Psychotherapy for trans people

Is therapy completely worthless, or might it have some use?

Reparative therapy has always failed, because of how it envisages health, and what it attempts to do. Aversion therapy attempted to make the victim associate their desires with pain, fear, discomfort and misery. If the therapist, claiming that the person needs to control their desires, to fit in with normal society, prevented the person from acting on their desires, that would be a “success”.

For me, any organism seeks out its own health and good. Just as a broken bone knits together, so the mind turns towards what will fulfil it. People are different, with different gifts, and that fulfilment is different for each. The individual does not cross-dress because she is disgusting, and wants to be disgusting, as my mother said, but as the best way she knows of approaching health. The question would be, why does she cross-dress? What does it achieve for her?

The aim would not be to prevent the person dressing, but to find options for her. Is there another way of proceeding, which she prefers? The choice would still be the patient’s. Barry wrote of a person who transitioned role and was going to have surgery, but then reverted and found a partner.

You might favour transition if you imagine that men should be a certain way, women should be a different way. If men are generally more “masculine” whether this comes from nature or nurture or social construct, you may be more comfortable expressing yourself as a woman. Even if you don’t believe these restrictions are appropriate, you might observe that they exist, and feel you will be more accepted after transition.

Intensive psychotherapy would find your wounds and scars. What are you repressing? What shames you, what do you fear in yourself? We are a social species, and trans women in particular are intensely pro-social. We are made in the image of God, loving, creative, powerful, beautiful. What do you want from life? Again, the question is not “Why are you so broken that you contemplate transition?” It is “Who are you?” I have addressed this question after transition, as everyone must, some time.

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The effects of hormones

Taking oestrogen reduces your blood pressure. Or not.

There was a study published in 2015 of 23 trans women and 34 trans men commencing hormone treatment, measuring blood pressure, BMI, lipids and sex hormone levels at the start of treatment and six months after. Trans men continued menstruating throughout the time. The trans women’s blood pressure reduced from 130 to 120.

When a doctor takes my blood pressure I become tense, and they tell me this may give a falsely high result. Trans women beginning treatment are likely to relax. They are on their way, so their stress will reduce. So blood pressure reduces. These people are undergoing such an extreme life change that it is impossible to isolate one possible cause of change of blood pressure. “The study had insufficient power to detect other associations,” the summary says, and I wonder, decades after doctors started giving us hormones, that so little has been done to find what they do to us.

I wanted to read the article Priorities for Transgender Medical and Health Care Research, but it will be published on 1 April.

From 2007, there is an NHS leaflet, addressed to both trans men and women. The aim of hormone therapy is to make you feel more at ease with yourself, both physically and psychologically. That is, the fact of taking hormones, whatever effect they have physically, affirms your transition so makes you feel better. Some people find that they get sufficient relief from taking hormones so that they do not need to change their gender role or have surgery. I had decided to transition: I am transsexual, therefore I will transition to expressing female. A more fluid way of proceeding, trying things out, would have been better. I railroaded myself.

Hormones will affect your appearance, but you need to be realistic (the leaflet says). Fat may be redistributed, hair loss may reduce though probably not significantly reverse, facial hair may be easier to electrolyse, you may grow breasts though that might take years- ten years, in my case. You may have blood clots in brain, heart or veins: a woman I met in Thailand had a stroke a few months later. You should stop smoking, which increases risk: I was told you could not have hormones until you stopped.

If you start to feel better this is a good sign that you are having the right treatment. However, I railroaded myself. I committed to the whole thing. Moving forward on that track made me feel better, because I thought I had the solution, waiting at the end of the track.

You may find erection and orgasm harder to achieve. You may become infertile: it is not known when. You may become less interested in sex. This was a good thing for me, as I was so thoroughly ashamed of it, but I might have found better ways of living with it.

It is unethical and impossible to conduct a study comparing transition with other modes of treatment. People wait for years to see an NHS psychiatrist, and have definite ideas of what treatment we want. From Lili Elbe onwards, doctors have seemed delighted to have a subject they could try things out on, rather than merely wanting to find the best way to help, which might be to do nothing.

“You will need to take hormones for the rest of your life.” I was told I had to, to avoid the risk of osteoporosis.

Study: Effects of Cross-Sex Hormone Treatment on Transgender Women and Men.

