Increasingly, the idea that no one size fits all is a critical reminder. As therapists we are working with people, not labels or categories.
What is the therapist’s responsibility in a person making a decision that they later regret? Gender Specialists are not in the business of telling people that they should transition. We can’t know what someone else SHOULD do. What we can do, is provide information that we have learned and share our experiences with people so that they can make a decision based on the most recent research and whatever wisdom we have picked up from our clients and friends along the way. Our job is to assist people to make the best decision regarding gender expression and behavior for themselves at this moment, in this context. We do not make it for them.
We do not stamp clients with a pink seal or a blue seal, affirming that they are male or female. Only an individual can know this about themselves. We do evaluations, not write letters. Letters are the result of an evaluation. Evaluations are complicated and serious experiences.
As a therapist, I rely on the information that a client gives me. If he/she/ze gives me a false narrative designed to convince me to sign a letter for transition related care, I cannot do my job. The issue of gatekeeping is truly problematic. In truth, I do not care what decisions any adult makes about their body. I do care if I am asked to be involved in their process. If I am the therapist or assessor, I provide information, education and experience to them and we work together to understand their experience and their situation so that I am comfortable that my assessment or evaluation is as accurate as it can be for this moment in time and this context. I need to be comfortable providing them with an assessment that says they are capable of informed consent and knowledgeable about the process and that the procedures will likely decrease their dysphoria. I cannot know that this is true and that is why it is likely and not will.
Not everyone who wants to transition will benefit from a cookie cutter approach. First socially transition, then hormonally transition, then legally transition and then surgically transition. There is no correct way to transition. It’s all individualized.
For instance, if a person does not feel like a girl that doesn’t necessarily mean they are a boy or that if one doesn’t feel like a boy, that they are a girl. They MAY be. They may also be a pink boy or a girl who has interests or behaviors that are outside of sex stereotypical interests and behaviors. We live in a context of sexism and a gender binary. We would have to get to know that person and do an assessment WITH the person about who they are and what they understand and what they expect and what they want.
We should be in the business of assisting people to find themselves on the gender spectrum. That they may be at one of the poles on the gender spectrum or they may be somewhere in the middle. Only the individual themselves can know this. Our society has a propensity to need to have people in categories so we know how to relate to them. The first things we identify are gender and race here in the US because we relate to men and women differently and to people of different ethnic or racial identities differently. If one belongs to the GLBT community, we might also try to figure that out early because they will relate to people in that group differently than in heterosexual groups. (This DOES NOT mean we do this with everyone all the time. This is a generalization.)
If a clinician has an older binary view of that every transgender person is a person born in the wrong body, they will make problematic recommendations. If a clinician has a view that people should all just adjust to the body they are born into, they will make problematic recommendations as well. Action can be a problem and inaction can be a problem. It is appropriate action and response that is the goal of good therapy.
Clinicians need to have a spectrum oriented view. There are people who believe they were born in the wrong body and since childhood have known this. They are a boy or they are a girl and when they are able to access transition related activities, the distress they feel about their bodies is greatly reduced. This doesn’t mean they will be 100% well-functioning and never feel depressed or dysphoric again. Being able to access transition related activities and procedures does not repair a life time of trauma nor a lifetime or being mis-seen, misunderstood, mis-mirrored. It cannot fix whatever has already happened. It also does not mean that the social context within which the person lives, will change. It may mean a person has the legal right to be treated and seen as themselves but that will not make people abide by that. Parents who rejected a child and said perhaps, you are a boy you will never be a girl, you have a penis, you don’t have breasts, you are a boy, likely will not embrace that child once that child has breasts and no longer has a penis but has a vagina.
It’s critical in our work to ensure that we are assisting a client to understand the repercussions of the decision that they are making to the best of our abilities. Quite often, people will have a fantasy view that changing their body will fix all that has been wrong in their lives. It changes what is between their legs or how their chest will appear. It does not change the social context. There is no magic in changing ones body.
If it improves what it feels like to be in shower, what it feels like to be in a locker room, what it feels like to be with friends, with sexual partners, what it feels like to be that individual inside a body that better resembles their gender identity then that is generally a positive choice for an individual to make. Does it decrease dysphoria?
If one expects it to improve how other people behave, that ranges from unlikely to depends on the context and if one is perceived to be transgender or transsexual. If someone is perceived to be the gender that they are, they very likely will experience less distress. They may have different distress related to the fear of being “outed” or discovered. That can be an entirely new anxiety an individual experiences.
Regret: feel sorrow or remorse for an action one has taken or not taken.
Regret is a complicated issue. Regret generally does not cause clinically significant distress. It causes sadness, disappointment, sorrow—compunction. Growing up my father would talk about how my brother had to learn things the hard way. Often people have to have a certain experience to know they do not want to have that experience. Some people only learn by doing. Some people cannot imagine what an experience will be like whether it is living as male or having children or moving to Florida. They cannot imagine, predict, anticipatorily experience a different state of being or experience.
For some people regret over a choice they made about gender expression is like that. They cannot know what it will help or address and what it will not until they do it.
There is a difference between making a decision at twenty that with forty year old eyes and 40 year old wisdom, one wishes that one did not make.
If at twenty, there was information that was then known and available, that at twenty one would have made a different choice then that is an area where something failed in the education and informed consent process. For instance, if a person was not adequately informed that taking hormones will likely adversely effect sexuality or sterility, something failed in the informed consent process. If they did not know their wife would leave them five years into their transition after promising that transitioning wouldn’t effect their relationship that is not a failure in informed consent, that is an issue about the partner’s self-knowledge or the relationship. Often what people regret, when it’s not the appearance of their body, is that they lost relationships and community and jobs because of the transition.
If I have seen someone and they give me a typical trans narrative and not the truth of their experience, then the evaluation will be in error. There may be no way to discover the information is not fully accurate. If I see someone and they later change their mind, am I at fault because I did not identify that they might change their mind?
Additionally, I know that clients have signed paperwork that describes the risks and benefits of hormones and at the time they begin to take hormones, they are so excited or so anxious, they do not pay attention to what they are signing or what their medical provider has said. This is true for many procedures or experiences. For instance, as general mental health practitioner, I often have to coach people about what to say when they see a psychiatrist. When the psychiatrist asks, how are you, they say fine and not that they have been morbidly depressed most days in the past month. They are not being deceptive, simply answering the question asked in that moment. They are anxious and forget what it is they want to talk with the doctor about.
So what should therapists be held responsible for when people regret making a decision about changing their body? It is a very complicated question I think. If we tell someone unequivocally that transitioning will improve their life, we are not doing our jobs. If we do not tell them that there are procedures that could improve their dysphoria, we are not doing our job. If we write a letter without an evaluation, we are not doing our jobs. If we only know about the binary and not the spectrum we are likely not doing our jobs. We should also know the details of the surgery and truly be able to describe the risks and benefits in a way that the individual client understand and truly can provide informed consent.