What research participants said:

The person was not transsexual, they were misdiagnosed, the real issue was not addressed, the person felt they needed to accept their body, had to accept social role/expressions.

They lost people in their lives, lost partners, lost children, were lonely

They were disappointed in the surgical outcome.

Passing was not possible.

They transitioned for someone else.

What therapists think are poor prognostic indicators:

Older age when transitioned

Someone who would be perceived as transgender, not as male or female

Heterosexual before transition

Mental health problems

Criminal record

Military service

Unrealistic expectations

Ambivalence towards surgery

Substance use

Self mutilation

Things I think right at this moment and I’m sure I’m forgetting something:

That before we accepted that people could be genderqueer or in between or neither, people who were those identities were forced to transition.

That people made the best guess at fixing what felt wrong with them at that particular moment and that as they lived and grew discovered it didn’t fix the problem. Sometimes living as the other gender gave folks new information with which to understand themselves.

That expectations are mismatched with reality and that too can be connected to poorly done informed consents. Genital surgery changes what is between one’s legs and will not make anyone accept someone or stop discrimination. I think very tall women and very short men suffer as well. Some therapists say to not address that, that in the old days people had to be passable to get surgery. I suspect it’s not an either or. It’s not whether I can live with the person being unusually tall or unusually short or having stereotypical features of their natal sex, it’s whether they can.

That informed consent is inadequate as it is actually done.

That surgical outcomes have vastly improved from when many of the studies were done.

That there is peer pressure to transition. That young people coming of age today come out into the queer community and not necessarily the gay, lesbian or bisexual communities. People have complained about a movie that a group of young people made about GLBT issues saying there was too much in it that was trans. That is looking at youth through a very old lens. We need new glasses. Young people today come out into the queer community which has trans youth. They also come out into a world where people explore body modification in a way that did not exist previously. They can pierce and tattoo and so taking the leap to sculpting with medical technology isn’t much of a hop.

My belief too is that the lesbian and gay communities have always abdicated responsibility for youth, partly because we have been struggling so much on our own. Partly because we are seen as child molesters who are recruiting youth. Partly, too, because we have never been a community but many micro-communities that are loosely in coalition. Lesbians spent the last two decade learning how to move through the world as parents and gay men have done the same thing the last decade or so. So youth today come out into a different world that is truly not supported much by adults at all.

Another component is that as a society we have medicalized so many problems. This DSM included grief. We have social problems that we have individualized and taken out of the social context.

We don’t resist as a group anymore. We take medication. Years ago people talked about how seeing therapists led to passivity. As a radical therapist, I didn’t buy that. In the same way as we explain what is happening in the brain when one has a psychotic break, we can talk about what happens in the brain when one is traumatized and abused, when one is limited by society or when society sets out to harm specific groups. I am guessing that I was wrong much the same way as any individual can behave one way and the group to whom they belong behaves in another way. As a profession, whether we want to or not, we’re becoming increasingly medicalized because of insurance and the standards of care that insurance companies endorse. But they endorse what they want to pay for and see what they want to see.

Some gender nonconforming people are inadequately diagnosed and that is on therapists and PCP’s but sometimes it is on individuals who intentionally won’t let us do our jobs because they expect we will limit, or harm or deny their identity or they see manipulating medical and mental health professionals as a radical act. People self diagnose a variety of medical conditions and go to their PCP who says, no, it’s actually this other condition. That happens here as well except that clients likely will reject a clinician saying it is real but may have another origin.

That issue is connected to bias and stigma about mental health. People in the US don’t take mental health seriously, and still see it as willful or malingering or exaggerating. It’s easy for people to self-diagnose when it comes to mental health related issues since it’s not like a medical disorder. If I see trauma and the person sees only their gender dysphoria, I will be perceived as a barrier and as denying the individual’s self-awareness or undermining their autonomy. Unlike medical doctors, what therapist do and know doesn’t count in a society that doesn’t respect mental health. We constantly compare gender to the gay liberation movement. Unlike being gay or lesbian, there really are other issues that can look like gender dysphoria and people who talk with friends or read on the internet about how to present to us to get what they believe they need are doing the best they can to fix something that is terribly wrong inside them but we all have to do a better job.