MDMA-assisted psychotherapy has demonstrated tremendous promise in the treatment of posttraumatic stress disorder (PTSD). Extreme disparities exist in rates of PTSD, with people of color and transgender (“trans”) and gender diverse people experiencing particularly high rates of trauma compared to white and cisgender people. However, the number of trans and gender diverse participants in clinical trials of MDMA-assisted psychotherapy for PTSD remains unknown, primarily because this information has not been collected and/or reported, but anecdotal estimates are very low. If we are to ensure access to the most cutting-edge psychedelic therapies for the communities that need them the most, we must continue to educate ourselves and evolve our therapeutic approaches to address their unique yet pervasive experiences of trauma.
Introduction to trans and gender diverse people
Broadly speaking, trans and gender diverse people are those whose gender identity and/or gender expression do not align in conventional ways with the sex they were assigned at birth. The United States does not collect data on gender identity at a federal level, so population estimates are approximate; researchers estimate that about 0.5 –3% of the U.S. population identify as trans or gender diverse (Meerwijk & Sevelius, 2017)—somewhere between one and nine million people. Throughout history, diversity in gender identities, expressions, and roles have been documented in societies around the world. In Western cultures, trans and gender diverse people are often socially marginalized for not conforming to rigid binary expectations of gender identity and expression. Rates of trauma due to stigma and discrimination are high in these communities as a result, and this is compounded even further for trans and gender diverse people of color.
The promise of psychedelic-assisted therapy to address trauma may represent a unique hope for trans and gender diverse individuals. However, trans and gender diverse people are vastly underrepresented in clinical research, and trials of psychedelic-assisted therapy have been no different. Generally speaking, data on gender identity beyond “male/female” is not collected in these studies. Even if a participant does identify as trans or gender diverse, they may not feel safe disclosing that information if they sense that the therapists are not familiar with gender diverse people, issues that face trans people, and/or that their identity may be an exclusion criterion.
Foundational considerations for working with gender diverse clients
To increase the participation of trans and gender diverse people in clinical trials and to prepare therapists for practice with these communities, it is essential to start with some foundational concepts. When working with trans and gender diverse people, language is critical to rapport building. Many trans and gender diverse people use names and pronouns different from that on their legal and/or medical documentation—often referred to as a person’s “preferred name and pronoun.” When a client introduces themselves, be sure to listen to the language they use, the name and pronouns they use, and mirror this language carefully. If you are unsure, it is better to ask directly than to guess and get it wrong. Language about gender is constantly evolving and varies by age, region, and race/ethnicity, as well as other factors, so we will always be learning from our clients about the language they use to describe themselves.
Even when working with “cisgender” (a term for someone whose gender identity corresponds with their assigned sex at birth) clients, it is important to refrain from imposing a binary lens on clients’ identities and self-expression. As in all aspects of therapeutic work, it is imperative for therapists to do personal work in terms of their own gender identity. It is exceptionally easy for therapists’ unexamined assumptions about gender to reveal themselves in their language without their awareness.
It is also important to examine the impact of the institutional barriers that may be present in your setting. For example, how do you ask about gender in your screening tool? Are binary male/female options the only ones offered? You may not think you are screening enough trans people to warrant updating this tool, but you cannot know unless you ask, and you communicate your values with the types of questions you do and do not ask.
Therapeutic issues unique to gender diverse clients
While there are several presenting issues that may be unique to working with trans and gender diverse clients, the issues that a client is bringing to psychedelic therapy may or may not be related to a person’s gender identity. Trans and gender diverse people experience the same life struggles and traumas as cisgender people, but there are unique themes that trans and gender diverse people may be working with, many of which may be especially amenable to psychedelic therapy.
Many trans and gender diverse people experience bullying, rejection, victimization—often by family members, peers, medical care providers—people who they should be able to rely on for support. They also experience higher rates of childhood sexual abuse than the general population. Studies have shown that experiences of discrimination among transgender people are associated with increased rates of depression, suicide attempts, and PTSD symptoms (Haas, Rodgers, & Herman, 2014; Jefferson, Neilands, & Sevelius, 2014; Reisner et al., 2016).
Trans and gender diverse people often express distrust of medical and mental health professionals for several reasons. Standards of care guidelines for providing healthcare to trans and gender diverse have historically required trans people to obtain psychological evaluation prior to undergoing gender-affirming surgery. Due to this history, many trans people have experienced healthcare professionals, including therapists, as “gatekeepers” or people who can prevent or delay them from accessing necessary treatments.
Further, many trans and gender diverse people report that they must educate their healthcare providers about their healthcare needs, because so few providers are adequately trained to work with them. In addition, some trans people have a history of conversion therapy experiences, or therapy that aims to change a person’s gender identity to conform to a cisgender, heterosexual concept of gender. Conversion therapy has been shown to be unsuccessful and extremely damaging. Trans and gender diverse people of color may be especially wary of medical professionals due to extensive history of medical abuse in communities of color. For these reasons, be aware that trans and gender diverse people may enter clinical settings with higher levels of distrust than other clients.
