Using Misgendering in a Therapeutic Context

When we put on workshops to train other students to work with transgender clients, one of the biggest points that we make is the importance of using correct pronouns. The therapist should create a safe, warm, welcoming environment where the client’s identity is accepted and celebrated. Calling a client ‘he’ just because she currently is not presenting or unable to present as female can be a painful experience for her and damage the budding therapeutic relationship.

However, mistakes do happen. Being human, we all will misgender someone at some point. Being therapists, there is a chance that that someone will be a client. So how do you handle a situation when an incorrect pronoun is used?

Of course, it is important for the therapist to correct the pronoun and apologize for their mistake. But can this mistake be used therapeutically?  Dr. Adam Schulman suggests that this mistake, while mortifying for the therapist, can be useful for the therapy. The therapist inadvertently creates a real life exposure to a painful experience in a safe environment, where both the victim and the perpetrator can explore the emotional impact of the event together. Instead of feeling obliged to give a polite acknowledgement of ‘oh it’s alright,’ the victim can admit the truth of the experience, openly telling the therapist about the pain caused by the mistake. This in turn could give the client the strength to speak up when the mistake happens in real life, both with friends and strangers.

Therapeutically, this brings to light an interesting question: is it ever appropriate for a therapist to intentionally misgender a client to open that dialogue? I personally dislike the idea, but I also struggle with using anger in a therapeutic context, so that may be a biased opinion. But theoretically, a clinician could choose to use this as a tool to allow the client to find their voice and speak out when injured by a misgendering. By showing the client their strength in reacting to this injury in a safe place, the client may be more able to speak assertively when it occurs outside the office. However, the clinician would need to be comfortable that the relationship was in a place where the client would be able to use the event to grow, and not just as a sign the therapist was careless or apathetic, as that can be deadly to the relationship.

Culture and Transition

Recently, I have been reviewing a lot of Sue’s work on Multicultural Counseling and Therapy (Sue, Ivey, & Pederson, 1996; Sue & Sue, 2008).  One of the major points he highlights the difficulty of therapists raised in majority Western culture working with clients of other cultures, given the focus on individualism both in our culture and in our expressed goals for therapy.

It struck me that I have not given much thought to how coming from a collectivist society would affect goals for transition.  When thinking over previous goals for therapy, they usually have revolved around individualistic concerns: feeling more comfortable with the self, living a happier and more fulfilling life, developing strengths to deal with unpleasant situations, et cetera,  How would a therapist focus goals with someone for whom the concept of “I” is meaningless?

My first thought was centering around changing the role in society.  For individuals who define the self as the service performed to the family or community, could therapy focus on making goals to allow the individual to identify barriers preventing the individual from feeling fully confident and fulfilled in those roles?  Or perhaps take the ‘self’ and ‘individual’ out of it, and approach these cases from a purely systems perspective in which one subsystem is undergoing a significant shift in relation to the family/culture’s gender roles?

I don’t have a simple answer to this question, but I do find it an interesting question to explore.  Perhaps later I will devote a post to the other tenants of MCT and how they would affect working with transgender clients.

 

Sue, D. W., Ivey, A. E., & Pedersen, P. B. (1996). A theory of multicultural counseling & therapy. Pacific Grove, CA: Brooks/Cole Publishing Company.

Sue, D. W. & Sue, D. (2008). Counseling the culturally diverse: Theory and practice (5th ed.). Hoboken, NJ: John Whiley & Sons, Inc.

DSM-V and ‘Gender Dysphoria’

Recently the APA approved the final criteria for the DSM-V’s diagnosis of ‘Gender Dysphoria,’ replacing ‘Gender Identity Disorder’ in the DSM-IV-TR.  This is an exciting shift to me, bringing the APA (and thus therapists who may be uninformed about gender) closer to the standards of WPATH.  However, I have seen significant concern within the trans* community, stating this is ‘new polish on an old turd’ of pathologizing the community.  I wanted to address this concern from the perspective of both a transgender advocate and future psychologist.

First, let me clarify that I would love a world in which there is no place for gender identity in the DSM (and I do believe we are getting there, which I will get to).  As a cisgender person, I do not know the sting of having the GID label slapped into your chart, the pain of having your personal identity called a ‘disorder,’ or depending on that diagnosis to receive basic treatment.  I agree it is a broken system.  But the system is improving.

