Personality disorders in trans people

Are trans people more prone to personality disorders than the general population, and if so, so what?

This research, published in March 2020, is trans friendly. It introduced me to the term “medicalised trans people”, that is, trans people who seek out diagnosis, hormones, or surgery, as trans people may simply be, without seeking these things. It finds a cause for personality disorders: as it says, we suffer stressful reactions from others because of our gender nonconformity, and that stress, and internalised transphobia, may cause anxiety or substance misuse.

It recommends that mental health professionals should affirm not pathologize our identity, but take account of these associated mental health disorders and personality disorders when establishing treatment plans. That will help us navigate the transition process, improve our quality of life, and reduce gender dysphoria.

We show a higher rate of anxiety and depression, and other psychiatric disorders, than the general population. They use the Minority Stress theory to suggest that exposure to minority stress may cause personality disorders, and ways of being with other people that mimic personality disorders. Hit me enough, and you make me expect to be hit. Repeated messages that our identity and core selves are unacceptable, which we receive from discrimination, may cause maladaptive personality traits.

Personality disorders might make it difficult to adapt to transition, and reduce our well-being and satisfaction after. They might influence how our gender dysphoria is demonstrated to others.

The researchers found that trans women’s personality profile was closer to that of cis women than cis men, and trans men’s resembled cis men’s.

The DSM V Alternative model for personality disorders (AMPD) diagnoses by moderate or severe impairment in personality functioning, and one or more pathological personality traits- negative affect, detachment, antagonism, disinhibition, and psychoticism. Well, if I have to fight for my rights I may come across as antagonistic. I have been seen as detached: I don’t show appropriate sadness at bad things happening, because it’s just one more thing on top of all the rest.

This could be seen as an adaptive strategy to reduce the effect of stigma on my health, produce resilience, and improve my social adjustment.

And then, I am afraid I do not understand the study. It says,

First, the AMPD dimensional assessment of personality traits indicated that the transgender sample presented, overall, a healthier and less maladaptive personality profile than their cisgender counterparts matched by gender identity. Second, the categorical approach to PDs diagnoses by means of structured clinical interviewing pointed out a considerable prevalence of PDs in our sample: almost half of the included transgender clients exhibited at least one PD diagnosis.

I don’t know if that says we are more disordered, or less. However, the study says the trans sample they assessed 50% had PDs, and that fits previous research. In the general population, large epidemiological studies show a prevalence of 15%. That might show we are more likely to develop PDs.

They suggest we develop personality disorders as a maladaptive way of coping with dysphoria. We develop social isolation, self harm, anger outbursts, and envy of others. Other minorities also have higher rates of PDs.

They found that we showed lower rates of PDs when assessed by questionnaire than when assessed by interview. They consider this shows that we still distrust the treatment process, treating doctors as gatekeepers even if they intend an affirming model of trans care. We want the hormones sooner than they will give them.

The research is here: Personality Disorders and Personality Profiles in a Sample of Transgender Individuals Requesting Gender-Affirming Treatments, by Annalisa Anzani and others.

Researching trans people

If there are half a million trans people in Britain, as Stonewall says, who are these people?

When I transitioned in 2002, about 5000 people had transitioned. Now, it’s about 50,000. When I transitioned, there were two classifications, transvestites who cross-dressed, and transsexuals who transitioned, set apart from the normal people who did neither. Now there are trans people. I heard of nonbinary people years after transitioning. When might the number of people transitioning cease to increase, and stabilise? Obviously before everyone in the world transitions, but before all the 500,000?

It makes sense to me that some people are more trans than others. Dora Richter was an exceptional human being, transitioning against huge pressure. If I had not heard of any other person doing it, I doubt I would have. It was in the culture. The culture makes things possible, but there may also be new ways of being in the future, not thought of yet but obvious once some creative pioneer adopts them.

I heard of three possible motivations to transition: for sex to be better; to relate to other people better; to be more onesself. I wonder if anyone ever transitioned for the mere aesthetic pleasure of the clothes- would anyone admit that, even to themselves? Reasons not to transition might include settling for second-best: you did not have the courage, you did not see how you could, you felt you had obligations to other people which precluded it. But they might in the person’s mind, or in some objective reality, mean choosing something better. You might find you could enjoy sex, relate to other people, and be more yourself without all that effort.