A conceptual framework for addressing unique therapeutic issues among trans and gender diverse people: The model of gender affirmation
Research overwhelmingly demonstrates that gender diverse people are more likely to have positive outcomes when their treatment is gender-affirming. Our culture produces overt and covert negative messages about trans and gender diverse people almost constantly, even shaming cisgender people for not adequately conforming to strict (and unrealistic) binary notions of gender. It is nearly impossible for trans people not to internalize these messages, resulting in low self-esteem, even suicidality. When our self-concepts are disaffirmed by others, it can result in what social psychologists call “identity threat.” Identity threat can result in negative coping behavior such as substance use, self-isolation, and seeking out affirmation in unhealthy ways. When transgender people face constant identity threat through violence, discrimination, and microaggressions, the trauma of such experiences leads to hypervigilance, distrust of others, and avoidance behavior, including avoidance of physical and mental healthcare.
Psychedelic therapy can reduce identity threat and decrease its negative impact by allowing the client to heal and release internalized transphobia. MDMA is thought to support clients in working through traumatic content by increasing one’s ability to process using the prefrontal cortex, the part of the brain that produces higher level reasoning. Simultaneously, MDMA suppresses activity in the amygdala, the fear center of the brain, which is overly activated in people suffering from PTSD. Psychologically, the Model of Gender Affirmation is a framework for conceptualizing transgender people’s experiences of this healing process and its psychological and behavioral consequences (Sevelius, 2013). According to the theory, we can improve health outcomes for transgender people by increasing access to gender affirmation and/or reducing the need for gender affirmation from others, thereby decreasing identity threat. Psychedelic therapy has the potential to do both.
With psychedelic therapy, we can increase access to gender affirmation in multiple ways. Ideally, the client experiences connection and affirmation from the therapists. The client may experience affirmation of themselves, as MDMA is known to increase one’s self-compassion and unconditional self-love. Psychedelic therapy that results in a mystical or unity experience can result in a sense of “divine blessing”, described as the experience of having God or one’s higher power communicate affirmation of the highest order (Eichenbaum, 2018). Overall, MDMA-assisted therapy can increase one’s sense of trust and connection, and for trans and gender diverse people who describe experiences of feeling like an outsider, these medicines may provide a pathway for reconnecting with oneself and others. In addition to increasing access to gender affirmation, psychedelic therapy may also reduce the need for gender affirmation from others. As a client experiences renewed connection with their body and self-compassion, they often come away with a visceral understanding that true affirmation must first come from within.
Even cisgender people often report openness to a broader conceptualization of gender after psychedelic experiences, and trans people who have spent a lot of energy trying to conform to binary notions of gender may feel relief in the experience of this type of openness. Psychedelic therapy, particularly MDMA-assisted psychotherapy for PTSD, offers deep healing that has the potential translate into true resilience for trans and gender diverse people when supported by trained, culturally humble therapists.
Eichenbaum, J. (2018). Dissolving the binary: The queerness of psychedelics. Chacruna Institute for Psychedelic Plant Medicines, https://chacruna.net/dissolving-binary-queerness-psychedelics/.
Haas, A., Rodgers, P., & Herman, J. (2014). Suicide attempts among transgender and gender non-conforming adults: Findings of the national transgender discrimination survey. Retrieved from: https://williamsinstitute.law.ucla.edu/wp-content/uploads/AFSP-Williams-Suicide-Report-Final.pdf
Jefferson, K., Neilands, T., & Sevelius, J. (2014). Transgender women of color: discrimination and depression symptoms. Ethnicity and Inequalities in Health and Social Care, 6(4), 121-136. doi:10.1108/eihsc-08-2013-0013
Meerwijk, E. L., & Sevelius, J. M. (2017). Transgender Population Size in the United States: a Meta-Regression of Population-Based Probability Samples. American Journal of Public Health, 107(2), e1-e8. doi:10.2105/AJPH.2016.303578
Reisner, S. L., White Hughto, J. M., Gamarel, K. E., Keuroghlian, A. S., Mizock, L., & Pachankis, J. E. (2016). Discriminatory Experiences Associated With Posttraumatic Stress Disorder Symptoms Among Transgender Adults. Journal of Counseling Psychology. doi:http://dx.doi.org/10.1037/cou0000143
Sevelius, J. (2013). Gender affirmation: A framework for conceptualizing risk behavior among transgender women of color. Sex Roles, 68(11-12), 675-689. doi:10.1007/s11199-012-0216-5
Jae Sevelius, Ph.D., is Associate Professor in the Department of Medicine at the University of California, San Francisco, and is a licensed clinical psychologist. At the Center of Excellence for Transgender Health, Dr. Sevelius’ federally-funded community-led research is focused on leveraging data to develop and evaluate transgender–specific, trauma-informed interventions to promote holistic health and wellness among transgender people, with an emphasis on serving transgender women of color and those affected by HIV in California and São Paulo, Brazil. For their scholarship on transgender health, Dr. Sevelius was recently awarded the 2018 Outstanding Achievement Award by the Committee on Sexual Orientation and Gender Identity of the American Psychological Association. Dr. Sevelius holds a Certificate in Psychedelic-Assisted Therapies and Research from the California Institute of Integral Studies. Dr. Sevelius’ research and clinical interests lie at the intersections of social justice, sexuality, health, and identity.