Patient leaflet– A guide to hormone therapy for trans people, pdf.

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The pink fog

Do not transition. Self-respect is a human right. Transition is too great a price to pay for self-respect.

Transition is a way to get self-respect, and so is tempting. You have never felt you are a real man. You feel less. You try to make a man of yourself, and always feel inadequate. You have the shameful secret that you cross-dress.

But what if you are trans? Then, Being a Man would be obviously wrong for you. You could express yourself in a way which fits your personality. You would be free. You would have The Answer- you know why you have never fitted in, and what you can do about it. The delight you feel when contemplating transition and the misery you feel at presenting male is confirmation. Having a long and difficult journey to reach freedom, every step you take on it delights you. You are in the pink fog, a wonderful term I got from my friend Joanna Santos, whose whole post is worth reading: Dreaming about the aspects you think you would relish about being a woman can lead you into a deep pink fog which can sometimes confuse things.

You ask yourself if other theories fit. Autogynephilia, perhaps: “Men trapped in men’s bodies”. No. I don’t think Renee Richards entirely cuts it either- “a lifelong committed transvestite”. Some object to the term transvestite, coined by psychologists and formerly used as a diagnosis of a disorder. “Cross-dresser” was coined by the community. Cross-dressing is a harmless way of reducing stress. If it arouses you sexually, that is nothing to be ashamed of: the clothes are lovely, and humans get horny at all sorts of things. Yet that is not all you are. You are not a failed man with a disgusting habit, and the habit does not define you. It is a harmless habit, though. It need not be all your life.

My other theory is that you are a “beta male“. You don’t fit “alpha” models of masculinity, but beta is the upgrade! You have ways of being which are a blessing to a community. You are soft, gentle, peaceful. You are empathetic and conciliatory, and like to fit in- this is a blessing, but has been distorted, to cause you to try to be a Real Man.

If you have been shamed by not being a Real Man, transition is a way to self-acceptance and self-understanding; however if you have been shamed, that is a psychic wound which can distort how you see the world and yourself. You went along with it for a time. You tried to make a man of yourself. You could not, and your shame increased, but you could not because it was not right for you. Find a therapist who can help you appreciate your own beauty. If you find someone who will love you for yourself, rather than for a false image of you, that will help.

I believe there are trans women who will be fulfilled by transition. I would never want to cut off the path to transition. But it is not the best way for everyone who starts it, and you may face discrimination and hostility.

Rather than a real life test, where you must change your name and agree never to present male again, I would recommend a period of exploration, to include extensive psychotherapy. You could present female or male, and you could try to express your feminine side while presenting male. What do you want?

Who are you, really?

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Labiaplasty

It is not necessary to have a vaginoplasty, unless you wish to be penetrated. The alternative is a labiaplasty.

When I was considering the operation, we called this the “cosmetic op”, as if vaginoplasty was not also cosmetic surgery. Surgeons competed to create the orifice- should they use penile skin, or scrotal? What about hair removal? How deep would they go? Dr Suporn of Chonburi, Thailand regularly achieved seven inches. A friend was angry at her psychiatrist for recommending orchiectomy more than a year before vaginoplasty, because she felt this caused her penile skin to shrink so that she could only get one inch. Then, colo-vaginoplasty is the option.

The neovagina needs to be dilated. There are no rules. I spent four hours a day with a stent in me, which I found painful and debilitating, and which was not enough. The body does not naturally cleanse the orifice, so you need to wash it out, and it can be smelly. I was told not to have my anus penetrated sexually, as that could breach the wall of my vagina. If you do not want to be penetrated, it may not be worth it. Yes, you may want to be penetrated later, but if you are not interested in a relationship with a man, consider labiaplasty.

Here there is a small orifice, about an inch deep, and labia are created from penile skin, which is more sensitive. Most or all of the glans can be retained, so that you may still be sexually aroused, and stimulated. You can make love.

You will no longer be able to swive. You will not penetrate another. And you cannot lie back and be ridden in the same way as you might have before. And, before, you could lie back and be stimulated- the glans has only changed position a few inches. It is worth considering what you gain.

