How to do your own differential diagnosis (and why it’s total bullshit that you would have to.)

I often resent the expectations made of detransitioners. In my dream world when you detransitioned there would be therapists you could actually access who have experience with patients going through detransition, you could say (publicly!) whatever you wanted about your choices and why you made them without being made into a symbol, and people wouldn’t demand much ideological loyalty out of you, since fundamentally you’re just a person who went through a weird, hard thing.

The main responsibility I wish detransitioners could opt out of would be being assumed to be a potential resource for helping other gender dysphoric patients discern what medical interventions they should get done. People immediately think that’s what we should be doing with the experience. The assumption is the best use of our regret is minimizing other people’s potential regret.

My problem with this assumption is that there are people who get paid to be resources for patients discerning what they can do to manage their gender dysphoria, and they’re not called detransitioners, they’re called gender therapists. Currently those therapists, and doctors who specialize in medical transition, are subject to intense social and professional incentives to skip a recommendation of the WPATH Standards of Care, which states that as part of the informed consent process for a patient obtaining HRT, the patient should be screened for “anxiety, depression, self-harm, a history of abuse and neglect, compulsivity, substance abuse, sexual concerns, personality disorders, eating disorders, psychotic disorders, and autistic spectrum disorders” (pg. 24.)

That’s an extensive list of conditions to screen for. The SOC explicitly states that the staff member performing these screenings doesn’t need to be a mental health professional, they could be “another health professional with appropriate training in behavioral health and with sufficient knowledge about gender nonconforming identities and expressions and about possible medical interventions for gender dysphoria…” (pg. 24.) How exactly does a non-mental health professional screen for a list of conditions that includes both personality disorders and autism spectrum disorders? (This becomes a bigger mystery when you consider that the only mental health professionals that are empowered to make ASD diagnoses are M.D.’s and psychologists.)

Even more concerning is that I keep meeting detransitioned people who received nothing that could be conceptualized as a “screening,” from any staff member at the informed consent clinics they got their HRT from. I know multiple women whose informed consent process consisted of being handed a couple of pieces of paper to initial repeatedly and sign, stating that they understood there may be unknown harms associated with HRT. Signing an informed consent agreement generally has the legal effect of protecting a doctor from liability should the treatment cause the patient harm, but unless there’s an actual mental health screening that takes place that’s NOT an informed consent process that meets the recommendations of the SOC. (My non-lawyer brain does wonder if a clinic skipping the mental health screening might invalidate those informed consent agreements for the purpose of a malpractice claim if the patient was experiencing severe MH symptoms when they signed the agreement)

Anecdotes from my circle of detransitioners are a data set with obvious limitations. It’s important to remember that as a public detransitioner I’m in a perfect position to hear the stories of people who had negative experiences at informed consent clinics. Unfortunately there’s no study data to contest my anecdotal information, because there’s no one collecting data on the processes of informed consent clinics in the U.S. This means we don’t have any numbers about what percentage of patients are getting healthcare that meets the recommendations of the WPATH SOC.

I’m not a fan of self-diagnosis when it comes to mental health conditions. Our ability to be insightful about the repeating patterns of our experiences, cognitions, and moods is limited when our mental health is compromised. (It’s limited even when we’re pretty close to healthy because of the human condition!) My own experience of self-diagnosing my combination of dissociative and obsessive symptoms as proof I was transgender, and having this self-diagnosis affirmed by every professional I crossed paths with, adds to my aversion to self-diagnosis.

The idea that someone suffering from mental distress has a responsibility to discern the cause of and best clinical response to their distress is irrational, unfair and extraordinary in medicine. When you have stomach pain and go to a doctor, it’s not on you as the patient to have figured out what’s causing your stomach pain. We accept that you probably didn’t go to medical school and you aren’t expected to have all the knowledge someone who did go to medical school has. It’s also an important difference that when you have stomach pain, your cognitive patterns aren’t being impacted by the same condition you’re trying to find relief from. That’s different than having mental health symptoms- for many mental health conditions a definitive aspect of the condition is that you can’t think rationally about the cause and effect behind your distress.

The promotion of transition paths in which people are steered away from the mental health screening the SOC recommends is deeply irresponsible. We are valuable people. That does not change because gender has been torturing us. The medical community should value us enough to take the time to find out all the relevant information that could assist us in either having the most effective and happy transitions we can have, or steers us to the most effective alternative clinical responses for our distress. Those women I know who were given 3 page informed consent agreements to sign in the waiting room? All smart, soulful, insightful, kind, good-hearted people that this world needs around. They are absolutely worth the time and expense associated with a comprehensive mental health screening.

