Universal Transition Therapy: Common Sense or Assumption of Inferiority?

[suzifrommd]

Universal Transition Therapy: Common Sense or Assumption of Inferiority?

By Suzi Chase, 2/9/16

https://www.susans.org/2016/02/09/universal-transition-therapy-common-sense-or-assumption-of-inferiority/

So what are we to make of the oft-repeated advice that it is unwise to contemplate a gender transition without psychotherapy? This admonition goes beyond, "many have found it helpful," and even beyond, "problems may arise that therapy could help solve." As someone who has transitioned, I would wholeheartedly support both those.statements. I also support psychological screening before prescribing transition-related medical care to ensure competence to understand the practical consequences of the decisions involved.

Saying all transitioners should seek therapy goes far beyond that.

It expresses the certainty that a trans person is, by their very nature, incapable of making decisions about their gender or handling the stresses involved.

[Michelle-G]

This is an interesting premise, but I think some of your conclusions might benefit from a little scrutiny.

Anyone can transition without any medical or psychological intervention whatsoever. It happens all the time and it's pretty much been happening since the dawn of history. Medical and mental health interventions are only prescribed when GRS is desired, and even then there are surgeons who will offer this procedure using an informed consent approach. Not many, but they're out there.

GRS is certainly not a requirement for a successful transition, and more and more people, particularly younger trans folks, are choosing not to do it. No therapy needed or prescribed.

Saying that similar advice is not given to cisgender people undergoing comparable changes is just not true. In the first place, comparing GRS (or even non-op transition) to a job change, a move to another country or beginning college is an inadequate comparison. These things are significant events, but they are not necessarily life-changing nor are they irreversible. A better comparison would be that of a terminally ill patient who desires to end their own life under a sanctioned Death with Dignity process. Before the life-ending medications are administered there is most certainly significant psychotherapy. This is not to express that the patient is incapable of making this decision, but rather to validate that he or she is, in fact, capable of making the decision and has done so with a sound mind.

One final note - psychotherapy does accompany, in one way or another, several of the stressful life transitions you mentioned. Most universities do have mental health centers that offer students and faculty free or low-cost therapy, mental health counseling is available to inmates, national guard soldiers can scarcely go a day through the deployment and redeployment processes without being offered counseling (and this happens in country as well), and in many social work, psychology and professional counseling programs therapy for students and interns is encouraged. In some internships and agency placements it is required.

[kira21 ♡♡♡]

I don't think she is talking about services offered, she is talking about services that are mandatory.  In most places that's pretty HRT. You can't compare going on HRT to end of life decision. It is definitely more on the level of life changing, than life ending in seriousness.

[sparrow]

I think it's common sense.  Transitioning is an immensely stressful process.  Having a safety net is a no-brainer.  It's like suggesting that all couples sign a prenup before they get married.

I've got a counsellor, not a therapist.  They know the lingo, they're well-connected to the community so they have good resources, etc.  Super useful.  Most often, I talk with them about stress and relationship stuff.

[AnonyMs]

I can't say I agree much with this one. That's a bit of a novelty as I usually pretty much agree with everything Suzi posts.

The WPATH SOC states itself Psychotherapy Is Not an Absolute Requirement for Hormone Therapy and Surgery which kind of undercuts the entire premise of the article.

I've seen numerous times online people recommending others get therapy. Its generally in response to questions people are asking, where you can tell they need someone to talk to. That's often why people go in these sorts of forums.

Who's is it saying "you need therapy"? Online in forums its said a lot (including by myself), but its generally in response to questions people are asking. You can tell they need someone to talk to. Apart from that who is saying this where its obviously not necessary? Not many people know I'm trans so perhaps I'm missing something, but I'm not aware there's a problem.

[stephaniec]

well here's my 1 cent. There seems to be a division in how people see therapy some see it as flawed and useless for whatever reason , bad therapists or immovable mental walls or some other reasons people don't like therapy, such as how is someone else ie a stranger able to understand me. then there is the other group that I admit to be apart of who have found immense benefit from therapy. I admit to having a excessive amount of it because I've had no one else in my life. Therapist have saved me from taking my life and sorting out problems so I see therapy as very beneficial in dealing with issues.. Neither approach is more valid other then for each individual, but that's where the problem lies. Both sides of the fence have their own valid reasons. When one side of the argument gets the upper hand through the powers of the medical authorities and forces the other side to comply rightly or wrongly then you have this schism .

[Michelle-G]

I don't think she is talking about services offered, she is talking about services that are mandatory.

But it's not, as AnonyMs has pointed out.

[Stevie]

 I saw a gender therapist three times.  I was already presenting as female fulltime on the first visit and she said she would give me the recommendation to start HRT but she said she was required to see me two more times before she could.

[kira21 ♡♡♡]

But it's not, as AnonyMs has pointed out.

What's not what?  Sorry,  I don't understand!

