I'm curious, to what extent do Psychiatrists work with transgender patients as attendings and during residency?
Transgender patients
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Personally, I have very frequently.
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Keep in mind transgender people are relatively rare in the population, despite the huge amount of media attention regarding transgendered persons these days.
In short, I see one or two a year compared to the dozens of people I see with schizophrenia.
When I was in child psych fellowship we had an attending who specialized in treating such patients and was one of the main providers who specialized in serving transgendered youth in the region, so he saw a lot, obviously.
Like most things in psychiatry, you can arrange your practice so you see a lot of such patients or not very many.
In short, I see one or two a year compared to the dozens of people I see with schizophrenia.
When I was in child psych fellowship we had an attending who specialized in treating such patients and was one of the main providers who specialized in serving transgendered youth in the region, so he saw a lot, obviously.
Like most things in psychiatry, you can arrange your practice so you see a lot of such patients or not very many.
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I saw none in residency, have 2 on my case load now.
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It might vary on where you live. I probably admit a transgender patient once a month or so. In residency, I treated a few at the VA and one or two at a college I rotated at. I live in a place that supposedly doesn't have great trans resources, but I suspect we have more trans people.
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There will be huge geographic variations and it will also depend on the setting you work in and also how much awareness you have. You will find more transpeople in say SF, portland, Seattle etc than you would in some less progressive parts of the country. If you are working in a LGBT mental health center will see more trans patients, same goes if you were working in an HIV clinic, or a community clinic or academic medical center that has specific services for trans patients. As mentioned above, the prevalence of transgenderism is much much lower than say psychosis, but trans people are much more common than were previously though as previous estimates were based on clinic samples and thus grossly underestimated prevalence rates. Also many patients may not disclose their gender identity to you. Psychiatry does not exactly have a good track record in this regard. It is not by accident that at the same time homosexuality was being expunged from the DSM, "transsexualism" made its debut. I have some friends who set up LGBT mental health clinics in the south and were surprised that they got many more trans people coming for services than LGB folk. In fact it may be the case, that despite the prominence of some anti-trans legislation in parts of the country at the moment, that in many of these places it is more acceptable to be trans than it is to be gay. which sounds remarkable to me (but this is what i have been told). Anyway if you don't specifically ask patients about their gender identity, how they would like to be called or referred to - then you may not find out.
Also bear in mind that although "gender dysphoria" is a DSM diagnosis, transfolk are not typically coming to see psychiatrists for this, rather they are another minority group. As such trans identity is incidental (though intertwined) with the presenting problem which is often substance abuse, personality disorder, mood disorders, PTSD psychosis etc. In general transfolk will be seeing other kind of mental health professionals for therapy to help them with transitioning or assessing them for gender affirming surgery etc. Very few psychiatrists are involved in this kind of work, though there are some notable examples (like Dan Karasic at ucsf) and if you went somewhere like that for residency you would have more of a chance to develop a special interest in working with this population. That said, there are residents who trained at places where there were not such services and developed special mental health clinics and got to work with a many more trans people than they would have otherwise. If you build it they will come. Which is not surprising, given the significant victimization they experience, they may be reluctant to come to services that don't specifically aim to work with them. Even then, there are some "services" that are supposed to help trans people that just traumatize them further, particularly some of these "christian" based counseling services...
Sadly, many psychiatrists and others in the mental health field have quite stigmatizing or outmoded views on gender and gender identity (and some places have been known for training transphobic psychiatrists - like Hopkins) so there are lots of barriers to engaging these patients in services. There is also a not insignificant itinerant trans population that is homeless and moves from place to place which is another challenge.
Also bear in mind that although "gender dysphoria" is a DSM diagnosis, transfolk are not typically coming to see psychiatrists for this, rather they are another minority group. As such trans identity is incidental (though intertwined) with the presenting problem which is often substance abuse, personality disorder, mood disorders, PTSD psychosis etc. In general transfolk will be seeing other kind of mental health professionals for therapy to help them with transitioning or assessing them for gender affirming surgery etc. Very few psychiatrists are involved in this kind of work, though there are some notable examples (like Dan Karasic at ucsf) and if you went somewhere like that for residency you would have more of a chance to develop a special interest in working with this population. That said, there are residents who trained at places where there were not such services and developed special mental health clinics and got to work with a many more trans people than they would have otherwise. If you build it they will come. Which is not surprising, given the significant victimization they experience, they may be reluctant to come to services that don't specifically aim to work with them. Even then, there are some "services" that are supposed to help trans people that just traumatize them further, particularly some of these "christian" based counseling services...