I found my desire to be passive and receptive in lovemaking mindblowing and distressing. I knew that as a Real Man I should be active. It seemed to be what women wanted. A line from radio comedy- a woman asks derisively, “You want me on top, waggling my hips up and down?”- stays with me, as archetypal female contempt for someone less than a man. Well, now I can’t swive, though I could use fingers or tongue on another. Either operation frees me from that Manly role, though perhaps finding the right partner or accepting my desire might have freed me in a better way. Sex with another was unpleasant, and I did not see how it might be better. And when I was passive, and a woman played with me, I found it humiliating.

I did not consider “the cosmetic op” a serious option, seeing it as less than vaginoplasty, as what an older person might choose, or someone with health difficulties restricting the time they should spend under anaesthetic. I wanted to resemble a woman as much as possible. If there is an option, think what might be good about it, however ridiculous it seems.

The other alternatives are orchiectomy, retaining the penis, and no operation at all.

What do you want?
Why do you want that?
How might it be achieved?

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Trans and homophobia

When I realised I was lonely and I wanted a relationship that’s what got me thinking well, I don’t want to be with a man, so the other option is to be with a woman. I thought I can’t be with a woman as I am because it just feels wrong. I saw a documentary on TV and I didn’t realise that women could transition into men so it was from that and realising how unhappy I’ve been all my life, that’s what I wanted to do.

Oh God, I thought, that’s just what gay people who want to drop the T from LGB say we are: it is internalised homophobia. I can only love a woman if I am a man. Being a lesbian “Just feels wrong”. I was bothered to hear this on Radio 4, Ovid in changing times. It also had an old interview with Jan Morris:

-Is it not the height of arrogance to assume that, having your penis taken off you can say “I am now a woman”?
-I have not said that. I am a person who felt self to be of feminine gender so adjust body to fit my inner feelings.

Later we hear her say, I was in a difficult situation, not certain of myself, I tried to be more one or the other. Now I know just what I am, I’m in the middle, really, I’m a bit of each. It’s a comfortable place to be.

We adjust what we say about ourselves, to fit what others will accept. I don’t know about “comfort”. Possibly rather she felt reconciled to the journey, she was not resenting or fighting it. Though I loved her for this:

-Are you ever able to stand up and see an element of absurdity?
-No. I think it is beautiful.

Of course I am absurd. We retain the concept of “normal”, even if we recognise that Diversity is a good thing, and I am certainly not that. I wanted something which many would call ridiculous, and I cannot justify except that I wanted it, because it was the way I could best express who I am. Emotion is absurd, and therefore people are absurd. But I resent on her behalf that allegation of a lack of insight- “Are you ever able”. What arrogance in the interviewer, to suppose that one could only transition if one didn’t understand.

I think I am beautiful.

But that line, being with a woman just felt wrong as he was. He talked of envying his male cousin’s anatomy in the bath, as a child, and how being a girl had been bad enough but puberty was awful; so there are two narratives here. It strikes me he is trying to justify his change, to create as many arguments as he can, and that is one. And gay people would say of course a woman can be with a woman. It is not “wrong”. I would agree- but this trans man said it was wrong for him.

If a gay person objected to trans on that ground, they are denying our existence, our ability to see our nature and make our choices. Phobic? Right back at you.

It does not help that his voice sounded female. Not everyone’s voice breaks properly on T. There is a trans man sound which some men have, a roughened alto, but his was completely female-sounding. The excerpt was without context, beyond that he was 39 at the time: I have no idea where he was on his transition journey.

Narrator: Not every change works out. We are always striving after what is forbidden, Ovid wrote, and coveting what is denied us.

Gender Incongruence of Adolescence and Adulthood

Would you rather be diagnosed with “Gender Incongruence” than “Transsexualism”? The International Classification of Diseases, which is worldwide unlike DSM which is for the USA only, is being revised. It may influence the DSM. Rather than being classified as a “psychiatric disorder” GD, or GI, might be placed in a separate chapter for “Sexual and gender related health”.

How you frame a diagnosis affects what people think of it, and what you do about it. If it is a psychiatric diagnosis, is it merely that psychiatrists are most qualified to make it, or does it stigmatise you? I believe I am a woman, or at least I want to express myself as a woman, and perhaps alter my body. The medical help I want is hormones and surgery, and counselling support to manage that change successfully and comfortably. Together, these alleviate my distress. From the point of view of fourteen years after transition, I want people to have assessment to find whether anything underlies that distress and desire, and to explore less dramatic options for alleviating distress, but from the point of view of immediately before transition I had made up my mind, and would call that assessment “gatekeeping”, which is oppressive. We know what we need. Give it to us.

