- • Gender dysphoria (dissatisfaction/confusion in relation to gender)
- • Atypical gender identity disorders
- • ‘Post-op regretters’: transsexuals who have had surgery but no longer identify with ‘trans’ identity
- • Dual-role transvestism (cross-dressing without wish to change sex)
- • Fetishistic transvestism (cross-dressing associated with sexual excitement)
- • Autogynaephilia (biological males with the sexual fantasy of having female sex organs)
- • Autoandrophilia (biological females with the sexual fantasy of having male sex organs).
Specialist psychotherapy services for gender identity and intersex conditions
At present, psychotherapy services dedicated to patients with gender dysphoria are limited. Gender dysphoria remains outside of the clinical experience of many psychotherapists who often find themselves under- /over-attending to the condition where it presents. Counselling exists in many gender identity clinics, but often this is limited only to helping those patients undergoing gender reassignment to acclimatize to their chosen (usually binary) gender role, rather than an exploratory type of psychotherapy aimed at those with differing forms of gender dysphoria, for whom gender reassignment may not be an option or goal.
The outpatient specialist psychotherapy service for patients with gender identity conditions and also the specialist psychotherapy service for people with intersex conditions described here are currently unique services and are provided by the Priory hospital Roehampton as an independent provider to the NHS. The services are open to referrals from patients across the entire UK and further if the patient is able to attend for therapy.
Aims of a specialist gender identity psychotherapy service are
- • To facilitate understanding of gender and how it relates to themselves and others (e.g. what do they mean by ‘always felt female’? Male/female are not feelings)
- • To reduce the degree of preoccupation and accompanying distress and unhappiness associated with their gender conflict or confusion
- • To enable the person to come to a specifically tailored gender identity, which they feel to be relevant to them, and help them to achieve a degree of stability in that gender identity.
Aims of gender identity psychotherapy ARE NOT
- • To persuade/encourage persons to undergo gender reassignment
- • To dissuade/discourage persons from undergoing physical interventions for gender reassignment (hormones/surgery)
- • To help people to appear or behave or ‘pass’ as a certain gender.
Delivery of therapy
- • Assessment: ascertain the type of gender identity condition, associated conditions relating to sex, gender, and sexuality, patient personal history and context of gender presentation, and any additional mental health problems.
- • 1:1 sessions: the patient is seen on an individual basis by the therapist who is later to be their group therapist in order to build a rapport before eventually joining the weekly group.
- • Group: weekly slow-open group dedicated to patients with some form of gender identity condition.
Specially adapted therapeutic model
(See Group therapy and group analysis in Chapter 2, pp. 42-7, and in Chapter 5, pp. 188-94; Mentalization-based treatment in Chapter 2, pp. 66-70, and in Chapter 5, pp. 229-34.)
This comprises elements of group analytic psychotherapy and MBT in a slow-open small group (approximately eight patients) with one therapist.
Patients in the group may have any condition relating to their sense of gender identity and would have undergone an assessment and a period of individual sessions with the group conductor prior to their joining the group. Therapeutic interventions are directed to individuals within the group, in addition to the group as a whole. Any member of the group, including the conductor, and not merely the conductor alone, may offer therapeutic interventions to any member of the group or to the group itself. It is up to the conductor to maintain the therapeutic setting and boundaries and to ensure that the subject of gender is mentalized with the group. Patients would typically remain in the group for 2 years.
MBT-Gender: mentalizing gender
Preconceived ideas or notions of gender offered by any of the patients in therapy are open to be considered, questioned, and examined by the therapist or the group. Examples include what it means to be a male or female and what a person means by ‘masculine’ or ‘feminine’: ‘I was very ‘girly’ as a boy ...’, ‘I like wearing very feminine clothes ...’, ‘I used to like boys sports .’
The group are discouraged from making assumptions in relation to gender, in terms of emotions, behaviour, or appearances, and are encouraged to consider a more diverse heterogeneous spectrum within gender and discouraged from restricting themselves to caricatured gender stereotypes.
Qualities of the therapist
The therapist must have the following qualities:
- • Comfortable working with persons with an array of sex/gender presentations, including those who have undergone physical sex reassignment interventions
- • Open-minded and accepting of persons with differing and diverse identities relating to their sex, gender, and/or sexuality
- • Their understanding of gender should not be limited to binary identities or caricatured stereotypes, but be familiar with more atypical/fluid/non-binary gender identities
- • Familiar with running therapy groups
- • Familiar with the principles of MBT.
Common themes: 'parallel processes’
The following themes have been observed, when running a specialist gender identity psychotherapy service. The themes were observed in:
- • The patients having therapy
- • The therapeutic process itself/in the therapist
- • As a dynamic within the organization delivering the therapy
- • As an organizational dynamic between organizations involved with the gender patient.
The observed themes were as follows.
Binary rigidity (examples)
- • Patients’ rigid understanding of gender roles
- • Patients switching between binary gender identities during the therapy
• Professionals being drawn into adversarial stances of ‘for’ or ‘against’ gender reassignment or mistakenly being perceived as occupying such positions.
Genital centrality (examples)
- • ‘Everything would be fine if only I had a vagina’
- • Clinicians mistakenly believing ‘nothing can be done’ therapeutically for those who have undergone genital sex reassignment surgery
- • Setting up groups for ‘pre-op’ or ‘post-op’ patients, rather than mixed groups.
- • In the patient: in relation to their identity
- • In the therapist whose patient’s appearance dramatically changes during the course of therapy
- • Which gender pronouns to use
- • In the organization: allied professionals not readily able to think about gender identity disorder/complexity.
Questioning of authenticity (examples)
- • Concern whether others will perceive them authentically in their chosen gender role
- • Patient feeling ‘inauthentic’ in original gender role, but later feeling similarly inauthentic in the post-operative transgender role
- • Professionals questioning the validity of psychotherapy for gender identity patients.