Possibly, many non-transitioning “trans people” have not started transition because the motivation is too weak. Just as Dora Richter was more trans than I am, so I am more trans than they are. Somewhere around the 500,000th person or the 500,001st, the transness would become undetectable.

You are gay if you experience gay sexual desire, even if you never act on it, but are you trans if you do not transition and do not want to? You might be “gender non-conforming” or “gender-variant” instead.

Are they free? Are they happy? The question is absurd….

I took part in that research.

What were my “motivations and desires”? I wanted to be able to be myself. I got that, though it has been a long road, and “being myself” is intensely uncomfortable. The “illusions”, I think, are our illusions of what transition will mean before we do it, but people saying “Don’t join the study!” thought the “illusion” was the idea that one really is of the desired gender.

I thought, qualitative research, going in depth into experience, is mere anecdote. We need to know whether transition improves people’s lives. Who knows whether my experience is representative or outlying? When I fell in love, I told her, I belatedly realised a penis might be useful.

But now I am unsure about quantitative research. There is no control group, as if anyone does not transition after seeing the gender clinic, they are not necessarily comparable. If someone reverts, that does not mean they were necessarily wrong to transition: when I did, I thought I might revert within five years, and try presenting male again, but I could only get to that point through transitioning. Am I happier than before? I appear less successful, in work and social life, but possibly it really is as good as it could ever have been for me.

I don’t want the research to stop people being able to transition if they want to. But then, people always have, some in worse circumstances than modern Britain.

Quantitative research, then. It might help form better categories. Rather than the one size fits all “Transsexual”, what are people really like? Can we create better categories? The work will at least help the researcher, as a doctorate looks good on a CV, but she will also have more experience of trans people which may benefit future trans patients- hers, and those of people who read her thesis. She has done her literature review, and intends to complete in two years’ time.

Agnes Zalewska

Should you participate in research projects on trans?

I found out about Agnes, or Agnieszka, Zalewska’s project “Illusions and realities. Transgender motivations and desires” on facebook, and people were wary. We don’t like the word “illusions” in this context. Some think the “illusion” might be our feeling that we really are of the gender we express. One would not go near it, based on the title alone. However we have illusions before we transition, of what transition will be like, both good and bad- I thought I would be sacked, and I was supported in work.

This is part of Mrs Zalewska’s Doctorate in Clinical Practice at the University of Exeter. She is an accredited psychoanalytic psychotherapist, and worked at The Laurels, the gender clinic in Exeter. Someone on facebook had seen her there, and found her professional and supportive. There are tales about the Gender Identity Development Service, of how some psychs left thinking it gave treatment too easily, but with that caveat I think this makes her an ally. Here is her crowdfunding page.

She is on twitter, but most of her tweets are retweets, generally fewer than one a month. She retweeted this from Marcus Evans, linking his article in Quillette “Why I resigned from Tavistock: trans identified children need therapy, not just affirmation and drugs”. Evans is hostile, and Quillette is a hard-right publication. Evans praises a discredited book. I don’t think a mere retweet shows Mrs Zalewska is hostile, though. She follows trans advocates including the Scottish Trans Alliance, and anti-trans propagandists including “transgender trend“.

Trans people exist. There are campaigners, desperate to portray us as a threat to women- trans women as male predators who should not be in women’s spaces, trans men as dupes being mutilated in a way they will regret. But that is based on a false understanding of who we are. In general I would say British academic research would give a greater understanding of us. Narrowly propagandistic work designed to show we were deluded or dangerous would not be ethical.

Mrs Zalewska is one of the authors of this article, “An exploration of the lived experiences of non-binary individuals who have presented at a GIC in the UK”. Only the abstract is freely available, including this recommendation:

for an affirmative approach that offers space for the non-binary individual to articulate their desires and come to terms with their identity. This exploration must take into consideration the person’s place within a social world that can be transphobic and limited in terms of potential medical interventions. Further research is needed to better understand this marginalised community.

I am not sure how far that takes us. Saying “Of course you’re not nonbinary” will just drive the patient away. Indeed the social world can be transphobic, and that might induce a nonbinary person to stay concealed, conforming to gender stereotypes. If a therapist was overly concerned about the transphobia of society, she might discourage a patient from transition.

