TransKit Module Three: Psychological

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MENTAL HEALTH NEEDS OF TRANSGENDER PEOPLE

Exploration of gender identity. This includes determining exactly what one's gender identity is, coming to terms with this gender identity, self-acceptance and individuation, and exploring individual–level ways to actualize this identity in the world. This may also include preparation and assessment for various gender affirming treatments and procedures.
Coming out and social transition. This includes coming out to family, friends, and coworkers, dating and relationships, and developing tools to cope with being transgender in a ciscentric society.
General mental health issues, possibly unrelated to gender identity. The variety of mental health concerns experienced by transgender people include mood disorders, generalized
anxiety, substance abuse, and post-traumatic stress disorder. Source: University of San Francisco, Transgender Health Center of Excellence

MENTAL HEALTH CONSIDERATIONS

Thirty-nine percent (39%) of respondents in a national survey of more than 25,000 genderdiverse respondents (US Transgender Survey – USTS) experienced serious psychological
distress in the month before completing the survey (based on the Kessler 6 Psychological Distress Scale), compared with only 5% of the U.S. population.
Forty percent (40%) have attempted suicide in their lifetime, nearly nine times the rate in the U.S. population (4.6%)
Seven percent (7%) attempted suicide in the past year—nearly twelve times the rate in the U.S. population (0.6%) Source: University of San Francisco, Transgender Health Center of Excellence

A PROBLEMATIC DIAGNOSIS | THE DSM HISTORY OF GENDER EXPANSIVE CLASSIFICATION

First appearance in DSM III – 1980
Continued in DSM 4 + TR
Changed to Gender Dysphoria in DSM-5
It Needs A New Home

DSM III, IV, IV-TR

Repeatedly stated desire to be, or insistence that he or she is, the other sex
In boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing
Strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex
Intense desire to participate in the stereotypical games and pastimes of the other sex
Strong preference for playmates of the other sex

DSM-5 | NOT MUCH BETTER

A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics.
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.
A strong desire to be of the other gender (or some alternative gender different from one's assigned gender).
A strong desire to be treated as the other gender (or some alternative gender different from one's assigned gender).

HOW THE PAST IS HARMING US

Most practicing psychologists and therapists working today learned about Gender Identity Disorder in the previous DSM manuals.
Dropping the "disorder" label is not enough. The presence of the diagnosis in the DSM allows the weaponization and pathologizing of gender-diversity

UNDERSTADNING GENDER DYSPHORIA | AMERICAN PSYCHIATRIC ASSOCIATION

Gender dysphoria involves a conflict between a person's physical or assigned sex and the gender with which he/she/they identify.
People with gender dysphoria may be very uncomfortable with the sex they were assigned, sometimes described as being uncomfortable with their body (particularly developments during puberty) or being uncomfortable with the expected roles of their assigned gender.

A DIAGNOSIS IS NOT REQUIRED

Gender Dysphoria ranges from nonexistent to debilitating based on the individual's gender identity. Just as gender is expansive, one's experience with their body as it relates to their gender cannot be explained or categorized in only one way; this is part of what makes gender dysphoria in the DSM problematic.
For some, particularly those who identify as nonbinary, alleviating the incongruence between their assigned sex and identified gender can occur within gender expression and not medical treatment.
The purpose of a diagnosis of gender dysphoria is to allow access to medical treatment.
A diagnosis of gender dysphoria is not required for an individual to identify themselves as transgender and does not invalidate the legitimacy of their identity.

INSIGHTS INTO GENDER PSYCHOLOGY

Asking a cisgender therapist to understand the incongruence of gender identity and biological sex is either met with false claims of comprehension or resistance to engage. This doesn't mitigate the need to find other transgender people to associate with and normalize our feelings.
Ever-present dissonance becomes the norm for transgender individuals. Considerable mental energy is expelled through conscious considerations of maintaining an inauthentic social persona during every interpersonal interaction.
As difficult as it is for a cisgender individual to comprehend the challenges, it is equally difficult for us to imagine a congruent
experience of identity and body (pre-transition).
Practical applications and examples have the greatest chance of helping cisgender providers understand the needs of the transgender, nonbinary and gender-expansive population.

DON'T PATHOLOGIZING PATIENTS

Attempts to link psychological theories such as attachment or identity development quickly become pathologized and weaponized by those who seek to invalidate the existence of transgender people.
Whether such attempts at exploration of cause are for developing your professional skills, used with patients, or used in general
conversation, The effect is the same – it's suggesting a type of flaw, abnormality or disorder in transgender individuals.

CHILDHOOD DEVELOPMENT | MILESTONE CONISDERATIONS

Gendered expectations begin before birth
Two Years: children begin to recognize the difference between boys and girls.
Three Years: children begin to identify themselves as a boy or girl.
Four Years: children recognize that change clothes or hair doesn't change status as a boy or girl.
Five Years: Most children stabilize in their gender identity.

CHILDHOOD CONSIDERATIONS

Consider how a transgender child might operate in a home. Every interaction, especially those with primary caregivers now become
complicated by a gender identity different from social norms and expectations.
Consider how play is affected, with a gender non-conforming child being placed in groups and settings with people who do not share
their gender identity.
Consider the complications of developing friends; where expectations and institutional sex-segregation determine "appropriate" friend pairings. Deviation from those norms often results in punishment; familial, institutional and social.

CHILDHOOD RELATIONSHIP CONSIDERATIONS

Transgender children often have life-long difficulties making friends, as practice and experience with typical gendered social roles were never experienced.