Sadly, many psychiatrists and others in the mental health field have quite stigmatizing or outmoded views on gender and gender identity (and some places have been known for training transphobic psychiatrists - like Hopkins) so there are lots of barriers to engaging these patients in services. There is also a not insignificant itinerant trans population that is homeless and moves from place to place which is another challenge.
If you are in a private practice setting, and have a patient that is transgender who is going through hormonal treatment or gender reassignment surgery, I would recommend sending that patient to a university setting. During hormonal treatment, I've found it very difficult to control mood symptoms.
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There's probably on average at least one transgender person on the inpatient unit at (hospital) at any given time and another down in the ED. (Just based on my experience, which is not long enough to have high confidence in this estimate.)
H
HarryMTieboutMD
Obviously what happened at Hopkins with both John Money and Paul McHugh was egregious and bigoted (respectively), but Paul McHugh is like 80 and stuck in the Perspectives... he's not really academically relevant anymore, so I'm not sure why the media keeps asking for his opinion on Caitlin Jenner, bathroom laws, etc.
That said, I think psychiatry needs to be cautious about how much we instigate ourselves into this issue (I don't think we need to at all). As Splik said, most patients should have access to a therapist with experience in this area specifically to guide them through the process, but I think doing things like "full psychiatric evaluations" prior to sex change surgery is unwarranted, stigmatizing, and almost draconian. When I see a transgender patient (for depression, bipolar, psychosis, substance, etc- not for so called "gender dysphoria") I am attuned to some of the trans-specific issues they have, but I am ultimately treating them for a psychiatric issue... this is no different than how any other specialty should interact with these patients. Paying attention to psychosocial issues is what any good physician should be doing.
Sure, we can get into long-winded debates about what pronouns to use or whatever, but most trans patients I have had have recognized my relative unfamiliarity with trans issues in general and are happy to educate me.
That said, I think psychiatry needs to be cautious about how much we instigate ourselves into this issue (I don't think we need to at all). As Splik said, most patients should have access to a therapist with experience in this area specifically to guide them through the process, but I think doing things like "full psychiatric evaluations" prior to sex change surgery is unwarranted, stigmatizing, and almost draconian. When I see a transgender patient (for depression, bipolar, psychosis, substance, etc- not for so called "gender dysphoria") I am attuned to some of the trans-specific issues they have, but I am ultimately treating them for a psychiatric issue... this is no different than how any other specialty should interact with these patients. Paying attention to psychosocial issues is what any good physician should be doing.
Sure, we can get into long-winded debates about what pronouns to use or whatever, but most trans patients I have had have recognized my relative unfamiliarity with trans issues in general and are happy to educate me.
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They keep asking his opinions because they like dissident viewpoints and I am sure he is only to happy to use his position as chair emeritus at hopkins to give his opinion.
Actually I think these patients should have a full psych evaluation prior to gender affirming surgery though I don't think it should have to be with a psychiatrist, and in the same ways as say transplant evaluations, most of the time it is not a psychiatrist. a good social worker can probably do a better job of a thorough psychosocial evaluation than a psychiatrist. However there are cases where people who should not have had surgery who did. For example there was a prominent psychiatrist in the UK who lost his license after being overly eager to support patient's request for surgery which included a woman who had schizophrenia and a grandiose delusion she was jesus, prompting her wish for surgery. She was not actually trans at all (and she did get the surgery). I know someone who clearly has borderline personality disorder and frank identity diffusion - he had some surgery and then later decided he wanted to be a man again - probably should never have had the surgery because never truly identified as a woman but thought men were too misogynistic and had identity diffusion. Obviously there are a lot of trans people who are borderline but this was different. And of course very severe mental illness could impair someone's capacity to make an informed decision or have unrealistic expectations. So I think it can be useful -it's more the way that it is done. There should not unnecessary barriers but evaluation should support patient's autonomy to make authentic decisions consistent with their beliefs and values.
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It's obvious the way McHugh writes that he's coming from a very biased position, but is there any good data supporting/refuting his claim that people who get gender reaffirming surgery don't get the... let's call it existential relief?... that they want from the surgery?
