The Making of Me by Rhea Askins

My first year of transition as a practicing psychotherapist in Ireland

Reflective Article

The Making of Me

By Rhea Askins

My first year of transition as a practicing psychotherapist in Ireland

Introduction

82% of transgender (trans) individuals have considered ending their lives. And suicidality is highest among transgender youth with the rate of attempted suicide at, roughly, 40% (Austin et al., 2020).

I was 30 when I realised that I was transgender. For me gender exploration had begun years prior to that, through clothing. At any opportunity, home alone, I sifted through my mother’s clothes and makeup, anxiously listening out for my family’s return. Then I would have to put myself away again until the next opportunity. My dysphoria – a sense of ill-fit between one’s appearance and inner sense of identity – solidified into secretive, ashamed elation. Contrary to anything I had ever known before. My epiphanic path is one of many among the transgender community.

In 2020, California’s Cedars-Sinai Medical Center found that many transgender people first experienced gender dysphoria at the age of 4. Transgender women lived an average of 27.1 years and transgender men lived an average of 22.9 years before starting to transition. For many, dysphoria was almost unbearable due to a lack of early mental health supports, that could have eased their gender transition and improved their quality of life.

It is worth highlighting some phrases before proceeding further:

At birth, doctors assign us to one of two common gender groups (boy/ girl) based upon the genitalia visible to them at that point; this is described among the transgender community as being either assigned female at birth (AFAB) or -male at birth (AMAB). Should a person assigned to a gender group later begin transition they are commonly referred to as being a transgender male (AFAB but transitioning to the male gender) or transgender female (AMAB but transitioning to the female gender).

In 2020, a study was published on the Cedars-Sinai hospital website under the title “Most gender dysphoria established by age 7.” The study found that 78% of transgender men, and 73% of transgender women surveyed first experienced gender dysphoria by age 7. In this online journal article, study leader Maurice Garcia, MD, wrote a statement that applies simultaneously to the current situation of gender care services in Ireland:

“While policies regarding transgender people’s rights are evolving, what is still clear and unchanged is the unequivocal need for accessible health care for transgender and gender nonconforming people of all ages.”

The National Gender Service (NGS) should be a support for transgender people who apply for interview via their waiting list. However, the situation in reality is quite different, based upon accounts from other transgender women I have met. The main consensual complaints about the NGS are as follows:

1) You may wait a decade to interview for an assessment to decide whether or not they deem hormone replacement therapy or blockers (medication blocking undesired hormonal effects) necessary. 2) Many transgender people that I have met report feeling infantilised by a gatekeeper culture in the NGS. They highlight that medically-trained interviewers assume to know what is best for another autonomous individual, expecting applicants to comply to expected gender norms if they are deemed to have gender dysphoria by the NGS. This culture could be easily improved by adopting an informed consent approach, which would make service users feel believed and supported, rather than having to prove who they are. 3) Politicians and other people who are not, and have never experienced what it is like to be transgender themselves, are making decisions on transgender healthcare in Ireland.

In my experience there are not enough adequate supports for transgender people in Ireland, and those seeking surgical transition have no choice but to travel abroad. In all, when attempts are not made, or are half-made to assist or embrace a group of people, ostracization and unwantedness can often be the message received by minority groups.

In recent years there has been progress, but there is still much to be done. An increase in the visibility, and normalisation of transgender people in mass media will reduce the perception of transgender people as something alien to those who do not know much about us. This and education are key if change is what we seek.

Finding Trans

I first discovered the term transgender online, aged 12. Before that, I had seen the exploitation of gender variance as infamous plot twists and punchlines in movies like “Ace Ventura: Pet Detective” and “The Crying Game”. In all, I never found gender variance to be shocking or worthy of laughter. Instead, I wondered why this perfectly valid form of personhood was considered to be climactic at all – because I identified with the representations I was seeing on screen; it just took me a long time to realise what that identification really meant for me deep down. I had assimilated the innately anti-transgender rhetoric espoused by mass media through their exploitation of it – which caused me to wrestle heavily, over years, with the possibility that I could in fact be that “punchline”, or “shocking reveal”; that I could in fact be transgender too.

During school I always preferred the company of other girls, wanting to express and dress like them, instead of suppressing my personality as a quiet, sensitive, apathetic boy to survive without sticking out of the crowd. Then I came alive at home, surrounded by my art supplies, videogames, books, and close family. But one vivid memory comes to mind above many others when I think about my historical gender variance and the path and the time that I took to realise that I was transgender:

I was six, wearing a pair of yellow, wooden, floral clogs, and a cousin’s Snow-White dress from the old Disney cartoon. I felt so free that day; it just felt right. But then my uncle arrived home and I suddenly froze up inside, sick, as though I’d been caught doing something terrible. But that ecstatic, aligning early dressing memory was just one of many events that made no sense to me for thirty years of my life – and it would, one day, lead to every neat and tidy box I ever thought existed exploding into a billion pieces, taking much of my old mindset and Self along with it.

