Setting up a specialist psychotherapy service for gender identity disorders

Ten years ago a specialist psychotherapy service was set up in the UK for NHS patients with gender identity disorders. The service was initially run as a pilot with the aim of determining whether psychotherapy could be helpful to patients referred with gender identity disorders with regard to the problems they had sought help for from the clinic. The unique service, which operates from a small specialist psychotherapy clinic in London, is now available to patients from anywhere in the UK.

The clinic specialises in offering psychotherapy to people with problems relating to their personality, sexuality, gender, violence or delinquency. The clinic receives national specialist funding and patients may be referred by any health professional from primary, secondary or tertiary care services anywhere in the UK. As the clinic is based in London, most of the patients are referred from within the greater London area, which is covered by a block contract. A smaller number of patients are referred from the rest of the UK, many travelling several hundred miles each week for appointments. The health authorities for these individuals will have had to agree funding for assessment and treatment for these out-of-contract referrals. The clinic is unique within the NHS in being able to offer patients time-unlimited psychotherapy, which is a recognition of the longstanding nature of many of the problems for which patients are referred.

I currently run the gender identity component of the clinic, allocating 1 day a week to the service. During this time I am able to carry out one patient assessment and run two therapy groups, each for eight patients. Thus, the capacity of the service is at present limited to 17 patients a week.

Referrals to the service

The usual presenting symptom of the individuals referred to the service for psychotherapy is a feeling of unhappiness or confusion with their sense of gender identity that they hope a talking therapy will resolve. If the gender identity disturbance is part of a transgender identity, the patients may also be considering physical treatments for sex reassignment, although this is not always the case. Some will have already had sex reassignment surgery but remain unhappy regarding their sense of gender.

Before the service was set up, it was unclear whether people with gender identity disorders would be interested in psychotherapy, would persist with it and find it useful, and also what specialist adaptations to the therapeutic delivery would be required. However, we have found that the patients offered psychotherapy consistently stay with the intervention. They report it to have improved the stability of, and their satisfaction with, their sense of gender identity, whether this be their primary biological one, a transgender identity, or indeed a non-binary gender identity (when the individual chooses not to identify as male, female or transgender). The steps needed to corroborate these anecdotal patient-reported benefits in an empirical manner will be discussed later in this article.

Literature review

There is scarce literature available on the provision of psychotherapy for individuals presenting with gender identity disorders. A National Library for Health literature search limited to papers on ‘transsexual’, ‘transgender’ and ‘psychotherapy’ of any modality yielded just 29 papers, most published over three decades ago.

A major limitation of the early literature, which was psychoanalytically based, is that the theoretical models were extrapolated from small numbers of case studies, and then applied to larger populations that may have varied from the individuals in the original studies (Reference GreensonGreenson 1968; Reference StollerStoller 1968: pp. 89–125; Reference StollerStoller 1975: pp. 39–108). The specialist service that I run has to date assessed and/or treated about 100 patients, some having only a few consultations, others in long-term psychotherapy over many years. Although the patients referred share a presenting symptom related to their sense of gender identity, detailed assessment reveals considerable diagnostic heterogeneity (Table 1).

TABLE 1 Diagnoses of 82 patients referred to the UK gender identity psychotherapy service

The literature on group psychotherapy for gender identity disorders yields only nine papers: Lothstein and his colleagues at the Case Western Reserve University Gender Identity Program in Ohio have described their work with expressive group therapy (Reference LothsteinLothstein 1977a,Reference Lothsteinb, Reference Lothstein1979, Reference Lothstein and Levine1981; Reference Althof and KellerAlthof 1980) and in more recent years I have published in this area (Reference Hakeem, Ruszczynsky and MorganHakeem 2007, Reference Hakeem2008, Reference Hakeem2010a,Reference Hakeemb).