Because of specifics regarding the (admittedly small) cohort of trans people I have seen, I do worry that surgery for those (specific) patients may do more harm than good.
Because of specifics regarding the (admittedly small) cohort of trans people I have seen, I do worry that surgery for those (specific) patients may do more harm than good.
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So are you just curious, or do you want to do this kind of work?
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The thing about doing one off psych evals in people who really want surgery .... I'm not for it. I did bariatric evals at one point. And people you've never met who really want a surgery know what to say for an hour. It's really only over time that the red flags pop up.
Like I had a patient who asked for a letter for a gastric bypass. She was my patient. When I'd first met her she told me "Food is my drug of choice!" She spent most of our acquaintance seeking stimulants.
She spent that appointment saying the right things though. I still denied her. Then she got MAD. She yelled at me. She said, "I'm taking my daughter to Europe in the fall (this was the summer). How am I going to fit into my bathing suit?!"
She then told me I was a terrible doctor, reported me to the action line, fired me and sought a second opinion from an outside provider. Who recommended the procedure.
She was declined based on my report. Point being, if she'd only gotten the outside eval she'd be trying to shove cookies into a stomach the size of a peanut right now.
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Like I had a patient who asked for a letter for a gastric bypass. She was my patient. When I'd first met her she told me "Food is my drug of choice!" She spent most of our acquaintance seeking stimulants.
She spent that appointment saying the right things though. I still denied her. Then she got MAD. She yelled at me. She said, "I'm taking my daughter to Europe in the fall (this was the summer). How am I going to fit into my bathing suit?!"
She then told me I was a terrible doctor, reported me to the action line, fired me and sought a second opinion from an outside provider. Who recommended the procedure.
She was declined based on my report. Point being, if she'd only gotten the outside eval she'd be trying to shove cookies into a stomach the size of a peanut right now.
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Yes, there's quite a bit. Of course, measures of QoL/psychological health in people who received this surgery are typically lower than the general population—but they're higher than their previous selves.
A few links:
http://link.springer.com/article/10.1023/A:1024086814364
- "Participants (232 MTF transsexuals) reported overwhelmingly that they were happy with their SRS [sex-reassignment surgery] results and that SRS had greatly improved the quality of their lives. None reported outright regret and only a few expressed even occasional regret. http://www.sciencedirect.com/science/article/pii/S1158136006000491
- The subjects proclaimed an overall positive change in their family and social life. None of them showed any regrets about the SRS.
https://www.skane.se/Upload/Webbplatser/USIL/Dokument/Sjukhusbibliotek/Johansson, Annika.pdf
http://europepmc.org/abstract/med/11758101
There's also a lot of evidence linking hormonal treatment and QoL/psychological functioning, etc. Obviously, not the same as surgery, but worth acknowledging. Example:
http://link.springer.com/article/10.1007/s11136-013-0497-3
Notably, rates of regret are extremely low.
I can understand why people are skeptical that sex-reassignment/gender-affirming surgery really helps people. But I think that, for many people, this indicates that deep down they really view transgenderism as a defense mechanism or something, where it's masking some deeper emotional conflict. (People used to think the same thing about LGB people too, but now we acknowledge there's nothing pathological secretly underlying LGB orientation and we just tell people to live their lives.) But all the evidence indicates that the problem is really quite simple: a person's subjective experience of gender is strongly and permanently different from the biological sex. And that's why surgery works.
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So the main problem with SRS and transgenderism is obvious, but not stated often enough-they are still their natural gender. If you are born male you will always be male and if you are born female you will always be female.
The vast majority of heterosexual people will not want to enter into an intimate relationship with someone of the same sex who has had surgery to be the opposite sex.
Splik's response in this thread was a little disappointing.
The vast majority of heterosexual people will not want to enter into an intimate relationship with someone of the same sex who has had surgery to be the opposite sex.
Splik's response in this thread was a little disappointing.
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Who is that a problem for? You or the person who is transgender?
A lot of the people who specialize in things like this aren't going to be in a university setting(some are, some arent). I don't understand why anyone would be 'sent to a university setting to control mood symptoms'. Psychiatry is relatively unique relative to most other fields in this regard.
