Pride: An Opposite Action Against Unnecessary Shame

June is Pride month. Here’s why clinicians should be focusing on transgender and nonbinary patients all 12 months of the year.

Let’s face it: Being part of a historically oppressed community can be stressful. We know that individuals who identify as transgender or nonbinary face higher rates of discrimination at all levels of American society.1 This discrimination ranges from microaggressions to lack of accessibility to frank violence, including verbal harassment and physical assault. The peer-reviewed literature describes the impact of oppression in minority stress models.2 Cumulative exposure to discriminatory environments create systemic health care disparities and worsened outcomes for historically oppressed communities.3

More recent data evaluate the transgender and nonbinary community’s resiliency through the building of positive coping skills and psychosocial support.4,5 These resiliency factors protect transgender and nonbinary individuals from the deleterious health consequences of systemic oppression. The list of resiliency factors is long and includes community building, activism, and role modeling. But, when discussing what best fights the harmful effects of systemic oppression, the common denominator remains: “pride.”

Attribution theory—developed by Fritz Heider and later modified by Bernard Weiner—examines the thought processes behind behaviors, their causes, and their effects.6 People make sense of the world around them by grouping behaviors into those that are internally or externally controlled. Society tends to view more favorably and support those who are deemed not to have control over their problems. Conversely, society often punishes those whose problems are believed to be caused by internal or individual-level factors and decisions. Attribution theory has been tested in multiple policy areas, including issues surrounding historically oppressed genders.6 Such theories are important to explain the impact of medically incorrect ideology that being transgender or nonbinary is a personal “choice” that can be prevented.

Many in the United States misunderstand, hate, fear, shame, or frankly deny the existence of historically oppressed genders. The majority of Americans have never personally met someone who is transgender or nonbinary.7 Those who know a transgender or nonbinary person are more likely to believe that a person’s gender can differ from their sex at birth. Gender minorities have existed in various cultures for centuries, including in people indigenous to North America.8 Although often stigmatized, in some cultures gender diversity has been legally recognized, celebrated, or even revered. In the 1950s, a psychologist named John Money proposed a theory of “gender neutrality” at birth.8 He described gender as developing from a socialization process occurring after birth. Although initially criticized, such theories are becoming more accepted in Western society as rights for nonbinary-identifying individuals are gained. Therefore, it is important to note that gender is a sociocultural construct, and the acceptance of gender diversity is impacted by exposure to transgender and nonbinary individuals.

Shame can be internalized when it is placed on individuals of historically oppressed genders in a broad range of formats and contexts. Persistently invalidating environments can lead to emotional dysregulation and associated areas of interpersonal dysfunction.9 This is unfortunate, since gender identity (referring to an individual’s innate internal sense of self) is not a choice and is found to be largely stable even amid exposure to nonaffirming environments and external pressures to “detransition,” or to go back to living as the sex assigned at birth.10

As a transgender physician, in moments when I begin to internalize oppression, I remind myself of Marsha Linehan’s groundbreaking work creating treatment for borderline personality disorder. Linehan developed dialectical behavioral therapy, which has now been proven to be effective in multiple clinical trials to reduce suicidality and inpatient hospitalization in various high-risk conditions.11 Dialectical behavioral therapy skills have been applied to the treatment of clinical distress caused by gender dysphoria.9

In dialectical behavioral therapy, Linehan teaches the use of “opposite action” when emotions do not fit the facts of reality.12 Experiencing shame, for example, produces the action urge to hide or avoid the shaming stimulus. The opposite action of an urge to hide is sharing the secret with others who will accept it. Over time, an individual practicing opposite action will develop feelings of pride. They will realize there is no fact-based reason to continue to feel shame.

Obviously, facts are important. So, what are they?

Gender diversity is real and exists. Gender-affirming environments, policies, and medical care are lifesaving and should be normalized.13 Being transgender or nonbinary is nothing to be ashamed of. Instead, many from these communities provide the world a sense of creativity and inspiration.

And then some of the facts are more saddening, particularly in the fields of medicine and psychiatry. Throughout the last century, patients of historically oppressed genders and sexual orientations have faced forcible silencing, violence, and medical atrocities. These horrors occurred at the hands of our predecessors and continue in many ways today. Our treatment of and experimentation with these communities include castration, lobotomies, electroconvulsive therapy, and aversive conversion therapy, all based on pseudoscience.14 The lack of our profession’s support for these communities persists in ongoing legislation and policies that ban transgender and nonbinary children from receiving medically necessary and lifesaving health care.15-17

We have pathologized normal diversity, identities, behaviors, and practices in our diagnostic and statistical manuals for far too long. For example, homosexuality was removed as a listed disorder in 1974, but persisted in various forms as an ego-dystonic condition until 2013.18 Transgender identity existed in various forms of the manual and persists today as an ego-dystonic condition known as gender dysphoria, a condition expressed by some transgender and nonbinary individuals.8 A gender dysphoria diagnosis is often necessary to justify coverage of lifesaving interventions to public and private health care insurers. This implies that a transgender or nonbinary patient is required to concede a mental health diagnosis before attaining medically necessary health care. In many ways, those in the psychiatric profession remain the gatekeepers of gender expression in patients from historically oppressed genders who wish to undergo a transition.

