On therapy and gaining access to what we need

Directly from the WPATH-SOC (World Professional Association for Transgender Health Standards of Care), 7th edition, p. 19:

Psychotherapy Is Not an Absolute Requirement for Hormone Therapy and Surgery
A mental health screening and/or assessment […] is needed for referral to hormonal and surgical treatments for gender dysphoria. In contrast, psychotherapy — although highly recommended — is not a requirement.
The SOC [Standards of Care] do not recommend a minimum number of psychotherapy sessions prior to hormone therapy or surgery. The reasons for this are multifaceted (Lev, 2009). First, a minimum number of sessions tends to be construed as a hurdle, which discourages the genuine opportunity for personal growth. Second, mental health professionals can offer important support to clients throughout all phases of exploration of gender identity, gender expression, and possible transition—not just prior to any possible medical interventions.  Third, clients and their psychotherapists differ in their abilities to attain similar goals in a specified time period.

When I was 17 years old, I admitted myself voluntarily to a psychiatric hospital.  I thought I was going to go there for a day or two, be able to finally catch my breath, and then work with those around me to make a plan for what I needed.  This is not what ended up happening.  I still wanted to leave after a day or two – that didn’t change – but suddenly, things were getting really confusing really fast, and lots of people had other plans for me.  Since I was still a minor, I really had no say in what happened.  I was there for 19 days.  I was put on 3 different medications.  I was told I suffered a psychotic break.  I was diagnosed with bipolar disorder (based on how I was behaving – short-term – and things I told them, such as, “I think I am bipolar”).  When I left, I spiraled into a major depressive episode that lasted about 4 months (and I felt highly unstable for years to come).  This helped confirm for me that I was, in fact, bipolar.  Something I believed for about 6 more years.

I am most definitely not bipolar.  I did go through a psychotic break, but in retrospect, I believe this could have been prevented had I not been hospitalized.  I think, ultimately, I just had an extended panic attack.  And having no idea what that was or felt like, I thought going to the hospital was the only thing I could do to help myself in the moment.

For the next 6 or so years, I complied with my mental health care.  I took all my medications every day, as they were prescribed (and those meds and dosages changed a lot over the years).  I went to all my appointments I was supposed to go to.  I talked to therapists, psychiatric nurse practitioners, psychiatrists.  I didn’t seem to be improving.  In a lot of ways, my mental state was getting worse.  I just followed along with the treatment plan because I didn’t know what else I could do.  In fact though, I couldn’t really tell you what the treatment plan was.  Was there a plan?  I don’t recall that being a conversation.

All of these experiences have greatly shaped who I am, and also my attitudes toward health care providers.  I’ll say right now, I am definitely biased and wary.  Once I decided I wasn’t going to take medications that didn’t seem to help, and I wasn’t going to listen to ideas that didn’t seem to make sense for me, there really was no going back.  Pretty much dropped out completely (except for going to a dentist and a chiropractor, haha) for a very long time.

Until I decided I wanted to access testosterone.  I thought I was going to need “The Letter” from a therapist, but in the end, the doctor I went to didn’t care about formalities like that.  (He’s also a sketchy doctor though.)

I feel very adamant that I should be able to easily access testosterone for the rest of my life.  Testosterone is doing for me what antidepressants, mood stabilizers, and antipsychotics never quite did.  And more.  I don’t want to go through hassles to be able to get it.  I’d go as far as to say that being challenged about it by a health care professional is highly triggering for me.  Because when I was younger, I was told what would be best for me for so long, and I followed.  And it was shitty.  So now the dynamic is going to be the other way around.  I know that’s extreme and reactionary, but I do feel that strongly at this point in time.  I hope that as I age, I will mellow out about it.  I’m sure there will be times that I’ll need help and I won’t know what is going on with my body, and I will be grateful for doctors’ and specialists’ expertise.  As for now though, I’m not there yet.

Although my experiences with mental health professionals have been shaky at best, I believe strongly in the therapeutic effects of… well, therapy (haha).  Without having been in therapy through those toughest years, I would not be where I am today, no question.  I learned how to talk and communicate from therapists.  I learned how to stop being so hard on myself.  I learned to let go of my past.  I learned that I cannot save others from their pain.  I learned what things really matter in life, and what things I am spending wasted energy on.  It was the slowest imaginable process.  None of these gems felt like they were working for me at the time, but in returning to therapy over these past 2 years, it all started to suddenly sink in, and I’ve made some real leaps and bounds.  I feel grateful for that groundwork I started in my late teens and early twenties, through therapy, even though I could not feel the benefits whatsoever at the time.

Two years ago, I attended a workshop at the Philadelphia Trans-Health Conference called, Who Needs Therapy?  Some Thoughts on Mental Health and Gender Variance.  It was largely an open discussion format, with a mix of mental health professionals, people with experience being in therapy, mental health survivors, and others.  Toward the end I had worked up the courage to ask the group, “What if I really connect with my therapist, but it is clear she is not knowledgeable about trans* issues?  Is it worth it to continue working with her if I want to explore this?  Is it up to me to attempt to point her to resources if I want to keep working with her?”

Everyone who responded to me was very adamant that it was not up to me, and if she does not do the work on her own, I should find someone who is knowledgeable or who is immediately and clearly willing to do the work.  It turned into a very impassioned discussion with a lot of people saying the same things.  I left feeling really confused.