The shift from GID to GD seems like an insignificant improvement, but it is truly substantial.  The diagnosis of GID was deeply flawed, and promoted a number of issues.  First, while superficial, was the name itself.  The wording of gender identity disorder implied that the individual 1. had a mental disorder and 2. the disorder was with the individual’s gender identity.  Gender dysphoria shifts this.  Instead of pathologizing the individual and their identity, it pathologizes and targets the discomfort caused by presenting as the incorrect sex, being misgendered, etc.  The individual is not sick, the individual is healthy but dealing with significant discomfort caused by their gender presentation not being congruent with their gender identity.

Second is the allowance for non-binary identities.  GID focused heavily on binary presentations in childhood, forcing agender, genderqueer, third gender, etc. individuals to lie about a binary identity to receive services related to transition to a more comfortable place.  GD opens the door for binary, non-binary, intersex, etc. individuals to all receive equal attention.

‘But Jessi!’ (you say) ‘I am genderqueer and have always been super happy with my appearance.  That’s pathologizing the trans* community by saying we all are unhappy with ourselves!!’

Not so!  Gender dysphoria is a diagnosis reserved for the unhappiness caused by an incongruent gender presentation.  If your gender presentation is congruent with your identity, or if you experience no unhappiness with your presentation, you do not quality for diagnosis.  Gender dysphoria is not synonymous with being transgender; gender dysphoria is simply a unique type of discomfort/anxiety/sadness that can be experienced by transgender individuals.

This brings me to my second point.  ’Gender dysphoria’ is not interchangeable with ‘transgender.’  A person can be transgender, diagnosed with gender dysphoria, change their name and pronouns, receive HRT, and be ‘cured’ of gender dysphoria.  GD only describes discomfort, so an individual no longer meets criteria when they are comfortable with their gender presentation and role.  The gender dysphoria is a transient diagnosis meant to be cured, whereas being transgender is an aspect of identity.  The same way you may go to the therapist for a sad spell, be diagnosed with MDD, and subsequently be treated, the same is true now for GD.  You do not go in to be diagnosed AS depression, you are a person WITH depression that can go away.  Equally, you can be diagnosed WITH dysphoria and that dysphoria can go away via whatever treatment is the best fit, be it hormones, surgery, name changes, or just affirmation to live as a more authentic person.

‘But lots of people don’t like things about themselves!  This pathologizes the trans* community by saying their unhappiness is a mental illness!  The diagnosis causes problems for equality and just needs to be removed.’

Again, two points.  One, something being in the DSM does not make it a ‘mental illness.’  It makes it something that can cause clinically significant distress that may be addressed by a mental health professional.  Due to the use of NOS diagnoses and V-codes, EVERYONE meets criteria for MULTIPLE diagnoses in the DSM.  I myself, a highly functioning doctoral candidate, meet full criteria for several diagnoses.  This does not mean I have a mental illness, nor does it prevent me from employment.  While being trans* and getting employed is an issue, it is not because the DSM makes it a mental disorder.  Very few bigots keep up-to-date with the latest publications by the APA.

Two, I do believe that anything relating to gender identity will eventually be removed from the DSM, the same way homosexuality was.  But awareness has to occur before this removal can take place.  For mental health professionals there is almost no training about issues related to trans* dysphoria.  I have been going to school to become a psychologist for over seven years, and in that time I have been exposed to only two hours of training.  One hour devoted to a panel discussing medical transition in undergrad, one hour watching a Barbra Walters interview discussing gender identity in childhood (in extremely binary language) in my graduate program.  If it were not for training I sought out on my own, this would be the extent of the knowledge I had on transgender mental health.  When you seek out someone for your letter (now possibly a masters level therapist, due to the changes in WPATH SOC 7) they may have only had that much training, or perhaps less.  Gender dysphoria in the DSM allows these individuals to see what is required of them and how to proceed ethically.  If we remove GD before this training and awareness, we open the door for therapists attempting to correct the behavior instead of affirming it because they do not understand.

It isn’t ideal, or even great, but it is a giant step in the right direction.  So instead of petitioning to remove GID/GD from the DSM, let’s focus on petitioning to increase training and awareness for mental health professionals who will go on to serve the trans* community.