born. I faced a new challenge: to bury Selina completely and become a good man. No, not just a man: a father.

Again, for the most part, I failed.

To be fair, I did succeed in many ways. I learned to meditate. I discovered my spirituality after decades of atheism. I was still able to hold down a job. These self-care practices allowed me to discontinue medications.

But when the underlying problem is gender dysphoria - the pain inflicted by enforced performance of masculinity - it was inevitable that leaning further into fatherhood would shatter my fragile mental utopia.

And on Tuesday, 21 December 2021 - Winter Solstice - Camelot fell. The woman raging within me keened her seclusion, hooked her claws, and tore open the shabby veil behind which she had been obscured.

I began gender transition six months later - and admittedly, my recovery could have gone better.

During social transition, I still struggled with depression and suicidal ideation. Scouring away every thin layer of mental health obstacle revealed another underneath - one more naked, pink, and raw than before.

I believe many obstacles remain to be overcome: more layers to peel back, more corners to illuminate, more cobwebs to clear out.

But I am different today than I was Winter Solstice 2021. Today I possess the ability to overcome those obstacles, as I demonstrated to my psychologist last week.

Difficult rebirth

I met my psychologist in 2019 - long before I even considered it possible to transition gender. My psychologist knows me.

At least, she knows how loudly I can bitch, especially when working for people unscrupulous enough to take advantage of a people-pleaser who never felt worthy of reward.

I enabled many managers to work me to failure.

No.

I worked myself to failure - willingly, as my due.

Then I lamented to my psychologist: I am never recognized; I am never seen; I am never understood.

For a transgender woman in a male-dominated field, I believe feelings of invisibility are inevitable. Of course I was unseen.

I was literally unseen, the woman masked under the masculinity I wore poorly.

Given my history, I'm not surprised my psychologist brought up old patterns when I told her about friction in a personal relationship. She observed my pattern many times - I was nothing, if not predictable in my failure to advocate for myself.

But something wonderful happened over the past two years of gender transition: I now possess the ability to feel my emotions and observe my patterns.

Healing through revealing

Much of the purpose behind psychotherapy is to become willing and ready to heal. We must want to change before any change can occur.

Transgender people, however, present complicated cases. It's not whether we are willing or ready for change, but whether we have the capability.

In psychotherapy, "change" implies continuing to deny who we know we are for the sake of those around us. "Healing" is to learn to lean into our sense of wrongness, to accept pain as our daily existence.

But until we accept who we are - until we accept we are transgender - and revise what change means, we cannot advance. Healing requires not evicting our sense of self, but embracing it through gender-affirming care.

And then…without a therapist doing anything else, gender transition readies us and changes us. Instead of years on a therapist's couch, we simply act as we are, and many troubles are immediately solved.

We become different people. Our cognition shifts. And it is very sudden - a tectonic release not observed in psychology, where progress is measured in baby steps.

The steps of a transgender Titan are immeasurable.

Breakthrough

Mental health professionals (and the insurance companies that pay them) would do well to embrace gender-affirming care. Transition brings staggering cognitive changes: the sudden capability to process situations previously invisible to us.

In no other situation do psychologists observe this sudden reworking in a patient, especially without psychotropic drugs. In no other situation does administering simple human hormones render a person capable of survival.

I ask insurance companies: is it better to treat a patient for years - maybe decades - with few breakthroughs? Or is it better to provide gender-affirming care and allow the human mind to rebuild its structure and fix its own problems?

If nothing else, gender-affirming care offers a cheaper, more rapid alternative to long-term psychotherapy. Isn't that precisely what insurance companies want? Isn't that the health care reform governments covet?

Transgender people - even with gentle gender-affirming care - break cycles of psychological patterns effortlessly, almost magically. We offer the field of psychology a rare opportunity to observe a human become self-aware.

We must not squander this opportunity. The transgender community affords a unique window into the human experience.

I never believed I could come this far. And all it took was gender-affirming care.