It had been very hard for me to find a therapist I click with.  I’d gone to a few in my mid/late-twenties, and felt really dispirited.  A couple of them were specifically gender therapists.  In the end, I returned to the main therapist I saw through some of my toughest years.  It was amazing to me she is still around and I could find her.  Re-connecting with her again after 8 years was mind-boggling in the best way possible.  Despite the feedback I got at that workshop, I wasn’t about to let go of her so easily.  Nor did I feel like educating her myself, or even asking directly what she did know and what she did not know.  I just continued to tell her how I feel, and I didn’t ever get the impression that she didn’t understand or wasn’t going to work with me on that.  However, when I asked her if she’d write me a letter for HRT if need be, she said, “No.  I don’t feel like I have that expertise.”  And I appreciated that.  It is all working incredibly well.

When going to my new doctor, I could have possibly had an easier time if I was forthcoming with the fact that I’m in therapy for gender issues (although I’m not in therapy with a gender therapist).  But I didn’t feel like I should have to.  So I didn’t mention it.  When the doctor asked me who is in my support network, I said my partner and my parents and friends.  I left out my therapist.  When she told me she would like to collaborate with the gender identity youth clinic in making a plan for me, I could have saved some time and hassles by saying, “My therapist already talked with them, and they won’t see me because of my age.  So the plan B is this.”  But I didn’t.  I just said, that’d be great and let my doctor make the phone calls and come to that same conclusion on her own.

Why?  Because I think that therapy is an important part of my well-being.  And I think that getting the best medical care possible, for what I need, will also be an important part of my well-being.  And I don’t feel like the two necessarily need to have much to do with each other.  Specifically, I don’t want to suddenly be taken more seriously and be given what I need, gender-wise, because I am in therapy.  I want what I say to be enough.  I want to access hormones without it being known I’m in therapy, if I can.

I am deliberately attempting to lay some of the groundwork, saying that this is perfectly acceptable.  Not all of us live within access to clinics or doctors who offer the Informed Consent model.  But I feel like I am in a position where I can work to change that.


8 Comments on “On therapy and gaining access to what we need”

  1. urbanmythcafe says:

    I have been thinking about the way that you have approached things concerning therapy, and with your primary care doctor. I think that it is great, and brave, and that you are making a path for other people who shouldn’t have to follow arbitrary rules.


    • janitorqueer says:

      Thank you so much. It means a lot to me to hear that. I guess, as radical as it is, I feel that within the foreseeable future, any and all primary care physicians should be aware of hormone replacement therapy for transgender patients, and be comfortable prescribing hormones.

      I still remember what you wrote about your leadership in bring transgender patients with you to a new doctor, when you had to find someone new in your area.


  2. Jamie Ray says:

    My therapist is straight, cisgendered, and feminist – she was not entirely comfortable when I started allowing myself to accept being transgender- and she visibly winced when I first started talking about top surgery, although now she gets it.
    I think it is more important to work with someone you trust (I trust Kathy -for years she told me “this is the way you are you are not going to change” without either of us managing to label it being trans). My issues (interpersonal) are all about trust and letting people see me – they go deep due to verbal and physical abuse (mother and grandmother) and although they are related to my transness (or gender non-conformity) I think they are better dealt with by a therapist who is not trying to view everything through trans lenses or put me on or take me off a particular trans-narrative track. Or to put it another way, I am glad she is letting me set my own course and not fast tracked into transition.


    • janitorqueer says:

      I think the therapist patient connection is the first and foremost priority for sure, whether that therapist specializes in exactly what you’re looking for or not.

      Pretty sure that’s even been proven – that it’s the face-to-face connection that makes more of an impact than any other factor, such as therapist’s philosophy or schooling, etc.

      Gender therapy is, admittedly, kind of a strange concept for me to understand. Therapy that incorporates an exploration of gender identity – that I can get on board with! Otherwise, if you know what your path is and what you need, why waste time in therapy just to access it?!!

      Thanks for sharing! Sounds like you found a good one!


  3. Great post. I feel sad for the experience you had at the hospital, tho not surprised. They are too set on the DSM and medication and so often the individual gets lost in the mix.

    I am surprised by the adamant reply to not work with your therapist on gender identity stuff, to even inquire as to whether or not she is open to becoming more educated. As a therapist, I also understand the whole need to practice aspects of psychotherapy that I am trained in. However, after going to a training on working with transgender youth, I asked the facilitator about where I can get more formal training on working with the trans community. She said there really isn’t formal trainings and recommended books and conferences. In my continued pursuit of educating myself, I have found this to be true. So in reality, if you have a connection with the therapist and she is open to educating herself then this is a perfect thing. I would hope that as you deepened in your gender exploration she at least educated herself around the issue at large so as to not do harm from simple ignorance. And yes it is imperative that everything not be seen through the trans lens as our psyche is so much more complex and multifaceted than that.

    Being trans myself has probably been the most educating for me and I so recognize how diverse each experience is. Every trans person relates uniquely to his/her experience – I am yet to meet two trans people who experience themselves the same. I am glad that the therapist you work with could meet you as you needed to be met and follow your lead and wisdom vs putting her agenda on you. This is crucial.

    While I did do therapy over the years exploring my gender identity as well as other life wounding experiences, I was able to find a doctor (not sketchy at all) who does her own assessment for prescribing hormones and wrote the letter needed to get top surgery covered by my insurance. The surgeon didn’t seem to need the letter to perform the surgery.


  4. janitorqueer says:

    thanks for this very thoughtful and thorough reply! That’s super interesting that there really isn’t any formal training on (trans)gender identities. It’s kind of awesome that the training comes from a hodgepodge of resources, books, personal anecdotes, etc. I just hope that those who do want to learn more, for their professional growth, go about it in a comprehensive way!

    That’s really great that you’ve found the doctor you have, and got connected with the surgeon; sounds like you’ve had minimal hassles on those fronts!

    And it’s so true – our psyches are so multifaceted, and I wonder if some therapists would unwittingly pigeonhole patients, in order to get them on the transition track that is more-or-less “prescribed.” I hope not!

    Liked by 1 person

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