The mentally ill elephant in the room

The problems Michael Bachelard describes with gender affirming care are actually problems with our entire psychiatric care system.

Part III

Let’s consider a hypothetical: imagine a young person, Grisha, with all the same concerns and unhappiness as Misha, the young person we meet in the opener to Michael Bachelard’s hideously unethical piece on young trans people and gender affirmation.

Grisha is autistic, depressed, and anxious; they have body dysmorphia and disordered eating; there’s a history of sexual assault and a PTSD diagnosis. But there’s one key difference: Grisha feels secure in their nonbinary gender identity and isn’t seeking to access gender-affirming medical care.

Borderline

We can extrapolate a few more things from this history. Grisha is frequently gripped by fits of misery; they have an unstable attachment style; and they struggle to trust therapists and to participate consistently in therapy.

I’m describing a constellation of traits and experiences that often attracts an incredibly stigmatising label: ‘borderline personality disorder’ (BPD). 

Even therapists and other mental health and social care professionals stigmatise people with BPD. I first learned of the existence of BPD from a counsellor at an HIV/AIDS service telling a roomful of people at a conference that clients with BPD are impossible to work with and were excluded from that service.

The entire category of personality disorders suffers from a similar problem — what does it mean to be told your entire personality is defective?

I take it to mean that your internal system of personal forces and tendencies is in some way contradictory, so that it reliably produces maladaptive responses to your social world and the feelings that world generates in you.

In the case of BPD, the contradiction seems to be a desperate urge to connect with people and seek support from them, coupled with an incredible fear of being hurt and huge difficulties placing trust in those supportive relationships.

Contrary to what the idiot social worker told that roomful of people, BPD is highly treatable. It does take skilful, constant, ongoing, committed therapy; treating BPD is not for the faint of heart. I am certain that I met the criteria for BPD earlier in my adult life, but I came through it, partly through therapy and partly through the love of very smart, committed friends, family, and partners.

Complex trauma

There is a strong argument to be made that BPD could be better understood and described as the kind of personality you develop when you grow up with complex PTSD. 

CPTSD is not acknowledged by the DSM-V, the American ‘rulebook’ for psychiatric diagnoses, but it is acknowledged by the ICD-11, which is the international rulebook for diagnosis of all kinds of medical conditions.

Here’s what I wrote in an earlier post about living with CPTSD:

The prevalent definition of cPTSD comes from Judith Herman, who describes it as particularly acute and ongoing trauma, particularly in childhood; the canonical example is ongoing sexual abuse, which was not recognised as a traumatic stressor in earlier versions of the DSM. 

I understand it slightly differently, however. In the original Latin, complex meant interwoven. For me, it’s not just the ongoingness of the trauma that produces cPTSD; it’s that the trauma becomes part of your personhood. The traumatic experience forms you as a person. Thus, treating cPTSD is fundamentally difficult: it involves changing your whole way of being in the world, not just treating symptoms or modifying unhelpful patterns of behaviour. 

And this is doubly difficult because of the fact of interbeing — our personhood is constituted in and through webs of relationship with other people, animals, objects, places, structures, and rituals. Changing yourself is hard when these webs of relationship remain in place and unmodified.

A person whose personality is not constituted ‘in and through webs of relationship’ with trusted others is going to be buffeted constantly by the conflicting and changeable demands of their emotional world and social environment, without having any safe harbour to rest within or any solid foundations to build upon. (Yes, that’s a mixed metaphor. Obviously, the person I’m describing is a lighthouse.)

It is important to acknowledge that all people with CPTSD (and many people without it) can experience aspects, features, dynamics, of borderline personality, without necessarily meeting all the criteria for diagnosis with personality disorder.

Treatment goals and obstacles

In the hypothetical I introduced above, ‘Grisha’ is grappling with a system of forces, including body dysmorphia, depression, anxiety, sexual trauma, and probably social trauma as well, from bullying, rejection and isolation.

Treating Grisha will involve gently and determinedly building their capacity to trust one person — the therapist — and when deep-rooted trust and support are effectively established, encouraging Grisha to use that relationship as a model for connecting with other people and building out a network that confers friendship, love and support.

However, Grisha and her single parent mother, uhh, ‘Greph,’ are going to face a huge challenge finding this kind of support within the Australian landscape of psychological and psychiatric care services.

Ten sessions of ‘brief psychological strategies’ isn’t going to touch the sides; people with BPD often see their therapists weekly or more often and have constant contact via phone-calls or text as they grapple with emotional crises.

Greph is likely to be frantically struggling to ‘patchwork’ an ad hoc and informal system of care around Grisha’s needs. Grisha’s primary therapeutic relationship is going to be with Greph herself, rather than a trained therapist, and this places a huge amount of stress on Greph, who isn’t trained and very likely has her own stressors and conflicts to deal with.

What’s the point

The opening scenario in the Bachelard piece offers Misha’s story as a failing of the system for gender-affirming care, but it is better understood as a failure of our psychological and psychiatric care system as a whole.

Gender plays a role in the misery that Misha reports, but I want to suggest it is not the primary issue, which is the difficulty of patchworking together an effective care system for a traumatised young person.

This comes through loud and clear in all the accounts Bachelard offers of young people who are struggling with gender transition or ‘regret,’ including Misha, de-transitioner Mel Jefferies, and the children of parents in the ‘gender critical’ support group: ‘Their gender-questioning children are mostly born female and are neurodiverse, and live with mental health issues.’

Bachelard presents laws against conversion therapy as a legal bogey-man: 

But this is complete bullshit. What these laws require is a wholistic approach that takes the gender incongruence into account, rather than treating other aspects of a child or young person’s presentation as a competing explanation for their misery.

Let me spell this out.

The law prevents someone taking active steps to prevent a young person from acting on their desire to affirm a different gender. 

It doesn’t prevent a care provider from saying, right now, and with all you’ve got going on, I don’t think it’s the right time to embark on a journey that involves heavy identity work and exposes you to social vulnerability.

It requires the care provider to treat the whole person, including the trauma history, the mental illness, the social isolation, the personality condition, as well as the experience of gender incongruence and the desire to affirm a different gender from the one presumed for them at birth.

They prevent a care provider from treating gender incongruence and mental illness as competing explanations for the deep-rooted unhappiness.

Conclusion

Apart from the hideously unethical reporting on Misha’s experience, I have serious concerns about the argument made in the Bachelard piece.

First, it presents the experience of a subset of the broader trans population — people who are grappling with personality disorder — as typical of the whole trans community. And while these conditions are certainly more common among trans people, they are not ubiquitous.

Second, it seems to implies that people with mental illness and/or personality disorder should be denied gender affirming care — on the presumption their gender dysphoria is ‘really’ caused by their autism, and/or their trauma, and/or their mental illness, or because they might be confused and regret it later.

Last, returning to our hypothetical enby ‘Grisha,’ a person presenting with all the same problems minus the gender dysphoria would still face an uphill battle cobbling together a care team with all the necessary supports. Their mother ‘Greph’ just wouldn’t get to blame their difficulties on gender affirming care.

I want one thing to be exceptionally clear. The problems Bachelard describes are problems endemic to our patchwork system of psychological and psychiatric care; they are not unique to gender affirming care.

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