Should distress (or “dysphoria”) be part of the diagnostic criteria? Well, that is a way to take away stigma from sexual fetishes. Getting aroused by high heeled shoes or whatever is perfectly healthy, and not a diagnosis for a classification of diseases. Only distress might justify medical intervention- not to make the patient normal by taking away the desire or arousal, but to alleviate the distress. That is an imperfect analogy for us. Doctor, I am not distressed at all by wanting to transition, only by society’s norms that I should not, and because of how difficult it is. I am not mentally ill. Medical intervention is justified because I am gender incongruent.

Making distress irrelevant, and focussing on the need for hormones and surgery, makes other outcomes apart from transition seem less appropriate. Then I would have found that liberating; now I find it disturbing.

Is a psychiatric or other medical diagnosis a stigma? I don’t think diagnosis is more of a stigma than being trans itself is. Cis people realise doctors are involved: if they accept me, they accept that; and if they do not accept me, that makes it no worse. The diagnosis might reduce stigma- if I transition, people might think I was being unwise, but having a doctor go along with it might reassure them.

We experience discrimination. I don’t feel adjustment of the narratives we use to explain ourselves will alter that, much: I do my best. This is what I want to do. This is who I am is the necessary basic narrative- if you can’t say that, no narrative will reassure you except temporarily; if that does not let others empathise and accept you no other narrative will.

I am pleased that I suggested “incongruence” as a diagnosis in 2012, and that the ICD is now catching up. What I want for our kind is:

from society- acceptance, however we choose to dress or present
from doctors- discussion of all the options, understanding of all the pitfalls of “work male, play female” and support to do that if chosen; and making us take full responsibility for hormones and surgery so giving them to us if we ask. A Real Life Test- you can be rewarded by hormones and surgery if you express female for a year and Never Lapse- is completely the wrong answer. Instead we should be encouraged and supported to play and explore.

Medical treatment needs paid for. We need our medical treatment, including surgery, quite as much as any other person needs medical treatment. Single payers or insurers should pay for it.

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Post-materialist

I have been a post-materialist since about 2000, but learned I was one yesterday. Before, I had understood it as a matter of spiritual maturity: people move from a position of condemning non-conformists and out-groups to seeing that every human being is doing their best, under difficult circumstances, to agreeing with Blake’s line, “Everything that is, is holy”.

I welcome diversity, which is part of the flourishing of each person, for the good of humanity. This is part of my identity, how I see myself as a good person.

Then the NYT explains me, quoting Ronald Inglehart: when people grow up taking survival for granted it makes them more open to new ideas and more tolerant of outgroups…bringing greater emphasis on freedom of expression, environmental protection, gender equality, and tolerance of gays, handicapped people and foreigners. It is no merit in me, but an accident of birth. This was shocking, even if in retrospect obvious.

As a post-materialist, it means I should seek understanding of my out-group, which previously I thought of as less mature: if you feel under threat, you circle the wagons. Less mature in me does not mean less mature in others. What is possible, for a person?

It might be that if you can make people feel safer, they will be less angry with the outsider, foreigner or non-conformist. Mr Trump and Mrs May go the other way, encouraging the anger. If you feel looked down on by “liberal elites” who tell you not to feel that anger, you may be tempted by moneyed elites who tell you the anger is right. Trump, never worried about survival, bends others’ anger for his own ends. Encouraging the anger, making people feel OK in themselves and rejecting liberal scorn, pleases them so that he does not need to give them anything worthwhile. How do you benefit, really, from excluding refugees? What gain is there, from making Muslims feel as excluded, powerless and angry as you feel?

Are Trump’s patsies capable of empathy, or of recognising their own feelings? Unable to admit how angry and frightened he feels, a man clings more tightly to his world-view, we are right and everyone else is wrong, and those people over there are a threat. This is simply the truth for him, separate from any anxiety he feels about being able to pay his rent.