Example: A transfeminine child who has recently disclosed her identity may feel the desire to interact in groups and circles previously limited to genetically female peers. Behaviors at the time of integration may be socially awkward or problematic, resulting in reinforced feelings of inauthenticity.

The development of a mask, façade, or similar term will commonly be heard in treatment. For many transgender individuals, this mask becomes the method of all interaction, stunting development. Isolation and loneliness as transgender children mature is the norm.

Example: Asking a transgender child, or more specifically the part of their identity they express externally, to participate, compete or interact with those who were assigned the same sex can often results in feelings of not-belonging, not being able to compete or relate, and can generally lead to feelings of not belonging.

For example, a trans girl (AMAB) will be expected to compete physically with the boys in their age-group. This can often result in poor performance, social rejection, isolation, and depression.

CARETAKERS & SYSTEMS

Schools, churches, sports programs, and clubs are excellent at providing gendered experiences based on a child's assigned sex. Each one of these reinforcements, while shown to be beneficial for the cisgender child, adds additional complications to self-understanding, selfconfidence, and typical identity development for transgender kids.

The number of social supports a transgender child has access to ranges from limited to non-existent.

ADOLESCENT + ADULT EXPERIENCE

AFFIRMING CARE

We have seen therapies designed to bring a gender identity in line with the assigned sex fail and be legally classified as an
abusive practice. Conversion therapy doesn't work.
The necessity for development, exploration and acceptance are just as critical in later stages of life as they are in childhood
development.
Especially for adults, exploration will typically result in anxiety and depression symptoms. Typical exploration of trying on
different names, pronouns, hair styles, clothing options, and beginning to explore gendered spaces that match their gender
identity can be harrowing and potentially (likely) dangerous.

AFFIRMING CARE EXAMPLES

Appropriate names and pronouns will be used as directed by the patient. This may include using an alternate name and pronouns depending on audience.
A provider will not distinguish between cis or transgender status, rather accepting the patients gender identification as
their actual objective gender.
A provider will understand that identity concerns or disturbances are generally related to the experienced trauma of identity suppression.
Identity exploration is now an option for patients. The provider is there to help facilitate that process, even if it means providing an hour of space to explore.

ADDRESSING TRANSPHOBIA

Despite still being commonly used amongst therapists, the concept of internal homophobia and internal transphobia should be avoided at all costs.
Transgender individuals report that such connotations fuel a sense of self-loathing, doubt, and increase suicidality.
Initial in-real-life interactions with other transgender-identified people can be precarious and anxiety inducing. Trans patients report feeling intense anxiety in the lead up to, and throughout the first encounter with another member of the transgender community.

It's reported this fear is often associated with concerns of exposing their authentic selves to another. As with any treatment, the more exposure a patient can achieve the faster they overcome these fears.

Respondents (USTS) indicated an element of this fear is giving power-to-harm to relative strangers. Knowledge of somebody's transgender status or identity who is not out is an easily-and-oftenweaponized tool of power and control.

GRIEVING A FAÇADE

While transition can bring a great sense of relief and balance into a person's life, and in addition to losses outlined so far, a
sense of personal loss will typically be experienced.
For transfemme patients, one of the most common periods of transition is near retirement and transitioning often means recognizing the death of the former identity.
The façade through which the world was viewed and interacted with was a valuable protective and coping tool. It's hard to let go of something that has provided you protection for so long, and which may have been the vehicle to professional and personal accomplishments.

THE SECOND PUBERTY

For both transmasculine and transfeminine patients, the administration of hormones brings on the effects experienced during a typical adolescent puberty. This second puberty does not come with the benefit of being surrounded by peers who are undergoing similar experiences. This can lead to greater anxiety, isolation, and mood swings.

Integration into groups or communities where transgender individuals can develop friendships is critical to achieve successful mental health outcomes.

APA GUIDELINES FOR CARE OF Transgender Gender Non Conforming Patients

Psychologists understand that gender is a nonbinary construct that allows for a range of gender identities and that a person's gender identity may not align with sex assigned at birth.
Psychologists understand that gender identity and sexual orientation are distinct but interrelated constructs.
Psychologists seek to understand how gender identity intersects with the other cultural identities of TGNC people.
Psychologists are aware of how their attitudes about and knowledge of gender identity and gender expression may affect the quality of care they provide to TGNC people and their families.
Psychologists recognize how stigma, prejudice, discrimination, and violence affect the health and wellbeing of TGNC people.
Psychologists strive to recognize the influence of institutional barriers on the lives of TGNC people and to assist in developing TGNC-affirmative environments.
Psychologists understand the need to promote social change that reduces the negative effects of stigma on the health and well-being of TGNC people.
Psychologists working with gender-questioning and TGNC youth understand the different developmental needs of children and adolescents, and that not all youth will persist in a TGNC identity into adulthood.
Psychologists seek to prepare trainees in psychology to work competently with TGNC People.

ADDITIONAL CONSIDERATIONS & KEY CONCEPTS

The experience of gender dysphoria is not disordered, does not in itself increase mortality and is recognized by every major medical and mental health organization as a treatable condition with positive health outcomes.
Though the typical age of gender identification is in early childhood, a lack of information, inability to explore, and
countless other factors (culture, religion, school, etc..) may impede the process of recognizing one's gender identity. As
such, a transgender identification later in life is not uncommon.
While it is true that many who experience feelings of gender incongruence as a child report developing a sense of self in
their birth sex; this must not be used as justification to deny affirming care, puberty blockers, or transition assistance to the
25% of youth who maintain a consistent transgender identity.
Interaction with others in similar states of gender incongruence is crucial to developing a positive sense of self and identity,
as well as social support and community.

AND MOST IMPORTANTLY

Happiness is attainable.