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The world needs more trans therapists

To transition, trans people have to see therapists. But those therapists rarely understand the experience of being trans.

Dec 3, 2021 UPDATED

How much influence should any one person have over another’s body? Why are there gatekeepers to gender affirmation?

As a trans woman, I’m both fascinated and directly affected by how much influence therapists and other mental health professionals have over trans people’s transitions. Though often earnestly invested in helping transgender individuals live authentically, most therapists have no idea what gender dysphoria feels like. 

The experience of being trans is not an academic exercise. To be understood, gender dysphoria must be experienced, not just theorized about and studied. Without an effective understanding of the experience, a provider might not diagnose a person with gender dysphoria—and without that diagnosis, that person would struggle to access vital care.  

Why is the gate to medical treatment kept almost exclusively by those who will ask me to prove I’m “trans enough,” according to criteria created by cis people? Where are the therapists who understand the trans experience firsthand?

To be understood, gender dysphoria must be experienced, not just theorized about and studied.

I started medically transitioning in 2018, as a first-year grad student at a notoriously progressive institution that was, thankfully, equipped to handle transgender issues. When I called the university's medical center to set up a consultation, excitement and anxiousness washed over me. Despite supporting many transgender friends through their own transitions, I didn’t know what to expect from the meeting. 

My doctor, a cis woman, was knowledgeable and sympathetic, taking time to carefully explain what medically transitioning would entail. I was told that male-to-female hormone replacement therapy (HRT) might increase my risk of blood clots, because of the effects of estrogen.

I also learned that if I ever stopped HRT, some of the physical changes it created, like breast development, would be permanent. I was given an informed consent form to sign; if signed, I would start HRT aware of the potential risks. 

The following week, a bottle of estrogen sat on my coffee table. 

This was only the beginning of my experience. It wasn’t until I began considering further  gender-affirming treatments, and saw more cis clinicians, that I realized how underrepresented my community is in medicine. 

I can not describe how reassuring and affirming it is for your doctor to literally feel your pain.

To undergo gender affirmation surgeries, (like vaginoplasty, subcutaneous mastectomy, facial feminization surgery, etc.), a trans person needs the written approval of a mental health professional in accordance with WPATH guidelines.

Many trans people who are treated by cis doctors don’t receive the informed and compassionate care I did. 

What are WPATH guidelines?

The World Professional Association for Transgender Health (WPATH), sets criteria known as the WPATH guidelines: “internationally accepted Standards of Care (SOC) for the treatment of individuals with gender dysphoria.” 

Available in 19 languages, the organization’s guidelines are implemented by therapists and doctors with the goal of helping them understand gender dysphoria, work out how to diagnose a transgender person, and determine how mental and primary care should be provided. 

For example, in WPATH’s handbook, the section “Options for Psychological and Medical Treatment of Gender Dysphoria” explains that HRT can be used to “feminize or masculinize” the body, and that individuals can engage in psychotherapy to build “social and peer support.” 

Another section titled “Competency of Mental Health Professionals Working with Adults Who Present with Gender Dysphoria” lists out the qualifications practitioners should possess before working with trans people. 

They recommend skills like “Competence in using the Diagnostic Statistical Manual of Mental Disorders (DSM) and/or the International Classification of Diseases (ICD) for diagnostic purposes,” having the ability to recognize and diagnose mental health issues other than gender dysphoria, and having a master’s degree (or equivalent) in “a clinical behavioral science field.”

trans therapist books

And then there’s section five: “If Applicable, Assess Eligibility, Prepare, and Refer for Surgery.” Section five gives guidelines for how a surgery letter—a letter written by a medical professional giving the “green light” on gender-affirming surgery, which is required for trans individuals to obtain these treatments—should be approached and supplied. 

Guidelines include ensuring potential patients have realistic expectations of surgery outcomes, sufficient aftercare procedures established, and full knowledge and opportunity to take advantage of their reproductive options. (For instance, trans women undergoing vaginoplasty or orchiectomy must be informed that in order to have biological children, they must freeze their sperm before treatment.)

To undergo gender-affirming genital surgeries, patients must obtain two separate referrals from two different mental health professionals. 

The American Psychological Association has similar guidelines and recommendations for assisting people with gender dysphoria. 

A diagnosis of gender dysphoria is itself also a requirement of obtaining many gender-affirming treatments, both surgical and otherwise (such as HRT and masculinizing or feminizing voice therapy).

Despite some recent advancements in policy and understanding, transgender people haven’t had the best experiences with hospitals, medical professionals, and insurance companies

In fact, the medical system can be outright hostile to trans people: 28% of trans people report having been harassed in medical spaces. 

 The truth is, our healthcare system all-too-frequently misunderstands and mistreats trans people—and it has dangerous consequences. Considering these circumstances, trans people are often hesitant to seek medical attention, fearing potential discrimination and abuse. 

Given the current political landscape, the fact that some doctors and medical professionals care enough and are informed enough to focus effectively on transgender physical and mental healthcare is a huge success for LGBTQ+ equality. But in a medical space directly addressing people's gender identity, it’s vital to have transgender people represented in the workforce who can look beyond diagnostic criteria, and through the lens of personal experience. 

Involving more providers with firsthand understanding of trans experiences would likely reduce the loneliness and mistreatment trans people face when seeking treatment, and this is a crucial step for inclusive healthcare.

trans therapist infograph

Throughout my transition, I’ve worked with multiple doctors and therapists to plan my HRT process, schedule surgery plans, and get my letters. Only one is transgender.

I can not describe how reassuring and affirming it is for your doctor to literally feel your pain, to know from both training and experience the answers to questions like “is it normal for my breasts to be sore?” or “will the injections hurt?” I have panic attacks at the thought of referring to certain body parts; my doctor understood and respected that without hesitation, and it vastly improved my experience

Is this fair? Should anyone have the right to decide whether a transgender or gender non-conforming person is “allowed” to transition? That’s another essay.

But for the moment, it’s the reality and system we live in, and the fact that most trans people need the permission of someone who hasn’t lived with gender dysphoria in order to live their lives holistically must change, and that change can start with more trans therapists.

Article originally published Nov 5, 2021. Updated Dec 3, 2021.

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