Is Trump going to permit discrimination against LGBT on “religious grounds”? The NYT said a draft executive order has circulated, but administration officials denied it would be adopted. They take the pulse of the nation. Will this energise their support, or the resistance? What are people saying about the proposed order? The order would increase hatred, and disempower non-conformity.

I am post-materialist because I am in one of the first hate-groups to be victimised. Thank God for the Windrush, I say, bringing Afro-Caribbean workers to Britain, beginning our long march to tolerance from which I benefit.

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Transphobia III

What is transphobia? I think of it as phobia, ranging from mild discomfort to visceral repulsion, but how does it arise? I asked, and a friend wrote that it is A system of oppression, frequently so deeply embedded in society that it can be presented as “natural”, which pressures people to assume that sex and gender are the same thing, that gender assigned at birth is ‘correct’ gender, and that conforming to gendered expectations is important.

Conforming to gendered expectations. This does not distinguish revulsion at me, expressing myself female, from revulsion at an effeminate man. I would have to pretend to be a Real Man to escape this obloquy. This could alter my view of TERFs, who have a disproportionate emphasis on trans issues, rather than more serious feminist concerns. Even though they themselves do not conform to gendered expectations, they hate my non-conformity

-because it mirrors their own, embracing what they reject
-or even because they project onto me their hatred of their own non-conformity, which makes life so difficult.
-or perhaps because when they discover RadFems, and feel at home, this is one of the ways to show they fit in with that group.

We should be allies. We suffer equally under the system of oppression, but that system pits us against each other. And they would say sex and gender are not the same thing, but that sex is a matter of reproduction, gender a matter of culture.

One said that people are scared when others do not conform to norms. We feel safe in homogeneity. I hope that when you can accept your own variation, you can accept that of others. She went on to say that we should not ask people to repress feelings of discomfort, but instead avoid wrongful behaviour. Exposure to trans folk may cure the transphobe, who will become more comfortable with us as s/he gets to know us- which is just how you treat arachnophobia.

One referred to playing the trans card, claiming trans discrimination where there is a real reason for different treatment. Having so few cards, I might be tempted by that; and when I am talking of how trans folk are wronged I could object to the conversation being turned onto wrongs we commit. Yet we should not play the trans card, it is an act of weakness. Oppressing others entrenches oppression, exacerbates the distance between us.

The transphobic person feels selfrighteous about it, and will have arguments why their behaviour is justified. Cis folk will not be so alive to the smell of transphobia. We can see it, and trying to persuade others no, it’s really transphobic, is horrible, bringing back to me my worst experiences of exclusion.

There is institutional racism. I read of a diversity course where the trainer posited every example as “What do we think of them?” rather than expanding the we to include groups with differences.

There is internalised transphobia. I feel wrong; being treated as wrong revives all those feelings of despair and rejection; I restrict my activities to avoid situations where I fear prejudice. I feel wary in pubs.

One said the word is wrong. It is hatred, not fear. I would say it is an aversion, and the suffix “phobia” though originally meaning fear has been expanded to mean aversion, as in arachnophobia again.

“It gives ignorant, narrow-minded, stupid people a label.” Um. No, I don’t feel that is helpful, because it suggests they are incorrigible, and I hope no-one is incorrigible. It is worth working to reduce transphobia.

One said, having experienced sexual violence from men, she was wary of men and so uncomfortable who she perceived as a man but who wanted to be treated as a woman. I sympathise. Her “instinctive feelings about her safety” arise from her experience, not just dislike of the unfamiliar. She feels discomfort when her reason- this individual is unthreatening- conflicts with those instincts. Her empathy could conflict, as well: she knows it is unfair to treat me so. I responded without criticising, and she said that she did not mean me: and I wept in relief, for we were not distanced after all, and wept at the distance I feel from others, some created in me, some created in them.

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Guilt and shame

Guilt is “I am bad because of what I did”; shame is “I am bad because of who I am”. It seemed my shame was like an overexposed photograph. All white without distinction, I could not distinguish the truly shameful from the everyday things which set off my jumpy, hair-trigger shame reaction. This could prevent a developed sense of guilt. At times, I felt guilty for things I could not control, such as the tribunals I lost, though not all were winnable or deserving. At others, I could excuse myself, I did the best I could. It seems to me these thoughts did not accurately reflect reality, were not a rational response to external factors but an emotional whirlwind.

I try absolutely as hard as I can. All the time.