Assessment

At our clinic we believe that it is helpful to both patient and referrer to maintain very few exclusion criteria for the psychotherapy service. We exclude only those with current florid psychosis or significant substance dependence, either of which would compromise the patient’s ability to use the therapeutic intervention. Even though such individuals are not offered the group psychotherapy, we may offer them a number of individual consultations to talk with them about their presenting gender confusion. At assessment, the clinical history includes careful detail regarding sex at birth (biological sex), gender identity and sexual and relationship history. This is essential to discern whether the presenting gender-related symptom is solely located in gender identity or is linked primarily to sexual interests or feelings that cause the patient distress (Box 1).

As Table 1 indicates, almost two-thirds of the patients in the service consider themselves to be pre-operative transsexuals. A quarter of the patients referred are post-operative transsexuals with a persisting sense of dissatisfaction or gender dysphoria after physical sex reassignment. Just over a quarter of patients are referred as having a gender identity disorder but, after assessment, are considered to be transvestites rather than transgender. The ratio of biological males to females referred to the service is approximately six to one.

The clinical history also requires careful attention to the patient’s understanding of their sense of gender identity spanning from early childhood to the present, including any periods when the sense of gender was concordant with their biological sex. It is not uncommon for patients initially to attempt to provide what I refer to as ‘the official version’ of their history, a ‘cut and paste’ account they have prepared to accord with what they anticipate professionals in gender clinics need to hear in order for them to gain access to physical treatments. If a patient does provide such a generic template of a history, then reassurance on the part of the assessor may encourage the individual to give a more accurate account.

Aims of treatment

A careful history enables the current gender-related presenting symptom to be understood in context. In addition, a discussion with the patient will identify their particular goals for psychotherapy. The aims of the therapy are psychological rather than physical, and it takes place irrespective of any physical changes the patient may be undergoing or planning to proceed with during the therapy.

The psychotherapy has two explicit goals. The first is to give the patient a greater understanding of the meaning they afford to gender as a construct in relation to themselves and society. The second is to enable the patient to attain a stability, acceptance and satisfaction with their individually tailored gender role, which may or may not correlate with their biological sex, and may or may not fit within a binary framework of gender. Achieving a greater sense of stability and security in their sense of their own gender (irrespective of their biological sex) will help them, regardless of whether they choose surgical alteration of their physical sex.

Once the aims are agreed by both therapist and patient, the model and setting of the proposed course of psychotherapy are explained.

Therapeutic model and delivery

Following the assessment, the patient is offered a few individual consultations. The number of consultations is tailored to their assessed needs. The main purpose of these sessions is to allow the patient to establish a therapeutic relationship with the therapist before they join a psychotherapy group. The small-group psychotherapy sessions are run weekly and last 75 min. The groups are classed as ‘slow open’, having a set membership (up to eight patients) whose places are filled as members of the group are discharged. As the service operates within a clinic that is still able to offer time-unlimited psychotherapy, the overall duration of treatment is determined by the patient, informed by their response to, and benefit from, the therapy. Most patients in the service find that their presenting difficulties relating to their sense of gender identity are satisfactorily addressed within the first 2 years of being in a group but choose to remain in the group for longer. Determining an ideal length of treatment in order for the service to be replicated elsewhere will be possible once a tailored evaluation tool for objectively measuring therapeutic response has been created and validated. This will be discussed later.

The group sessions involve a modified group analytic psychotherapy incorporating elements of mentalisation-based therapy (Box 2). Group analysis (group analytic therapy) was devised by the psychiatrist S. H. Foulkes in the early 1970s and has its roots in psychoanalysis, social theory and systems theory (Reference FoulkesFoulkes 1964). Mentalisation-based therapy has primarily been developed for use in borderline personality disorder (Reference Bateman and FonagyBateman 2004). In psychotherapy for gender identity disorders, mentalisation involves working collaboratively with patients towards a greater understanding and clarity of their reported feelings or convictions regarding their gender. Unless the patient has an additional diagnosis of borderline personality disorder, this is usually the only mentalisation deficit to be addressed. However, most patients initially struggle to envisage the meanings afforded to gender by themselves and others. This gender-focused ‘non-mentalisation’ includes mentalisation of how others may perceive or attribute meanings regarding the patient’s gender. The binary nature of the gender conflict, along with the social nature of gender, make group therapy the preferred approach. In individual therapy, therapists can find themselves drawn into a protagonist/antagonist dynamic with the patient that is very much like the male/female binary dyad.