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So? The vast majority of heterosexual people don't want to enter into an intimate relationship with the vast majority of heterosexual people either. And yet the world spins on
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Thanks for the reading. It looks like--distilling things way down--early-onset TS and other general behaviors related to the (typical expression of the) desired gender/sex are important predictors of positive outcome.
I simply think it's a topic that requires a great deal of sensitivity but should also come with a great deal of skepticism--I can't think of any other psychiatric diagnosis (GID) for which we (currently) recommend a permanent physical alteration. Looks like actual rates of GRS are much lower than the general incidence of TG (from what I've seen) and patients who undergo GIS are probably significantly different from the TG patients I've seen in the context of (mostly consult/emergency) psychiatry.
Many endocrinologists who specialize in hormone replacement for transgender patients are university affiliated. Easier to coordinate and communicate with psychiatrists under one roof.
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The university in my area created a special program for this disorder. Not all areas and academic settings will have it. But Jett is right, they do have hard to control mood symptoms.
Perhaps speaking to things being regional, the way people talk about this issue in my area (at least, those who claim to have relevant expertise an interest) is quite different from the idea of the psychiatrist having to act as a "Skeptic" who should "Recommend a permanent physical alteration". From a therapy standpoint, one should be prepared to help patients explore their own gender narratives, encouraging fluid expressions over time without a focus on reaching a point of absolute conviction regarding what their gender will be for the rest of their lives. In this frame, it is reasonable to help a patient explore the meaning of either hormone therapy or gender reassignment surgery, and not be in the position of having to recommend or permit these steps. Patients who are requesting hormone treatment or surgery do not need a recommendation from a psychiatrist, rather, and evaluation should focus on ensuring that the patients wishes are not the product of a psychiatric process, and ensuring that their desire to have the physical characteristics of the opposite gender is enduring.
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The one person I see is a young lady who is the product of sexual assaults and cannot stand to look at her body while wanting to cut her breasts off and has started hormone injections.
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nvm
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This is an obvious false equivalence. If anyone can't understand why, please feel free to PM and I will explain it. It's sad and a little disconcerting that 4 people liked a post so lacking in logic. I hope it was based on ideology.So? The vast majority of heterosexual people don't want to enter into an intimate relationship with the vast majority of heterosexual people either. And yet the world spins on
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Can you address @birchswing then? His post says the same thing, really, but gets around this response of yours.
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A lot of places have moved to having folks conduct these as forensic evals, if they have the resources. Though this practice is resource limited. A good forensic psychiatrist doesn't base the impressions on the one hour interaction.
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No, it was a joke. If you need help understanding the finer points of witty comments, PM me. It's a little disconcerting that you missed it so completely. I'm assuming it was based on ideology.
In any case, your original post is the illogical one: you start by confusing sex with gender, and end (somewhat bizarrely) by implying that the sexual interests of heterosexual people are the final word on the ethics of SRS.
FYI, of the dozens of trans people I've met, about as many have been in relationships as the cisgender people I know. Often their partner is queer or also trans. Sometimes their partner is straight. A partner is a partner.
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this is a fair point....although when I think about it no reason the patient cannot see a community psychiatrist and their endo at a university medical center. I just found the idea that patients with 'hard to control mood symptoms' should be referred to a university medical center(for mental health treatment) insane.
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Specialized programs will offer more resources for them to engage with than just a generalist due to the specific nature of the illness.
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If I was requested to do a psychological evaluation for a transgender surgery, I would have a difficult time stating that they could not make this decision for themselves so long as they have decision making capacity and if they lacked that capacity, then it would be up to a court to determine them incompetent. Which diagnosis or mental state should be an exclusion criteria? I guess there could be concerns such as a patient with Borderline PD that might change their mind a month later. (Oops, too late. 😱) Should that really be our decision and why?
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No, it was a joke. If you need help understanding the finer points of witty comments, PM me. It's a little disconcerting that you missed it so completely. I'm assuming it was based on ideology.
In any case, your original post is the illogical one: you start by confusing sex with gender, and end (somewhat bizarrely) by implying that the sexual interests of heterosexual people are the final word on the ethics of SRS.
FYI, of the dozens of trans people I've met, about as many have been in relationships as the cisgender people I know. Often their partner is queer or also trans. Sometimes their partner is straight. A partner is a partner.
If you go through said poster's history, you'll see you're not exactly arguing with this board's best and brightest mind.