English bitch Olivia says, You’re frightened that you’ll have [bariatric surgery] and your life won’t change. It’ll stay as it’s always been because this really is who you are. Or words to that effect. I love that character, and hope she will have some character development, not just be the English Villain. She says and does some brilliant things and, because she is English, the outsider, I have just looked up in Wikipedia that she only appears once again. UK broadcast is about three months behind.

This is the usual digression.

Here’s Ten Metre Tower, in which people climb up a tower to look down on a swimming pool, and decide whether to jump. I have done this. There was a crowd up there, and eventually I jumped, not being able to climb down. Watch them. More than one walks to the edge, then walks back, and fear of falling wars in them with fear of climbing down. As they turn away from the edge, fear of the course chosen grows and fear of the course rejected recedes, so several pace back and forth. I remember the exhilaration as I decided to climb up, then apprehension at the top. I am glad I jumped.

I am a human being. I do my best, and make mistakes occasionally. That experience of pacing back and forth between the edge and the stairs down from the tower is a common one, and I have been climbing down. Do I want to jump? (Metaphorically, I mean, I have never been up such a tower again.) Today it was around going cycling, which would be effort but get me out in the sunshine. I took my bike outside and found the chain badly needed cleaning and lubricating after a lot of riding on wet road. So I cleaned and oiled it, and did a bit of housework.

I have been climbing back down the tower stairs. Or not climbing the tower in the first place. It is where I am, I am unsure how to move on from here, and I will not feel guilt about getting here. I know I do my best. I feel guilt and shame would merely enervate me not spur me on, but climbing down means I climb down more easily. Aspiration or hope would be good.

And it is my judgment, not that of others. I know me better than they do.

That group judge me, and I wondered, if I went to the other group how will I feel about them knowing about the first group’s judgment? Am I ashamed of having this happen to me?

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Strength

Softness goes with strength, at least in toilet paper adverts…

Where is the strength in trans femininity, strength I can feel and exert rather than observe from the sidelines, ruefully thinking that’s just not me, I could not possibly be like that? The manly strength I aspired to when I sought to Be a Man, that idea of strength gets in the way of finding strength now. Strength in endurance does not feel enough.

In Walter Scott, there is a wife who makes all the important decisions, managing her husband so he imagines they are his. On less important decisions she will give way to him, to preserve the illusion. Manly directness fails before feminine wiles. Being clever, I like the idea of cleverness, persuasiveness, winning, but am infected with cultural attitudes ascribing virtue to qualities ascribed to men. Is “virtue” linked to the Latin for “man”? Latin “virtu” translates to “power”.

There is passive strength, strength to endure. When women stand up for themselves, this is called “sassy”- disrespectful- “Feisty”, which derives from the German for fart, meaning unpleasantly intrusive on attention, or “nasty”, a word which women are claiming. They are called “viragos”, aping men. There is huge cultural pressure against women behaving in that way.

Alexis and Barry debated women’s strength here. I don’t know whether Barry’s experience of women’s equality is specifically a Kiwi perspective. She defined strength as self-discipline, ambition, and emotional stability. These are certainly virtues, but unshowy. They will make confrontation easier, but don’t define how one acts in a confrontation. And, convinced of my wrongness, trying to see how I ought to be, has corroded my emotional stability. Because I fear my emotions, they overwhelm me.

Self-discipline, ambition and emotional stability could be stronger in a confrontation, where physical violence is not permitted- like most confrontations in civilised society. Then the attempt to intimidate is as much a sign of weakness as wheedling is, and calm insistence is strength.

Does being “compassionate, tolerant and fair” make one less likely to stand up for onesself? Possibly, but not necessarily less likely to achieve goals. For the most tolerant and fair person there is the moment you dig your heels in. Then emotion comes to the fore, visibly expressed. That is the moment of weakness. “You’re getting emotional” is a trump card- therefore you must be irrational, and wrong. The compassionate person sees the blind spots of the other, and sees how far the other might be led; and so leads consensus. Together, we are stronger.

Of these virtues, I feel emotional stability is the thing I need to work on, by emotional understanding and self-acceptance.

2 Corinthians comes to mind- Power is made perfect in weakness…When I am weak, then I am strong. I went to look it up; and I still don’t get what it means.

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