Analytic therapy groups can be classified as either ‘homogeneous’ or ‘heterogeneous’, depending on whether the presentations of patients in the group are similar or different (Reference FoulkesFoulkes 1975). As all the patients in our gender identity groups have or have had an issue relating to their sense of gender identity, the groups would be considered to be homogeneous. The rationale for running a homogeneous group for people with gender identity disorders was to avoid the risk that the gender conflict would be under- or overattended to in a heterogeneous group. In a homogeneous group, in which the conflict is present in some manifestation in all members, it may more comfortably take a foreground or background position.

As indicated in Table 1, groups may include individuals who wish to pursue sex reassignment surgery, those who have already had surgery and those who feel transgendered but have no intentions to have surgery. At the gender identity clinic, my transgender groups also include patients who are not easily categorised within a pre-operative or post-operative framework. Some show diagnostic fluidity between the categories of transsexual and transvestite. There are also rare cases of autogynaephilia in which the patient wishes to retain a male gender identity but with female genitalia or other female physical parts. Thus, although the group at first sight might appear to be homogeneous it may be considered to be heterogeneous.

Specialist adaptation of therapeutic technique

There is often much confusion among both patients and professionals regarding the terms ‘sex’ and ‘gender’. It is probably easiest if the biological, phenotypic and chromosomal sex differences of ‘male’ and ‘female’ are considered as having an organic basis, in contrast to the role meanings afforded to these sexes in the form of ‘masculine’ and ‘feminine’ genders, which are social constructs. Gender is a psychosocial virtual entity without location in a person’s body. It solely exists in, and is perpetuated by, the society in which the person lives.

Patients referred with gender identity conditions frequently have a rigid, binary perception of gender. They feel that they do not comfortably fit into this framework and therefore feel persecuted by it. This mismatch usually leads them to question the validity of their own gender, rather than that of society’s gender classification framework. In contrast, gender-confident individuals may comfortably play with or subvert societal gender frameworks without experiencing any insecurity in their own sense of gender identity. Such mixing and matching of elements from across the perceived binary divide is seen in the recent phenomena of the ‘metro-sexual’ male and the female ‘lad-ette’.

In psychotherapy for gender identity disorder, the clinician’s task is to deconstruct rigid gender frameworks perceived by the patient, so as to open up a range of what is possible for the individual in any given gender role.

Deconstructing a binary gender rigidity

When a patient uses the terms ‘masculine’ or ‘feminine’, their understanding of these words should not be presumed. Rather, it should be explored in the therapy within a mentalisation framework. The aim is not to discourage use of the terms, but instead to encourage a degree of enquiry as to what they mean to those using them (mentalisation), rather than presume a universally understood meaning (non-mentalisation).

Although patients may refer to ‘male’ or ‘female’ clothes, attitudes, mannerisms, thinking styles and interests, it is the task of the therapist in this specially adapted therapeutic work to ‘de-gender’ the things that patients have ‘gendered’ in their minds. Long-standing ‘gendering’ adds to identity confusion when individuals find themselves mismatched with the perceived gendered framework. If aspects of themselves are identified as qualities they had classified as ‘male’ or ‘female’, a gender conflict will be reinforced if these are incongruent with their biological sex.

As regards clothing in particular, the therapist should maintain that, although the patient or the society in which they live assign gender associations to particular items of clothing, these are merely societal constructions. Therefore an interest in any particular garment does not impart a greater or lesser validity to any particular gender identity. Patients should be encouraged to wear to sessions whatever they would normally wear and any gendered associations they may have afforded to their clothes can then be considered within the exploratory arena of the therapeutic group.