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Let's please stay on topic and avoid personal attacks. This thread topic should not bring up personal opinions about transgender issues.
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You're on the right track, in that patients are evaluated for capacity, and lack thereof precludes the surgery. There should not be a diagnosis or mental state that is an "exclusion criteria" beyond presentations that render them incapable of demonstrating capacity.
Your example of severe BPD is a good one. If someone can't describe a consistent choice, they typically lack capacity. Presentations on the psychotic spectrum also often could not demonstrate capacity.
And? What does that have to do with being sent to a university medical center vs someone in particular in the community?(for their psych issues, not the endo issues)
Refer to the person who has made this niche area a focus of their practice....they may be at a university center but they may be in the community. Either way where they are really doesn't matter(unlike in other medical specialties. In this case you are going to be referring to a specific person, not an academic center in general.
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I think there's a community assumption that you get the best medical care (including psychiatric care) at your university training center. Not really true, but an assumption.
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Of course on that token, just because a specialized program exists, doesn't mean it's necessarily any good. The local HCA-type standalone hospital that I've moonlighted at supposedly has a transgender program, though no one has ever been able to express to me what makes it any different from the rest of their units.
...of course that didn't help stop a transwoman with raging BPD from throwing a full-blown tantrum at me at 3AM in the ED when said hospital refused to take her as a transfer ("______ Hospital is the ONLY place that can address my transgender issues! If I stay here, I'm going to get substandard care!") because of a medical clearance excuse that could only be translated as "we just don't want to deal with this person tonight."
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I'm necroing this thread because I felt the topic has more substance and warrants more discussion than what was covered before it died. Specifically, I would like to know why transgender is not considered a delusion.
An earlier poster brought up a good point: your sex is your sex, with or without surgery. Your sex cells and genes do not change because your genitals have changed. This is contrasted with homosexuality which simply begins and ends as a choice -- a preference. You either prefer red grapes or green grapes, you either prefer male partners or female partners. You cannot argue the pathology of preference.
But transgender is more than a preference; it is a belief about ones self.
I've also read the comparison with people suffering from depression: they recognize their life is great, but their internal and mental outlook is inconsistent. The individual outwardly recognizes reality, but their belief about reality is to the contrary. Despite being fundamentally based in the same breakdown of reality versus perception, depression is treated as an illness, while being transgender is not.
If a male patient comes in and claims they believe they are the son of God, therapy is (hopefully) aimed at correcting this belief. If a male patient comes in and claims they believe they are a woman, we defer to their judgment because "gender is in the mind." But then again, so is a belief in being the son of God.
An earlier poster brought up a good point: your sex is your sex, with or without surgery. Your sex cells and genes do not change because your genitals have changed. This is contrasted with homosexuality which simply begins and ends as a choice -- a preference. You either prefer red grapes or green grapes, you either prefer male partners or female partners. You cannot argue the pathology of preference.
But transgender is more than a preference; it is a belief about ones self.
I've also read the comparison with people suffering from depression: they recognize their life is great, but their internal and mental outlook is inconsistent. The individual outwardly recognizes reality, but their belief about reality is to the contrary. Despite being fundamentally based in the same breakdown of reality versus perception, depression is treated as an illness, while being transgender is not.
If a male patient comes in and claims they believe they are the son of God, therapy is (hopefully) aimed at correcting this belief. If a male patient comes in and claims they believe they are a woman, we defer to their judgment because "gender is in the mind." But then again, so is a belief in being the son of God.
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I am going to give you the benefit of the doubt and assume you are not trolling (though the necrobumping a thread about something quite different, and stating that homosexuality is a choice are red flags). However it is obvious that you aren't a psychiatrist and don't understand what words like delusion mean or what depression is, and if it was an innocent question, it is not entirely unreasonable (assuming you not a physician or medical student).
A delusion is a fixed belief not based in reality that cannot be understood in the context of culture. What makes something delusional is not whether it is true or not (delusions can be true, and false beliefs are often non-delusional) but the way a belief is held and the reasoning behind that belief. If someone believes something to be true despite all evidence to the contrary with absolute conviction, and even uses evidence to the contrary to support the belief, that may be suggestive of a delusion. Further, if the reasoning makes sense, it is not a delusion even if the belief may seem odd. For example a man may believe his wife is having an affair because she comes home late from work and is more aloof. The reasoning makes sense, even if his belief is untrue, thus it is not a delusion (but may be an overvalued idea). On the other hand if a man believes his wife is having an affair because Donald Trump winked at him on the television, then that is a delusion, because the percept that "donald trump winked at me" does not explain why I know my wife is having an affair. Delusions also move from thinking that into knowing that. It is not just something someone thinks, but something they know with absolute conviction despite reasoning that does not make sense.