Googling a bit, I was amazed to find this site: callforparticipants.com. If I wanted, I could search it to see if any of my idiosyncrasies was being researched atm, then pour my heart out to a researcher and appear in various obscure PhD theses. Everyone should have a hobby. Even though I reveal myself completely here, I find the thought distasteful- to be questioned and summarised.

“The aim of the study is to increase awareness of the people who undergo gender transition.” It will help people considering transition, Mrs Zalewska writes. People transition in considerably more hostile environments than the UK is in 2020. The study is self-selecting. I clicked the ohsotempting button marked “Take part in this study” and got a request for my email address.

I don’t think it can do any harm, to me personally, or generally. I am not sure it will do great good. It would help to understand experiences of transition, but that might be better in quantitative than qualitative research- a representative sample of transitioners. It can never be established if we are happier transitioned, because the groups to be compared- those who considered transition, but didn’t, and those who transitioned- can’t include a proper control.

One might ask the same question about motivations to participate. What are your illusions, motivations and desires, and what is the reality? I can’t see any benefit to me beyond feeling I have given Mrs Zalewska, someone I do not know, a gift. However as the issues she considers with patients include transgender and sexuality, I may help those patients.

Ethnographic research

Have you participated in a research project on trans issues?How might it convey our humanity, or even our experience, to the reader?

I get requests occasionally, publicised through facebook, from undergrads and researchers, and even senior lecturers show an interest. Quantitative research, looking at objective figures, can be useful- how many of us commit suicide? But it cannot say why. Qualitative researchers interview us. How can they make sense of the mass of data? When I participated, the researcher asked each subject the same questions, and transcribed the answers, including ers and ums. This allowed answers to be grouped by question. The more you generalise about the group, the less you know about the person.

My friend did her PhD interviewing trans folk, and has just published a follow-up article- in a journal, behind a pay-wall, but she emailed me a copy. This was my introduction to Grounded Theory. The article, still less this blog post, is no substitute for a general description of Grounded Theory, but may give some inkling.

None of us can give a coherent account of ourselves. I am aware of conflicting motives in me- all those books I never get round to reading, how I wish to appear against how I am really, how I subconsciously consider decisions and debate within myself. This blog contradicts itself. Even if I attempt to tell the truth, the interviewer will distort what I say by their own biases.

In grounded theory, the researcher collects data before attempting to theorise, deriving insights from the data. Barney Glazer, who originated it with Anselm Strauss, specified a series of steps which must be carried out in order for this to work. The finished research represents what the subjects say, whether that is objectively true or not. It depends on the researcher’s openness, and willingness to tolerate ambiguity, and be shaped by the data rather than previous theories.

Knowledge of the previous research literature can allow a researcher to understand the data better- why does the subject feel the need to say X- but can reduce creativity. Jennie values the “Aha!” moment.

The interviewer affects the data. To gain the subject’s agreement, she has to describe the project. One might use Quaker listening: active attention without particular prompts, as the choice of prompts affects the narrative. Knowing that someone valued what I say, I would be enabled to speak: I learned the lawyer’s tactic of just saying nothing, so that the hapless victim will attempt to justify what he has said, and stutter to a halt. The interviewer holds the power: a conversation between equals may not be possible. bel hooks asserts that white women do not listen to black women with attentive respect: trans folk, so universally despised, may be unconsciously disrespected. Our own habitual experience and response may reduce our power. Stating why I had the operation even to a sympathetic listener, I feel the need to justify my decision. If I detected doubt, my attempt to justify myself might become more desperate.

Yet starting from knowing nothing, paying attention to the narrator with no need to contribute to the conversation can be a powerful sign of regard and caring.

The empowered narrator can at least tell the truth as she sees it, without fighting off all the attacks she has ever suffered on that perception. The sympathetic researcher can convey some understanding of that to the sympathetic listener.

My radical feminist friend is preparing an application for funding for ethnographic research on trans folk. Her view that I am not a woman, that mine is an invalid choice constrained by patriarchy, will affect all the work of her research team. Acceptance of transition as a valid choice would affect it the other way. She believes no “objective” view is possible. I feel openness to our position is the only valid way to research us in this way.

Degas, The Tub