Over the past couple of years, I have come to develop a growing interest and expertise in working with gender variant children and adolescents experiencing Gender Dysphoria and related issues. I thought it was about time that I write a little blog about issues in transgender mental health and how a psychologist can help.
Gender Dysphoria is a sense of unease and dissatisfaction with the biological sex one is born with. Gender Dysphoria can mimic other mental disorders like anxiety, depression, social withdrawal, etc. This discomfort often acts as a catalyst to change one’s body and gender expression (how one presents to the world) to be more in accordance with one’s gender identity (the gender that one feels oneself to be).
I find this graphic useful in providing an understanding of the differences between biological sex, sexual attraction, gender identity and gender expression:
Early childhood - Some children start displaying a preference for gender variant behaviour at a young age. Many parents are unsure about how to respond to their child's desire and worry about the impact this preference could have on their school and social lives. Most young children who display "cross-gendered" behaviour do not go on to become transgendered adults.
Puberty is a time when the body begins to change and adapt gender specific features (breasts, changes in genitals, voice, hair growth, menses, etc.). Most transgendered individuals report experiencing intense dysphoria when their bodies begin to change. Many transgendered individuals become more aware of their identity by this age, but lack the financial resources and power to make any significant changes.
Medication is available to “delay” puberty until the individual is old enough to decide whether or not to transition. This has the benefit of essentially avoiding the trauma of experiencing the physical effects of puberty in the unwanted gender. When the adolescent is old enough to make an informed decision about the risks/benefits of hormone replacement therapy (HRT), puberty can commence in the gender of preference.
Early Adulthood – With emotional and financial independence some people feel free to begin to address transgendered issues and look into transitioning. However, some are not as free to do so, due to family, financial barriers and lack of access to services.
Later Adulthood – Some transgendered individuals delay transitioning until later in life when they feel able to do so. This can be satisfying, but can also have the disadvantage of producing a less physically "passable" outcome. Furthermore, these individuals often regret having waited so long to transition and friends and family may have difficult time adjusting to the changing identity of someone they have known for so many years.
Deciding what to do – Making decisions about transitioning, what level to transition to, or whether to attempt any transition at all require time and support. There are fears of how one will be accepted by family (parents, partners, children, grandparents and others), friends, colleges, fellow students, etc. There can also be anxiety about ‘passing’ or how convincing one will be to others as a man or woman (i.e. whether or not one will be “read” as transgendered). It is important to note that there is no singular path that every trans person takes. They each have different experiences and make different decisions. Some individuals assume an identity as “gender queer” or “gender neutral” and some decide not to transition at all.
Transitioning – For those transgendered individuals who decide to transition (to present and live in the other sex outwardly), these emotional/psychological issues may come up:
Psychotherapy can help transgendered clients as they travel through the process of finding fulfillment in who they are.
A recent longitudinal study conducted by researchers at Boston College found that teens who participate in the arts (music, theatre, fine arts) are more likely to report feeling depressed than students who are not involved in these programs. In contrast, students who are involved exclusively in sports are the least likely to report depressive symptoms. Interestingly, those students who participated in arts and sports are still more likely to feel sad than those who participate in sports alone.
Why is this?
I recently spoke to a group of high school students about suicide. As I was speaking, I came to the realization that a lot of people are uncomfortable talking about it. In fact, the teacher asked me to come in to address the class because she herself was unsure about how to broach the subject. Suicide rates (including both attempted and completed) among Canadian young adults and adolescents are alarmingly high. Check out the Statistics Canada information here if you are interested in the figures.
One of the problems is the stigma so often attached to the topic. No one wants to talk about it. If someone does commit suicide family members and friends speak about it in hushed tones. Everyone judges the "suicidal girl" at school (or the colleague with "mental problems" in the work place). But, considering suicide is something that can happen to any person, no matter their socio-economic status or past history it is worthwhile for every person to know what to do or say to a friend or loved one who is at risk. After all, would you rather have a somewhat awkward conversation or a dead friend?
A great number of people who commit suicide do so without talking to a professional first. Friends and family are usually the first to notice that something is amiss. Keep your eyes open for warning signs like depression, hopelessness, increased isolation, and self-blame. And don't be afraid to ask if they are thinking about killing themselves. You could save a life.
Many of us struggle with our relationship with food. We need it for nourishment, but too much or too little can cause gigantic problems. For some, food brings a sense of comfort or warmth (e.g. herbal tea, chocolate). Researchers suggest that this is due to the chemical make up of the food we are eating.
New evidence suggests that some flavours such strawberries, chocolate, blueberries, tea, raspberries and more systematically enhance our mood because of their structural similarity to valproic acid - a chemical found in medications that are used to treat mood instability. So the next time that you are feeling down, grab a handful of blueberries and munch away.