Discovering my truth came as quite a shock. I began developing my new skin, my new identity; embracing a chance to live as my true self. An anxious leap into a brighter future, and one I would have regretted rejecting. That was the start of the making of me.

My aim, now, is to therapeutically support the LGBTQ+ community because meeting others with shared experiences to mine truly alleviated much of my social anxieties, feelings of isolation, difference.

Transition in Practice

I was excited to be transitioning and moving towards a greater sense of alignment between who I was inside and how I looked outside. But I was concerned that changes in my appearance could impact my clients and my career. Doubts arose over my future in the field, but I chose to take it all in my stride.

I learned of Lucie Fielding and other trans mental health professionals practicing in America, and this made me feel less alone, but in Ireland and this had either never happened, or was never publicised in the country’s history before. In the event that there had been transgender psychotherapists practicing in the past or at the same time, I toyed with the tentative title of Ireland’s first “out” transgender psychotherapist. However, shortly thereafter I decided that such a title did not define me or the work I did in my therapy practice. I include my gender identity in my professional biography as I am proud of the woman I am, and truly believe that representation is essential if gender variance and the LGBTQ+ community is ever going to be accepted and normalised.

Finding peers and supports proved to be the greatest gift I could have given myself early-on, and this is usually one of the first things I explore with clients who are presenting with issues related to gender, grief and sexuality.

The sense of isolation and loneliness can leave many transgender people feeling 1) societally unacceptable due to archaic, systemic social constructs that oppress many and are viewed as “right” simply because of how long they have been accepted as the benchmark, 2) lost and 3) alone. The social pressures to supress your true identity and to conform are deeply damaging psychologically and can be mortally debilitating, which is also why representation and support networks are essential for transgender people.

Although not every transgender person can, or chooses to pursue the same avenues in terms of transition there are some that have become synonymous with the transgender community. The common types of transition some people choose to undergo in order to achieve a greater sense of alignment between who they are inside and how they appear and are perceived outside include:

Social transition, during which a person can alter their dress, gait, voice, and daily practices to that of their true gender. The option to medically transition exists, which involves undergoing HRT in order to feminise/ masculinise one’s physical appearance, hormones, and mindset as a result. And there is also the option to surgically transition which can include, but is not limited to, facial-feminisation surgery (FFS), “bottom surgery” – or gender-confirmation surgery (GCS), and “Top surgery” – or breast augmentation (BA)/ mastectomy.

In February of 2022, when I had started to disclose my newly-realised truth to my nearest and dearest, I began my social transition by undergoing a year’s worth of laser hair removal. At that time, over coffee, one of my transgender peers shared a story with me about the day that she decided to open up a conversation about her gender identity with her former therapist.

Outside of the family home for fear of being overheard, sitting in her car due to her sensitivities around the subject she was preparing to disclose that night, her mouth was dry, her heart was racing when she got to the point of phrasing her feelings, that she might be transgender. Her therapist’s comment to follow this hugely trying piece of self-disclosure shocked me, due to its ill-informed and potentially damaging consequences and lack of ownership.

He stated very confidently: “I don’t think you’re gay.”

It is mandatory for mental health professionals to engage in on-going training. However, in this instance – which is not the only event of this type that I have encountered – said therapist displayed ignorance; gender and sexuality are two separate things – just because a person is transgender does not mean that you can connote their sexual orientation or preferences from that fact. Also, clients who may belong to a part of the LGBTQ+ community may come to a therapist without a need to discuss their sexual orientation or gender identity; human beings are multifaceted and one part of us happens to be our gender identity, and sexuality.

I have integrated learning from my friend’s experience into my work with LGBTQ+ clients who come to speak with me.

Simultaneously, I started seeking a source for HRT. At that time, I knew little of the years-long waiting lists and the reports of systemic bias towards people who looked as though they would blend in after transition, and conform to a heterosexual orientation.

When I met and enquired with a local GP about starting HRT, I discussed my fears about certain aspects of transition that I had read about in my research. I expressed concern over testosterone blockers, and the idea of what I had heard described as “chemical castration” online. They stated that they didn’t think I really sounded sure of what I wanted, simply because I expressed concerns. Ultimately, they did submit my details to the glacial NGS’s waiting list. Again, this is another example of a damaging, ill-informed professional whose utterances could have severely impacted the mental health of a person who was seeking compassion and assistance. We need to do better!

