Trauma & Transgender Identity: How Trauma impacts Gender Identity
Which pronoun do you identify with? He, she, or they? Questions like these now permeate schools, colleges and the workplace as a means to create a sense of safety, affirmation, and equality for those who identify as transgender or gender non-conforming.
It coincides as more and more youth in recent years are identifying as transgender or non-conforming (i.e. not identifying with the gender they were born with). A study by UCLA in 2017 estimates 150,000 youth ages 13 to 17 identify as transgender in the United States.
While the number of transgender youth and adults is growing, few clinicians or health care professionals know how to ethically treat transgender patients, especially minors. Many believe validating their desires is supportive enough with limited desire to explore the psychosocial factors that can contribute to transgender identification or defined as gender dysphoria from the American Psychological Association. The medical community also faces ethical challenges by grappling with issues of hormone blockers and sexual reassignment surgery for youth.
What is accepted though are alarming psychological risks faced by the transgender community.
According to the National Institute of Health, 41% of them reported attempting suicide as compared to 1.6% of the general population. Those who expressed a transgender identity or gender non-conformity at schools reported harassment (78%), physical assault (35%), and sexual violence (12%). About one-sixth left school or higher education due to harassment.
With the escalated prevalence of mental health issues for transgender populations, the literature suggests clinicians and transgender seeking therapy would benefit alike in being comfortable to explore the multi-factorial influences of trauma on one’s life: childhood adversity, neglect, abuse (physical, sexual, verbal), and ruptured or unhealthy attachments with their primary caregivers.
The National Institute of Health cites a 2017 study conducted in Italy where patients meeting the criteria for male-to-female gender dysphoria (GD) were interviewed for childhood maltreatment with regards to emotional abuse, neglect, physical abuse, and sexual abuse. A high proportion of reported maltreatment where the subjects also reported higher body dissatisfaction.
Part of the reasoning is the pre-frontal cortex region of the brain doesn’t reach full maturation until one reaches their mid to late 20’s. This is the part of the brain that regulates emotions, impulse-control, and decision-making. Puberty is an important part of the maturation process as sex hormones become more fully developed which parallels brain development and thus those are against hormone therapy believe this to be true. Others who are against hormone therapy or sex reassignment surgery point to a 30 year old longitudinal study in Sweden where the rate of suicide increased for those who underwent surgery compared to control groups.
Those who are in favor of hormone suppressants known colloquially as puberty blockers to treat children who are transgender or gender non-conforming believe the medications which suppress the body’s production of estrogen or testosterone, allows the body to hit pause on the changes that would occur during puberty.
“That’s really what these pubertal blockers do,” Dr. Rob Garofalo told PBS’S FRONTLINE Documentary News Show.Garofalo is the director of the Lurie Children’s Hospital’s Gender and Sex Development Program. “They allow these families the opportunity to hit a pause button, to prevent natal puberty … until we know that that’s either the right or the wrong direction for their particular child.”
Doctors who use puberty blockers say they allow children who experience gender dysphoria — the feeling that they’re in the wrong body — the time and space to explore and settle on their gender identity.
The ethical issues that need to be addressed when working with transgender individuals considering hormone or sex reassignment surgery include the following: autonomy, beneficence, nonmaleficence, and informed consent. The individual must have autonomy of thought and intention when making decisions about medical treatment. Participants, especially minors, must understand their desires, hopes, and expectations might not correlate with reality. Beneficence implies doing only good, only what is in the patient’s best interest. When it comes to hormone therapy for minors, what is the the patient’s best interest and how do we assess it? Should it come when a minor reaches legal voting age in the United States (i.e. 18 years old), should it come earlier any proxy through one’s parents, or should it be held much later when there’s more cognitive, social, and sexual development? Some physicians may consider surgical alteration of healthy organs, would not be in line with this principle. Nonmaleficence must ensure that the treatment does not harm the individual in an emotional, social, or physical sense. And informed consent means the patient is aware of the risks and benefits of medications/procedures. With hormone, it’s complicated on whether physicians, psychiatrists, and other medical and therapeutic professionals should also have a say in authorizing consent.
All this to say is there’s a need for clinicians to ensure they are thoroughly educated and can help create safe spaces where issues that can factor into transgender identity can be explored. The National Institute of Health cites a study where researchers found a high frequency of traumatic experiences within the first 10 years of life. Colizzi et al. (2013) found a high percentage of insecure attachment (70%) in their sample of 50 adult transsexuals. Finally, in a recent study, Lingiardi et al. (2017) found a high percentage of unresolved/disorganized states of mind (50%) and a considerably high percentage of secure patterns (39%). Moreover, 29 (66%) of the 44 individuals had traumatic childhood experiences relating to the loss of an attachment figure or physical or sexual abuse.
When it comes to GD patients in the study, they showed higher prevalence of anger towards fathers and idealization towards mothers relative to control groups. Fathers of GD participants were less accepting, available and supportive compared to fathers of controls. In more than half of trans participants (56%), there was a co-occurrence of multi-type maltreatments during childhood. Relative to controls, GD participants had experience of significantly more traumatic forms, including both active trauma and severe neglect.
Trans women, compared to control males: (1) were more neglected by both parents; (2) had more involving, rejecting and physically and psychologically abusive fathers; and (3) suffered more frequently from an early loss of the father. On the other hand, trans men, compared to female controls: (1) were more often victims of intensive rejection, neglect and early separation from fathers; (2) had more psychologically abusive mothers; and (3) prematurely experienced more losses of close relatives and friends.
Based on these statistics, it’s imperative to consider attachment and trauma and how they could play a role in bringing to light conflicts and defenses of trauma and early relationships with parental figures. As healing professionals, we can help GD patients to integrate trauma and relational ruptures with the goal to empower them to reflect on its impact on their lives and, eventually, its relevance on treatment decisions. That is ultimately what I believe is the therapeutic equivalent of the Hippocratic Oath in medicine which is to do no harm.
Related Stories:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5799708/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3043071/
https://www.medicalnewstoday.com/articles/321483.php#3