Now, someone could have delusions about their sex. In fact, it is not uncommon in the course of schizophrenia and even mania. But if a man had delusions about being a woman, they would have absolute conviction in that belief and the reasoning wouldn't make sense or would be related to perceptual distortions. For example, a man may say "my name is jessica, I heard angels tell me that my parents lied to me all these years because satan got to them and they wanted to stop me carrying the son of god" then he would be delusional. A woman may believe she is a man named mike because she received the wrong mail (addressed to mike) and at that moment she knew she was really mike. Here there is a delusional perception (interpreting an actual occurrence in a distorted way).
A further example: A man may go to the doctor for a pap smear, the physician notes he has male external genitalia. The physician states that he cannot perform a pap smear. The man becomes irate, stating he does not have a penis but a slightly larger than normal clitoris but wishes to have a pap smear as he was concerned about his risk of cervical cancer which he knows can kill women such as himself. If the man believes this to be true, this too would be an example of delusion.
But transpeople do not believe they have different chromosomes to what they have, or that they have different genitalia to what they were born with. They do not have a conviction that they are simply female or male despite evidence to the contrary. They do not contest their sex. What they contest is their gender which is not simply based on biology but is socially constructed. Gender is a subjective state of being though has objective (behavioral correlates). Gender is not simply a product of biology or the body. This is exemplified by the way girls who do not subscribe to social expectations of behavior were called tom boys, and boys who did not conform to gender norms were called sissies. It is why we might describe people as masculine or feminine, or why certain lesbians might be referred to as butch, or soft butch, and certain gay men referred to as queens, fairies, or their behavior described as "flamboyant". You must also note that intersex individuals are neither biologically male or female yet typically take on a specific gender role.
Trans individuals seeking hormones or gender affirming surgery do not come along stating "I am the opposite gender", and such are the cultural pressures to conform may in fact experience significant ambivalence and it is in fact only in recent years that more people are coming forward for treatment. If someone had a delusion about being the opposite sex they would not likely keep it to themselves. conversely many trans people learn early on to hide their inclinations even if it causes them significant distress. Trans individuals don't believe they are the opposite sex but that there is a mismatch between their biological sex and their gender. They make seek therapy to help them come to terms with their gender identity. Something like delusional disorder where an individual has a specific fixed belief about something begins in the 30s and 40s typically (and often later than that). In contrast typically gender non coformity begins in early childhood. They don't believe they are the opposite sex, but wish to be treated like the other gender, or feel strongly aversive about their sexual characteristics (e.g. "the sight of my penis disgusts me") or note that they always felt different.
As you pointed out gender dysphoria is a disturbance of the experience of the self, not a disorder of thought (which is what delusions are).
any physician knows that anything that can go wrong with the body does go wrong. So the belief that there cannot be a mismatch between biological sex and experience of the self flies in the face of biology. There is some interesting research in this area. For example individuals who lose their genitals often experience phantom sensations of those genitals (like phantom limb). This is because our body image is hard-wired into the circuitry of our brains. this means that if the brain's representation is different or extends beyond the physical body we will experience phantom sensations. Ramachandran has suggested that a dissociation between physical body and the brain's representation of the body may occur during embryological development and contribute to the development of transsexualism.
Some people have made an association between body dysmorphic disorder and gender dysphoria. There is a subtype of BDD where this loss of insight that was previously seen as delusional (but is no longer conceptualized as such - it's just an obsessive compulsive spectrum disorder). However patients with BDD who have surgery are not satisfied, their distress is not abated (albeit possibly temporarily) in fact they may become worse. Conversely, those with identify as transgender who seek gender affirming surgery tend to do much better (and when they don't it is because they have other issues and may have thought everything would be miraculously better afterwards when there is no panacea).