Many countries require therapy as part of the process. As someone pointed out, it's not a requirement of wpath,  but rather a decision that the healthcare system has made that we are not capable.

Don't get me wrong, I hear the arguments for why it's highly likely to be beneficial, but I agree with suzi,  why is it compulsory? Why can't I decide for myself if I need it. 

I say 'I',  I am past that stage  and wasn't even so much as talked to about therapy. I was diagnosed,  no therapy.  I actually would have liked to have been offered some, but I would have resented having it forced on me,  like I wasn't able to even think about transition without therapy to work my head out. When therapy is compulsory then it assumes your head is unsorted. If the assumption was that you would likely want therapy, then it would be optional.

[AnonyMs]

Many countries require therapy as part of the process. As someone pointed out, it's not a requirement of wpath,  but rather a decision that the healthcare system has made that we are not capable.

Don't get me wrong, I hear the arguments for why it's highly likely to be beneficial, but I agree with suzi,  why is it compulsory? Why can't I decide for myself if I need it. 

Some countries and/or doctors require it, some don't, but its definitely not universal. In the USA informed consent without therapy seems quite popular. Its not the healthcare system that deciding this, but individual doctors. I'm not really clear on whats required in Australia but I suspect its a mix. Most of Europe sounds quite appalling.

I don't particularly agree with WPATH myself (I want medical informed consent SRS in it, no RLE), but its a whole lot better than what some doctors practice. I think a more interesting article would be why some countries/doctors don't follow the "best practice" WAPTH.

Personally I had therapy of my own choice, and it was helpful. I started HRT as soon as I decided I was ready, which unfortunately took a year. I can see some people not needing it.

[JLT1]

Estrogen and testosterone are both controlled substances.
Without therapy, one would be going into a doctor and demanding a prescription for a controlled substance for a condition that the doctor cannot or is incapable of making a medical diagnosis on. 

It us true that some doctors will prescribe pain medication for conditions that have not been completely diagnosed.  However, pain meds do not do what HRT does.

Jen

[AnonyMs]

Hi Jen,

I don't follow. Are you discussing what should be, or what actually exists today?

What exists today is no universal requirement for therapy, as evidenced by informed consent and WPATH.

[Michelle-G]

Estrogen and testosterone are both controlled substances.

No, they are not. The lists of controlled substances (there are 2) are readily available with a quick web search.

Without therapy, one would be going into a doctor and demanding a prescription for a controlled substance for a condition that the doctor cannot or is incapable of making a medical diagnosis on. 

Also not true. First, therapy is not required. Second, that assumes that the doctor has insufficient training to prescribe.

What is the condition? Hormones do not treat gender dysphoria. Hormones realign the internal chemical configuration of a human body toward a desired outcome. Most physicians have the training and skills to do this to some degree, and endocrinologists do this even better.

Diagnosis of gender dysphoria is a separate issue altogether and hormone treatment may or may not be desired by the patient.

[kira21 ♡♡♡]

Estrogen and testosterone are both controlled substances.

No, they aren't controlled here either.

Without therapy, one would be going into a doctor and demanding asking for a prescription for a controlled substance treatment for a condition that the doctor cannot or is incapable of making a medical diagnosis on.

You're are right to some extent... Like the psych who did my referral said to me 'the whole process of diagnosis of gender dysphoria is largely redundant; To diagnose gender dysphoria, I ask you if you are gender dysphoric and you diagnose yourself'.

It us true that some doctors will prescribe pain medication for conditions that have not been completely diagnosed.  However, pain meds do not do what HRT does.

Jen

I guess, that's very similar to pain medication as well as depression and a variety of other conditions. In order to diagnose pain, I ask you if you are in pain and pain meds can be very serious too you know! So can antidepressants, very serious indeed.

And many doctors are used to HRT drugs. Also doctors are called upon throughout their career, to deal with conditions that they haven't encountered and to adopt new drugs and approaches that they haven't used before. That shouldn't be an excuse.

In my opinion, diagnosis for gender dysphoria is done through self determination. You don't need to be lead to it, some people know, so therapy should be optional. Treatment is done with well tolerated drugs that have been widely used, with relatively predictable effects, in comparison to other drugs to treat other conditions. 

[babyava]

I truly enjoyed the article and the thoughts that came from considering it.  I think the perception of therapy is one that must be changed within this.  To receive therapy is not a sign of weakness.  For some it is entirely appropriate as a step in gaining strength.  For others it is entirely appropriate as a step in gaining growth, and others it is a step in gaining a sense of security and confidence in who they are.  None of these necessarily constitute weakness. 

As for the examples of those who do not receive therapy before being placed into stressful conditions, it probably would also be a good idea, but first we have to overcome this stereotype, ironically, that therapy is an admission of weakness. 

[kira21 ♡♡♡]

And something that should optional not mandatory. Even if it's a positive thing, you are still saying 'you need this positive step because you are by default in need of support'.