Yet, through it all, the transgender community has championed pride alongside their cisgender allies. The numbers within the community grow, particularly in younger generations, where 2% identify as transgender.19 And the pride celebrations every June have become bigger, bolder, and more accepted by mainstream society.

Now is the time we need pride the most. We cannot succumb to fear or shame, and we cannot stand down to threats of violent oppression. We are under attack by a conservative legislative agenda that ignores our medical evidence and peer-reviewed literature. We must fight for our patients to receive the medically necessary health care they deserve. We should call in allies to actively engage and support those of historically oppressed genders the other 11 months of the year. We need to mentor, develop, and promote trainees and colleagues from historically oppressed communities, and include them in the research and peer-review process. We should value their professional contributions and provide them with authorship and payment for their lived expertise (which is what I prefer to call lived experience).

Most of all, we need to remain composed, as we are the eye of the hurricane. And this month, our pride will sweep across the country.

Dr Lerario (@MPLerario) is a board-certified neurologist and graduate student of social service at Fordham University, where they perform activism and research for the transgender community. Their work has been published in Neurology: Clinical Practice, the Journal of Speech Language and Hearing Research, and the Harvard Public Health Review Journal, among others.

References

1. James S, Herman J, Rankin S, et al. The Report of the 2015 U.S. Transgender Survey. 2016. Accessed June 10, 2022. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf

2. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychol Bull. 2003;129(5):674-697.

3. Streed CG, Beach LB, Caceres BA, et al, on behalf of the American Heart Association Council on Peripheral Vascular Disease; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Radiology and Intervention; Council on Hypertension; and Stroke Council. Assessing and addressing cardiovascular health in people who are transgender and gender diverse: a scientific statement from the American Heart Association. Circulation. 2021;144(6):e136-e148.

4. Matsuno E, Israel T. Psychological interventions promoting resilience among transgender individuals: Transgender Resilience Intervention Model (TRIM). The Counseling Psychologist. 2018;46(5):632-655.

5. Testa RJ, Habarth J, Peta J, et al. Development of the gender minority stress and resilience measure. Psychology of Sexual Orientation and Gender Diversity. 2015;2(1):65-77.

6. Haeder SF, Sylvester S, Callaghan T. Shared stigma: the effect of LGBT status on attitudes about the opioid epidemic. World Medical & Health Policy. 2021;13(3):414-435.

7. Minkin R, Brown A. Rising shares of U.S. adults know someone who is transgender or goes by gender-neutral pronouns. Pew Research Center. July 27, 2021. Accessed June 10, 2022. https://www.pewresearch.org/fact-tank/2021/07/27/rising-shares-of-u-s-adults-know-someone-who-is-transgender-or-goes-by-gender-neutral-pronouns/

8. Turban JL, de Vries ALC, Zucker KJ, Shadianloo S. IACAPAP Textbook of Child and Adolescent Mental Health: Vol. Transgender and Gender Non-Conforming Youth (2018th ed). International Association for Child and Adolescent Psychiatry and Allied Professions; 2018.

9. Sloan CA, Berke DS, Shipherd JC. Utilizing a dialectical framework to inform conceptualization and treatment of clinical distress in transgender individuals. Professional Psychology: Research and Practice. 2017;48(5):301-309.

10. Turban JL, Loo SS, Almazan AN, Keuroghlian AS. Factors leading to “detransition” among transgender and gender diverse people in the United States: a mixed-methods analysis. LGBT Health. 2021;8(4):273-280.

11. Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63(7):757.

12. Linehan MM. DBT Skills Training Manual. Guilford Press Publications; 2015.

13. Dolotina B, Turban JL. A multipronged, evidence-based approach to improving mental health among transgender and gender-diverse youth. JAMA Network Open. 2022;5(2):e220926.

14. Blakemore E. Gay conversion therapy’s disturbing 19th-century origins. June 28, 2019. Accessed June 10, 2022. History. https://www.history.com/news/gay-conversion-therapy-origins-19th-century

15. Cole D. Arizona governor signs bill outlawing gender-affirming care for transgender youth and approves anti-trans sports ban. CNN Politics. March 30, 2022. Accessed June 10, 2022. https://www.cnn.com/2022/03/30/politics/arizona-transgender-health-care-ban-sports-ban/index.html

16. Goodman JD. How medical care for transgender youth became ‘child abuse’ in Texas. The New York Times. March 11, 2022. Accessed June 10, 2022. https://www.nytimes.com/2022/03/11/us/texas-transgender-youth-medical-care-abuse.html

17. Miles K. Families of transgender youth in Alabama face some difficult choices. National Public Radio, National (Morning Edition). May 3, 2022. Accessed June 10, 2022. https://www.npr.org/2022/05/03/1096075578/families-of-transgender-youth-in-alabama-face-some-difficult-choices

18. Drescher J. Out of DSM: depathologizing homosexuality. Behav Sci (Basel). 2015;5(4):565-575.

19. Jones JM. LGBT identification in U.S. ticks up to 7.1%. Gallup. February 17, 2022. Accessed June 10, 2022. https://news.gallup.com/poll/389792/lgbt-identification-ticks-up.aspx