Gradually, pre-existing terms and conditions of gender are deconstructed, with the therapeutic aim of reducing the primacy afforded to gender as a construct variable to a level afforded to more benign (in this context) variables such as age, class, race or ethnicity. The rationale behind this is that if patients’ pre-existing heightened awareness of gender is lessened to the extent that it no longer occupies an overriding focus, there will be a concomitant reduction in their gender-related dissatisfaction and psychopathology.

Features specific to psychotherapy for gender identity

In addition to the special adaptation of therapeutic technique required for working with gender identity disorder, I have observed a number of features specific to this field during the running of the specialist service discussed here. These are listed in Box 3 and described below.

Parallel processes

In discussing the four features specific to gender identity disorder in the previous section, I repeatedly noted that a particular feature was evident not only in the patient, but could sometimes also be seen in the therapist, the organisation and people outside of the clinic. One example that I give is that of genital centrality, where patients, specialist clinics and non-specialist psychotherapists evaluate or classify individuals in terms of their genitalia. This phenomenon reflects what in psychotherapy are called ‘parallel processes’: features of either the cognitive style or the pattern of interpersonal relationships of patients in therapy that are also observed (in parallel) in the wider context in which the therapy is delivered (Reference HakeemHakeem 2010b).

The next step: the need for a validated evaluation tool

As mentioned earlier, the national psychotherapy service for people with gender identity disorder was originally established as a feasibility pilot. I had no idea whether patients would want such a service or find it useful. The response, however, has been striking. Patients who have gone through the therapeutic programme have reported that it has been useful in its specific focus on understanding themselves in relation to their sense of gender identity.

Obviously, such patient-reported outcomes are anecdotal evidence only. The next stage in the development of this specialist intervention will be to support the patient feedback and our observations by an evidence-based qualitative and quantitative outcome study. The initial task faced is to create a valid and reliable evaluation tool to measure satisfaction with and stability of gender identity irrespective of whether this correlates with biological sex. At present there are no such tools to measure gender stability or sustained gender identity. As outlined here, adherence to a perceived rigid binary gender framework is unhelpful and, at times, iatrogenic for people with gender identity disorder. Consequently, any evaluation tool would have to avoid restricting gender identities to a binary repertoire. It would need to allow for fluid and creatively tailored gender identities such as genderqueer and other non-binary gender options.

MCQs

Select the single best option for each question stem

1. 1 Individuals with a changeable and uncertain sense of gender identity disorder should be offered:

   1. a cross-sex hormones

   2. b sex reassignment surgery

   3. c psychotherapy

   4. d behavioural conditioning

   5. e antipsychotics.

2. 2 The adaptation of psychotherapy described here incorporates elements of:

   1. a psychoanalytic psychotherapy

   2. b mentalisation-based therapy

   3. c group therapy

   4. d cognitive–behavioural therapy

   5. e both mentalisation-based and group therapy.

3. 3 Psychotherapy for gender identity disorder should be offered:

   1. a only to pre-operative transsexuals

   2. b only when sex reassignment has not helped the patient

   3. c to any patient who feels they could benefit from it

   4. d as an obligatory component of physical sex reassignment

   5. e if there is psychiatric comorbidity with other mood disorders.

4. 4 The aim of specialist psychotherapy for gender identity disorder is to:

   1. a assist patients progress through sex reassignment

   2. b discourage patients from having sex reassignment

   3. c enable patients to socialise

   4. d teach and reinforce gender-appropriate behaviour

   5. e increase the stability and satisfaction of the patient’s sense of their gender, regardless of their biological sex and societal gender frameworks.

5. 5 Common themes observed in the work of gender identity psychotherapy are:

   1. a binary gender rigidity

   2. b genital centrality

   3. c questioning of authenticity

   4. d confusion

   5. e all of the above.

MCQ answers

1

c

2

e

3

c

4

e

5

e