My somewhat eccentric, but altogether inspirational 80-year-old grandfather decided that he would climb Mount Katahdin this spring. I had never hiked a mountain and decided to accompany both him and my father on the trip. I am by no means a hiker or an outdoor enthusiast. My typical fitness endeavours include walking up the stairs at work and mowing my lawn (it's not a big lawn). I did nothing to mentally or physically prepare for this trip and suddenly found myself at the bottom of a 4902 ft mountain. To put it in perspective, the CN tower is 1815 ft tall. And to make matters worse, we decided to hike on a weekend when the easiest trails were closed. The trail we hiked was one of the most difficult on the mountain - almost vertical the entire way (4902 ft in 3.2 miles). In the 8 hours that ensued, I had plenty of time to muse about my experience and how it resembles the process of overcoming mental health difficulties. Allow me to explain.
Often times you aren't prepared.
As I mentioned above, I was in no shape to climb a mountain. I hadn't prepared for this. I suppose I could have trained, but life is busy and I decided to do it on a whim. Mental health difficulties can take us by surprise. We usually aren't prepared for emotional problems that arise and don't know effective strategies to deal with them.
Sometimes your only option is to take the hardest trail to the top.
It would have been much easier if we were able to take an less difficult trail, but unfortunately, they were covered in snow and dangerous for hikers. When I got home, I talked to many people who had reached the summit on other occassions, but managed to do so by taking a less strenuous path. This option was quite simply unavailable for us.
When mental health problems arise, some people are able to recover more quickly than others and do so with minimal effort. For example, some people respond very favourably to a particular medication or therapeutic modality and find relief rapidly. Others struggle for years to find the right formula for recovery and stumble along the way. Some of us have to take a more challenging route.
First view of the summit.
From the bottom it seems impossible.
The trail did not start off easy. It was difficult from the beginning. The first hour was the hardest because I couldn't stop thinking about how much further I would have to go. I was also worried about what was ahead. I kept telling myself, "I'll never be able to do this," "Who am I kidding?," I'm not in good enough shape for this," "My hiking boots are from Walmart; everyone is going to know I'm a fraud."
When you are at your lowest point and you see how far you have to go, it's easy to give up and start doubting yourself and your abilities. You may think, "I'm never going to get over this depression," or "I'm not brave enough to face my fears." Fear or negative predictions about the future can limit us before we even get started. We all feel weak at the bottom of the mountain.
Keep the summit in your mind - Don't give yourself a way out.
As I started to hike, a little thought entered my mind: "I could turn around at any time if I really need to, go back down the hill and relax in the comfort of my car." Focusing on that thought made the hike that much harder. I wasn't keeping my mind on the goal - I was trying to find an easy way out of the climb. When I realized this, I changed my thought to "I will go as far as my 80 year-old grandfather goes."
It's easy to give up when it gets tough. If you tell yourself that there is a way out, it's hard not to take advantage. Sure mental health problems are difficult to live with and nobody likes living with them, but drastically changing our lives is just as hard - if not harder. It can be easier to slip back into old habits and routines when the going gets tough. It's important to keep your eyes on the summit and challenge the little thoughts that urge you to give up.
Keep your eyes on your feet.
Before I climbed a mountain, I pictured myself looking at the summit and striving towards it. Kind of like that little mountain climber on the Price is Right. But, after actually experiencing a climb, I realized that you have to keep your focus entirely on your feet. You can't look at the scenery or the destination because you will fall. Each step is important and you have to be conscious and aware of your footing. Getting to the top takes a series of carefully planned and executed steps. If you don't pay attention, it's easy to stumble and scrape your knee.
So often when attempting to overcome problems in our lives we spend a lot of energy looking at the scenery. The scenery could be your problematic past (the path behind you) or your ambiguous and therefore, terrifying future (the path ahead). But the only thing that we can truly control are the careful steps we take every moment. The decisions and choices we make each day. It's important to stay in the present for 3 reasons: 1) if you focus on the past or the future, you will stumble 2) it's the only thing we can control 3) it takes a succession of small steps to make it to the top.
Some boulders are bigger than others.
Boulders come in all shapes and sizes. Some were as small as a pebble and others were bigger than my entire body. Some steps were easy and others were extremely difficult. It's much the same on the journey to recovery from mental health problems. There are some obstacles that are significantly difficult to overcome, while others may seem effortless.
I would not have made it up the mountain were it not for my climbing companions. We commiserated together, helped each other up when one of us stumbled, and cheered each other on. The journey to the top was an individual achievement. And I didn't make it up as fast as the others, but they helped me to get to the top.
Supportive interpersonal relationships are crucial on the road to recovery. We need people by our side to act as cheerleaders, nurses and supportive listeners. It can be hard to reach out to others and ask for support, but trying to climb a mountain alone is miserable and isolating. It's possible, but it makes the journey much harder.
Keep these things in mind as you climb your mountain!
Licensed Psychologist in Fredericton, N.B.