You could take that list from page 24 to a psychologist on your own and ask to be evaluated for all the listed conditions. A counselor, a marriage and family therapist, or a social worker can’t evaluate you for autism spectrum disorders, only a psychologist or an MD can do that. I don’t have a recommendation for how you get the money together to see a psychologist. If you’re thinking about going to an informed consent clinic for HRT I’m not confident that you have health insurance. If you do have health insurance, maybe they’ll pay for the visit if you’ve hit your deductible. You’ll need to be referred either your MD or your counselor/therapist/social worker and they’ll need a good reason to give you the referral. I hope they’ll agree that discerning the cause of your sense that your body is incorrect is a good reason. If you’re relying on a Medicaid plan I am also hoping the wait lists for the psychologists available to you are not 6 months long. (Part of my job is assisting families who need their kids evaluated by psychologists or psychiatrists for IEP’s in school, and at least around me those wait lists are no joke.)

If seeing a psychologist to get a comprehensive evaluation is not a possibility for you because of expense, my very reluctant recommendation is you take what assessments you can on your own. In a just world this would not be the patient’s responsibility, but in the spirit of radical acceptance you should make the effort to be as informed as you can be. These are my recommendations based on the personal histories I’ve heard in the detrans community.

The Dissociative Experiences Scale measures the severity of daily dissociative symptoms. A prominent trans activist once wrote an article arguing that trans people experience more dissociation than other people, thus if you dissociate often it’s another reason to think you might be trans. I would counter if you dissociate often you want to be extremely cautious regarding choosing to modify your body and the power dynamics of the relationships you enter into. (Not just romantic- workplaces, friendships, family.) It’s super common for people who dissociate to self-harm and to end up in controlling, abusive situations. (Hey, feeling pain is better than feeling nothing, right? Wrong. If you’ve had that thought run through your head recently that’s a giant red flag your mental health is compromised and you should put big decisions on the back burner.)

The Self-Harm Inventory measures not just deliberate self-harm, but compulsively seeking out risky experiences. If you have a history of self harm PLEASE put the big decisions on the back burner and see a counselor to resolve that pattern. Being self-destructive through medical transition is a hell of a set of choices to recover from, so you do want to double check that your choices, when looked at with a very logical and detailed oriented eye, will increase your effectiveness and happiness. You’ve probably had fantasies of the person you were supposed to be since you were a kid. The content of those fantasies is different than the outcome medical transition can create. So just make sure you really do want the likely, logical outcomes your choices will create. (I know happy trans people! In their transitions they were very clear about the difference between their fantasies and their lives.)

The Yale Brown Obsessive Compulsive Scale can give you some insight into both the severity of your compulsive behaviors and obsessive thought. I didn’t know until I took it that, while I’m not particularly compulsive, I’ve got a prominent obsessive streak. (Wouldn’t you know family members tried to tell me that for years? I’m good at dismissing haters. Too good.) Being a person who is relying on an obsessive, persistent fantasy to cope with life is distinct from being a person who would be made most happy by modifying their body to be perceived as another sex. Again, I know people who were made happy by exactly those choices! You want to be as real with yourself as you can be about what’s a realistic plan and what’s a coping mechanism.

The PTSD checklist is a tool for identifying common trauma symptoms. Again, please see a counselor and resolve these symptoms before making big decisions. Unresolved trauma has a big impact on our ability to think clearly about taking care of ourselves.

Finally, here are screenings for alcohol abuse and drug abuse. You want to be sober when you make these choices. In part so that you’re being smart about these choices. The flip side is even if you are being smart, medical transition is going to increase some areas of stress in your life. Often it will be unexpected, surreal stress, and you need to make sure you’re in a place where you can handle tolerate the stress without substances. Alcohol and drugs are not great for helping us stay embodied, they’re not great for helping us be realistic in our judgments, and they’re straight up terrible for anxiety and depression. If you end up transitioning, you need to make sure you can handle that stress without picking up an addiction. If you are already dependent or addicted, you are not currently in a healthy place where you can be smart about medical transition. Get to that place first before taking any action.

There’s a common misconception about detransitioners that we’d like everyone to detransition. I think there’s a stage of detransition when the detransitioning person is processing horror at both how they were assisted in harming themselves and the low standards the trans community holds doctors to, and sometimes people deal with that by getting emotionally invested in specific individuals and their choices. As part of my own self-care I refuse to engage on that level with another person’s choices. I can’t make you take your time with this. I can’t make you be careful. I can’t make you agree with me that you deserve doctors who consider you valuable enough to give you some pretty basic assessments. Beyond the occasional essay I’m not going to try. I do think at some point in the future you may agree with me that it’s an extraordinary situation when patients are so completely on their own in discerning where their distress is coming from and what they can do to alleviate it. In the mean time, stay safe.

Written by

LMFT/LPC, detransitioner, advocate for taking it easy

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