I won't get into the depression analogy here, but if you think people with depression externally have a great life then you don't really get depression. The idea that depression is just negative thinking gained popularity 50 years ago but has now been largely debunked. A negative thinking style leads to bad things happening in your life, and this makes people depressed. I have yet to meet a patient with depression (including frank melancholia) who's depression could not be understood at least in part from their life story.
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My post won't be nearly as interesting as @splik 's, but I'll reply nonetheless: when was the last time you chose your preference for anything? That is, did you choose to prefer red grapes, or did you discover that you simply do prefer them and therefore choose to eat them? Choice and preference are 2 very different things. Preference often influences choice, but that doesn't make them the same.
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Transgender patients can suffer from comorbid depression and pain issues, so it's important not to assume that transitioning, or gender reassignment surgery, has "fixed" everything.
See: Dhejne C, Lichtenstein P, Boman M, Johansson ALV, Långström N, Landén M (2011) Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden. PLoS ONE 6(2): e16885. doi:10.1371/journal.pone.0016885
See: Dhejne C, Lichtenstein P, Boman M, Johansson ALV, Långström N, Landén M (2011) Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden. PLoS ONE 6(2): e16885. doi:10.1371/journal.pone.0016885
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You're right. I wrote that very late at night. "Choice" was a poor ... choice of words. No one chooses their preferences.
And thank you splik for the informative reply. It has changed my understanding of the definition of 'delusion'. I am not a physician, just an avid reader and rare poster of this board.
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Especially considering that there are many biological factors (e.g., certain hormone exposure in utero, among many other factors) that affect such preferences.
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I think that it shouldn't matter whether homosexuality is a choice or a preference. It was convenient in the 90's-00's to push it as a biological predisposition because that's more convincing when arguing for equal social/legal treatment. If you don't believe that sexuality is a binary, then it seems to me that it logically follows that there can be at least some component of choice.
As for transgender, I still wonder about transgender in the context of "developmental delay, schizophrenia, ??something psych" NOS, because I've seen ~5 patients fitting that mold and, at least in a couple of those cases, I hand the feeling that the behavior was imitative and/or reaction seeking (and was often somewhat inappropriate).
As for transgender, I still wonder about transgender in the context of "developmental delay, schizophrenia, ??something psych" NOS, because I've seen ~5 patients fitting that mold and, at least in a couple of those cases, I hand the feeling that the behavior was imitative and/or reaction seeking (and was often somewhat inappropriate).
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No, it doesn't follow unless you are confusing preference with behavior.
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no this conflates attraction and sexual behavior. you don't choose who you are attracted to, or who you fall in love with, but you do choose who you have sex with. also choice is not necessarily biologically determined, there is also social determinism (which plays a huge role in shaping desire and attraction) as well as psychic determinism
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While most preferences are probably not chosen, I think, to at least some degree, you can choose to influence your own preferences and your preferences can change due to life experiences. Examples: I now prefer IPA's but that's partially because I chose to drink enough IPA's to start to appreciate them, but I didn't prefer them initially. As another example, I don't think it's uncommon for some people to have changes in who they're attracted to after trauma.
Recognizing my own potential ignorance, maybe there's a more specific/strict definition for the term "preference" when using it in a psych. context?
The big debate right now is to what degree culture and developmental upbringing influences "preference". To use your example (which I have to say, could have come out of a Trump press conference), why did you feel the need to drink IPA in the first place? After the first sip, you could have figured out there were much more pleasant ways to get drunk than drinking fermented dish soap, but you persisted and felt the need to keep trying them, probably because thats the trend among microbrews and in beer culture. Psychologically, its the same reason that wine tastes better when you know how expensive it is. Saying you now enjoy IPAs does not reflect your inherent taste for it, or if it is an inherently good drink.
Falling along with that, most of the kids who express a desire to be a different gender at a young age will desist by puberty (although most of those will ultimately identify as gay or bisexual). Its unclear what happens after that, but hopefully they figure out ways they can maintain their identity within society. There are some people who will figure out ways to be sufficiently feminine with male genitalia (or vice versa), and there are some people who never truly feel like they are the opposite gender even after reassignment. But there are some people who just feel that a mistake was made at birth, and there's no amount of social conditioning that will say otherwise, and they have the choice of living their one life as a lie, drinking dish soap until they die. The other extreme occurs with people advocating that children have sex reassigned before puberty, likely mistakenly "treating" children who have an affinity for the opposite gender for reasons that has little to do with genitalia.