Despite the transphobic encounters I was exposed to, I ventured forward and eventually discovered a telemedicine company with whom I began the process within four months, avoiding entry into a lengthy waiting period of, at least, three-and-a-half years before being interviewed to find out if I would be approved to begin HRT.

At this time, I am saving for, researching and planning the next parts of transition that I feel I want to pursue, but my sense of wholeness has already improved since I started HRT through the dignified informed-consent model that assumes an adult individual can make decisions for themselves; unfortunately for many, Ireland does not yet use the informed consent model.

Surgical transition is often sensationalised in media as a punchline, or big reveal, which – due to its reach and popularity – implies that being transgender is akin to a secret, thus invalidating the existence of transgender people as people in disguise amongst us. When, really, being transgender is as valid a form of personhood as any other; how we present, express ourselves and live our lives is not up for discussion as many presume it is. A person who is assigned female or male at birth, and is comfortable with their assigned gender identity is not challenged or tasked with proving their validity as a person who dresses, sounds or behaves a certain way.

I encourage allies and transgender people who read this piece to question the implicit superiority of the expectations that are being placed upon transgender people by society. You do not need to prove yourself to others, sound a certain way or try to fit a mould to suit another person.

I began my transition in order to live and feel more whole and authentic, but exposure to attitudes encouraging beauty standards, body types and behavioural alterations in order to blend in, just added more and more of somebody else, and less and less of me.

How much was I going to alter before I lost myself in my transition?

Instead, I decided that I would transition towards empowerment, the person that I wanted to be, and bring with me all facets of my old identity – passions, interests, etc. – that still felt like a relevant part of me. It is with this autonomy that I proceed with my transition, holding firmly to this solid ground when facing negative client reactions or any of the other challenges that the professional side of my transition may present.

Conclusion

A diary I had cracked in order to chart the year 2022 bears scratchy black felt and browned, pressed leaves on the cover; it was given to me by my godmother for my 30th birthday. I had started to journal one night in February of that year – exactly one year ago, at the time of writing – and the very first page begins:

30. Feels so young and so old at the same time… but this time feels different. I’m not sure what series of events led me to this but years of ignored gender diversity notions suddenly landed on me [tonight]. My body and diet and mind have been turned upside-down, I’ve lost weight and I can’t stop facing the fact that I’ve been unconsciously suppressing and that is that I want to be a woman…”

As it appears here, so it flowed from my black pen then. Needless to say, I was dumbfounded. It explained so much that never made sense before; inexplicably fluctuating confidence levels and comfortability in myself, challenges involving intimacy, self-shaming behaviour for myriad innocent acts, and the suppression of any inklings of gender diversity and/ or sexuality into the realm of fetishisation and dismissal (Serano, 2007). Soon after my epiphany, I entered sessions with a therapist specialising in issues related to the LGBTQ+ community and I am an advocate for such manoeuvres of selfcare in sessions with my own clients today.

Since then, I have learned that my gender identity has always been female and that my journey was not as much one of “becoming” female, but of changing things in my life, for myself, in order to align my inner sense of identity and my external appearance which then creates an alignment of the self as a whole. My experience in realising that I am transgender has brought me to face anxieties, truths and challenges with a proactive mindset and I have met many other amazing women, on similar journeys to mine, who have adopted a similar perspective.

“Passing” matters to transgender people for a host of reasons – two of which can be either personal satisfaction, or personal safety in the world. If you do not stand out, the belief suggests, you stand less of a chance of being discriminated against or having hate speech or violence befall you. However, the more I experience, the more I realise that there is no definition of “womanhood” – only my own, that is the definition I am pursuing. This realisation is one that alleviates much of my earlier concerns regarding voice pitch, walking gaits, body size and shape, and mannerisms; for every recommendation I hear in order to “pass” more successfully as a woman in the world, I encounter a cisgender woman who contradicts such overgeneralisations.

It is through my own personal and professional journey that I have come to realise that transition is part of life for everyone. And it is my hope that those in need of my assistance might find me through this piece. Further, it is through compassion, understanding and education that you can help the push towards embracing the LGBTQ+ community going forward. Your kind word or action of love may just be what saves the life of a person who is simply attempting to be and become who they know themselves, inside, to truly be.

References

Austin, A., Shelley, C. L., D’Souza, S. & McInroy, L. (2020). Suicidality among transgender youth: Elucidating the role of interpersonal risk factors. Journal of interpersonal violence, 37, 5-6. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/32345113/

Garcia, M. (2020). Most gender dysphoria established by age 7, study finds. Cedars-Sinai. Retrieved from: https://www.cedars-sinai.org/newsroom/most-gender-dysphoria-established-by-age-7-study-finds/

Serano, J. (2007). Whipping girl: A transsexual woman on sexism and the scapegoating of femininity. Seal Press.