When Do You Tell Your Gender Therapist What’s Really Going On?

CB Sky

Gatekeepers are abusive, evil things. Their practises are dangerous; gatekeeping culture creates a scenario where a vulnerable group is victimised further. When I started changing, I saw very quickly that the first rule was to keep information close to me. Away from them. They wanted to see a picture, and they would get it. That was the plan, anyway.

Like most of us, I was starved for resources and in a lot of trouble. By the time the gender clinic got to me, I was living as I am and knew no other way of life. I showed up as I usually did on hot days: summer dress, face full of colour and glitter (I had time to play and I’m easily sidetracked with a makeup kit). I was also battered, poverty stricken and suicidal with minimal support — my doctor had threatened to take my medication away if I didn’t ‘sort this out’. I relied on short-term, disconnected services after that.

“I’m in trouble,” I said to the gender psychologist that day, eyes downcast. My arm stung from digging my fingernails into it as I traced my finger along the words inked into my inside forearm, ‘forgive me’. A reminder. I didn’t mean to end up in her office. It was an induction session — several of us were there — and I found myself liking her, even though she didn’t actually give any part of the talk. Her answers to questions were careful. I was scared about how confidential things actually were.

Turns out, not really confidential: clinic therapists were free to share details with the rest of the team there. But I was in trouble and despite the risks, these were people who would be seeing me in the long term. People that could give me the continuity I lacked in my other support and they weren’t threatening to take my meds away for being ill.

I still think the best practice is to avoid topics that could be considered comorbid, meaning they might be negatively interacting with gender issues. Such things are can be priority before the clinic allows a medical transition to progress. I’m still of the opinion that transitioning is the thing that gives dysphoric people the best chance at dealing with their comorbid issues. In my case, my gender was disguising several issues that I didn’t even know were there. Transitioning, particularly hormone therapy, drew back the veil and allowed me to see what was wrong.

But sometimes, our specific health needs make it difficult to know what we want. I’m not talking about a bit of anxiety or depression. No condition in and of itself is going to automatically confuse what we want. But specific coping mechanisms, like if a person seeks approval as an anxious reaction in a strong culture of surgery, warrant some consideration. It’s wise to spend some extra time working out if that person is seeking approval or actually suffers from dysphoria about that area of their body. At that point, we need to tell the gender therapist what’s really going on.


Working with clinic staff is scary; they are still gatekeepers, no matter how benevolent they might be. Not everywhere has staff of good conscience, and even in systems that aim to assist first will have individuals that obstruct. The setting itself is troublesome here in the UK: therapy without confidentiality is not therapy. Sharing what goes on with the medical team when there is no clear, immediate danger is not confidentiality. And I know there are exceptions; I spent over ten years in responsible positions over vulnerable people and there are some things that just can’t be kept secret. I get it.

Until that changes — and I’m talking about the UK here, but I know ‘letters of concern’ happen in other countries — the clinic psychologist won’t ever be 100% safe to be frank with. Therapy without confidentiality is not therapy. Most of the time, we can’t tell them anything but what they want to hear.

But I did anyway. Tell the truth, I was annoyed that I did. Livid with myself: I had to go to an induction, keep my mouth shut and watch. Those that know me will smile there; I don’t know how to keep my mouth shut. But I did and still do need help.

It was a risky move, but one that paid off in the end. The person I worked with was quite conscientious of my trust issues. She took care to be transparent. And yes her affiliation was a problem — I told her so. But we managed anyway because my need outweighed the risk.


I suppose that can be said of any treatment: we get the treatment because the risk of not doing it is far greater than the risk of doing it. I used to say that about my medication when arguing with folks (back when folks argued with me about this stuff): my meds keep me from being actively suicidal. Yeah I’m a hormonal crazy person that can’t deal with humans five days of the month, but it’s that or being suicidal again. Easy choice.

I get that not everyone is so lucky. Not everyone has the benefit of a system like the UK’s where people (after an excruciating wait) can reach out if they’re in trouble. Some gatekeepers are worse than others and not all systems are created equal. But if the resources are there, sometimes we have to break the rules and tell them what is really going on.

My step into the unknown was one of the most frightening things I ever did: I told a person who had the power to let me live or die that I needed help. A person I didn’t know. A person that I had a good impression of and, over the course of that intense exchange, I saw was perceptive, intelligent, thoughtful and more than a little calculating. Someone who could be extremely dangerous to me, but also someone that would take me on and really help me face my demons.

We only want to tell them what they want to hear until we need to tell them more. We only want the to see what they need to see until the image places us in danger. We only want to be the thing they expect, until we don’t know if we want to be it. Sometimes we can work it out ourselves. Often, we just know what we want. But when we don’t, it’s time to tell our gender therapists what’s really going on.


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