To A T

Should mental health professionals be in the business of gatekeeping clients desiring a sex-change? 

As a therapist, I have to say ‘no.’ It’s a somewhat qualified ‘no’ though. Maybe I should ask if transitioners should obtain therapy before going into transition? For that I would answer ‘yes.’ Simply because I think that working with a good therapist can be good for most of us human beings. My best friend, who lives in Nashville, is a psychiatric nurse, has been for thirty years. She’s fond of saying that “two weeks of therapy a year should be required for all well-adjusted people. Of course the really crazy ones cannot help but get it.” 

I say no, because of motivation. Both that of the transitioner and that of the therapist who works with that person. Research has shown repeatedly that the single most important variable in therapy is the relationship between therapist and client. The better that is, the better the result of the therapy. And, I think that the required nature of gatekeeping tends to eradicate any ‘true’ relationship. It places the therapists in power-over positions in regard to clients. Dominants never actually are told by subordinates how the world looks to me. Subordinates very usually have much better insight into situations and personalities than do dominants, simply because subordinates rarely presume all is well as is. Dominants almost always do.

Relationship cannot be forced. Otherwise you get what we so often see, someone who says the right things (whatever those may be to an individual therapist,) who withdraws (therapists and clients) increasingly large parts of themselves from relationship in order to get a letter or to write a letter. I have seen many mandated (court- or probation-ordered) clients react very negatively to a situation that could well help them to resolve some of the difficulties they have in coping socially: drunk-driving, body-wasting from heroin, deep-seated self-hatred that often forms the basis for rage-filled attacks on others, suicidality, homocidality. 

I once had a client who struggled for two years to remain clean. He knew all of the rules about sobriety. He could talk the talk, but every month or so he’d find he couldn’t walk the walk. He was always withdrawing parts of himself, both from himself and from his groups and from me. He thought there was a regular script he should follow in order that probation would release him. But, he kept coming up dirty on periodic drugs-tests; and his anger would overflow so badly that when he did relapse that he would invariably become involved in bar-fights, bad ones. He was re-arrested and served more time (about six months all told) while he was in-program. 

We finally got to a place where it seemed to me that he was finally beginning to realize that I really did care about him. It wasn’t just a paid-transaction as he had always said it was.

He had this very pat story about an uncle (16 y/o at the time) who “tried to molest me when I was about five.” One day during session I just said to him, “That must have been really hard to beat-up someone who was so much bigger than you.” 

He started crying huge heaving gasping wails. My supervisor who was next door came over to check on us. 

Finally my client said: “I cannot lie anymore, Radha. He did molest me and I felt so helpless. I didn’t want it to happen, but I couldn’t fight him. He was too strong.” 

He spent another eight months in treatment, but instead of working on drinking we worked on PTSD and self-esteem. As far as I am aware he hasn’t relapsed again. That was three years ago. I used to see him occasionally at NA meetings. His physical health was shot to pieces and he died last year. But, he reestablished relationships with both of his sons. He become a reknowned speaker at recovery meetings in the area. He didn’t have fights anymore. 

Had he remained simply remanded to program I really doubt that he would have changed very much. His anger and resentment, his fears, ruled him and until he was able to feel he was more than just a case he was unable to actually talk about his real life. The interior place he hid himself for protection.   

I believe that gatekeeping is not a positive interaction for either therapist or client. It violates that basic core experience of being in relationship. It’s in that area that work on one’s own psyche occurs. In those silent and walled-away places, where we hide ourselves when our hurt and anger are too great for us to hold, and where we hide what we imagine that no one else will be able to hold either, we only allow someone we are in relationship with to enter those places. I believe that few or none of my collegaues in the gatekeeping profession are allowed by their clients to enter that space. 

The relationships that most, if not all, gatekeepers have with their clients are ones of expectation, half-truth, anxiety about what is said and what is withheld. In point of fact the entire gatekeeping relationship adds to the client’s hiddenness, actively encourages them to avoid any true connection with the therapist.

Gatekeepers and their clients both seem to arrive at the initial session with one of two notions. The client seems to generally think that there will be a series of questions and proper responses will be required in order for them to get what they want: go-aheads for HRT and surgeries. If she or he can simply say the right things the keys to the sex-change gateway will appear and for them the gate will swing open, the relationship at that point is effectively over. 

I often wonder what our clients really require from us, what we really require from them? Is this relationship simply a paid-transaction like any other prostitution transaction? Does anyone ever explore or define, resolve or work-at real psychic health and the blocks that might be keeping the client from that? Or is it enough to require X number of sessions and the payments for those: a meal-ticket? Most clients seem to think so from all I have heard from other transitioned women and men. 

If we do make demands on our clients for divulging real and deeply-held emotional and physical wounds, is that the best avenue we can take? Or does that cause real harm and a continuation of the profound lack of understanding of relationship that transsexual clients will normally present with? I suspect the latter. Forcing one into a relationship by hanging over her or his head some carrot is not what therapy is about. It is yet one more coercive strategy that the client must find a way to cope with and still get what she or he wants.

The therapist gets money, the client gets more deeply conditioned into hiding themselves, learning to give just enough to get by while keeping the true core of themselves hidden from the coercive person in the other chair who is totally reminiscent of parents, siblings, teachers, and peers who have hurt and dismissed them before. We recapitulate the very psychic traumas the client has experienced throughout her or his life. We violate that first and best principle of all medical practice: “Do no harm.”  

If the client thinks it, does that make it true? Well, it may not be true in the therapist’s mind, she or he may believe that they are actually providing a necessary and important service. They may feel they are actually “doing therapy” with their clients. Yet, to require a certain number of visits to get a letter of sanity doesn’t feel like “doing therapy” to me. I’d rather try to discuss and reflect on the client’s “real issues.” Desiring a sex-change for an adult human being doesn’t appear to me to be pathological in any way. Sign the letter at the first opportunity and tell the client that if they want therapy instead of just a letter then I am available for that. If one simply wants a letter, pay me $400 now and in three months you’ll have one stating that you are sane and do not have psychotic symptomatology that is causing you to desire your body to be mutilated rather than repaired. 

It’s a rather simple process and has the added advantage of enacting a truth: that the only thing that is of concern to the client is that a plastic surgeon or an endocrinologist treat them for their gender dysphoria. That is the crux of the matter, doing therapy or doing gatekeeping and collecting the toll required for one to pass-through the gender binary gate to the other side. We should try to make those two options clear as new blown glass.

Gender dysphoria does seem unusual for the cissexual who has never experienced the dissonance of his or her own sex. For them it is highly unnatural. One who hasn’t experienced the very real and devastating pain of knowing you are not whom others see and demand of you to be certainly causes a multitude of legitimately labelled personality and mood disorders. But, the treatment does not effect itself simply through a surgery or HRT. It’s my belief that the gatekeeper/therapist never gets to the core of the person they see, or only rarely manages to do that. The client walks into the room with a thick and impervious wall that they never see any reason to make a gateway through for the therapist to enter into their psychic life.

That is the tragedy of gatekeeping. Clients are only assisted by, very often lying, “jumping through hoops,” maintaining the semblance of relationship without ever entering into one with the therapist. As a therapist I can attest that without relationship one never ever works in positive ways with their clients. Connection, not disconnection, is the core of the healing process.

As a survivor of gender dysphoria I can also tell you that the entire gatekeeping experience does nothing in most cases to assist the client in living through his or her sexual and physical traumas and his or her coping responses to those: their depressions, anxieties, manias or deeply felt senses of alienation and lack of connection to others. Gatekeeping simply adds a new wall of separation within a person who has already built fabulous walls of separation within him or her self.  Gatekeeping makes a mockery of the process of therapy and leaves most of its clientele regarding the process as being inimical rather than beneficial. 

It’s time to stop gatekeeping. Hopefully, in its new DSM-V that’s scheduled to be published in 2012, the American Psychiatric Association will remove gender identity dysphoria from its listed pathologies. There is more and more evidence available that points to the fact that GID is a normal variant of human being, not the result of a disordered mind. The evidence is already there that therapy’s core is the relationship between the client and the therapist. I believe it’s high time we, as therapists, admit that and go back to practicing legitimate and efficacious therapy and leave toll collection to the employees of toll collection agencies.

 

Explore posts in the same categories: Connection, Mental Health, Relational-Cultural Theory, Social Relations, Therapy, Transsexuality

This entry was posted on August 13, 2008 at 10:31 am and is filed under Connection, Mental Health, Relational-Cultural Theory, Social Relations, Therapy, Transsexuality. You can subscribe via RSS 2.0 feed to this post's comments.

Tags: Client-Centered Therapy, Gatekeeping, GID, Mental Health, Relational-Cultural Therapy, Relationship, Therapeutic Process, Transsexuality

Both comments and pings are currently closed.