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The Schema Therapy Bulletin

The Official Publication of the 

International Society of Schema Therapy

Dresses, Spiderman, and  Gender Dysphoria: A Gender-Affirming Schema Therapy Approach
by Cesar A. Gonzalez (USA)

Anatomy is Not Identity
After weeks 6 to 7 weeks into a fetus’ development, the expression of a gene induces changes that alter the trajectory of the development of a fetus’ sex characteristics and how expectant parents will eventually respond to the socially acceptable question of, “Are you having a boy or a girl?” In other words, “Are you expecting a baby with a penis or a vagina?” The moment this question is answered is when there are social rules put on the expectant parents and the unborn child.  These sex characteristics guide social expectations of “what boys do” and “what girls do” and impact how individuals view themselves, others, and their futures – as well as which colors or clothing they will use, which recreational activities they will pursue, what occupations they will be encouraged to follow, and even how much emotion is acceptable to express. 


At approximately 2 to 4 years of age, most children will have already internalized stereotypes of “what boys do” and “what girls do” and will have professed their gender to their parents. For most children, gender expectations based on sex characteristics informs their gender identity, defined as the internal sense of being a boy or girl. The term cisgender is used to describe congruence among individuals whose gender identity is in line with their sex assigned at birth (e.g., most individuals are cisgender women or cisgender men).  The term transgender is used to
describe individuals who report that their gender identity is incongruent with their sex assigned at birth. Among transgender individuals, many report distress due to the incongruence between their sex characteristics and gender identity – this distress is termed gender dysphoria


If one were to randomly select 100,000 adults living in the United States, it is estimated that approximately 580 adults would identify as transgender.  For adolescents (ages 13-17), the prevalence estimate is that for every 100,000 there are 730 adolescents that identify as transgender.  While the prevalence of those who identify as transgender may appear relatively low, the likelihood of mental health clinicians seeing patients in their practice is moderately high due to the psychosocial difficulties that many transgender individuals report. For example, multiple studies have suggested that the lifetime prevalence of attempted suicide among transgender individuals is anywhere between 40-50%. The estimated 12-month rate of depression among transgender individuals is approximately 47% and is significantly higher than the estimated 8.7% among the general population. In addition to the elevated rates of mental health concerns, transgender individuals will often seek out medical interventions such as hormone therapy or surgery to alleviate gender dysphoria – in turn, most physicians and surgeons require that there be a diagnosis of gender dysphoria diagnosed from a mental health clinician before they will render services.  


It is out of the scope of this newsletter article to provide a comprehensive explanation of best practices for providing care to transgender and gender diverse individuals, however, for schema therapists interested in understanding the basics, I refer you to the American Psychological Association’s Guidelines for Psychological Practice with Transgender and Gender Nonconforming People which is available at: https://www.apa.org/practice/guidelines/transgender.pdf In addition, the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People is available for free on the website of the World Professional Association for Transgender Health (www.wpath.org). 


The goal of this newsletter article is to illustrate an example of how schema therapy is consistent with the contemporary goal of treatment of reducing gender dysphoria through providing gender affirming care, not through changing the patient’s gender identity. 


Early Maladaptive Schemas among Transgender and Gender Diverse Individuals

Given the high levels of stigma, prejudice, and discrimination that transgender individuals experience, known as minority stress, it is expected that maladaptive schemas among transgender and gender diverse individuals are elevated compared to the general population. While no large studies have examined these hypotheses, there are small observational studies from multiple countries that provide evidence for this hypothesis. For example, a study published in 2011 comparing transgender and cisgender individuals living in the county of Hungary suggested that transgender individuals had higher endorsement of emotional deprivation, defectiveness/shame, social isolation/alienation, vulnerability to harm/illness, self-sacrifice, and approval/recognition seeking.  In addition, there is data that suggest difference among maladaptive schemas between transgender women and men. A study published in 2013 found that when examining 15 schemas between transgender women and men living in the country of Iran, transgender women reported significantly higher endorsement of maladaptive schemas in the disconnection and rejection domain. 


In a sample of transgender patients with gender dysphoria in my clinical practice (94 transgender women and 64 transgender men) approximately 42% are classified as having current suicide risk. Out of the 42% with suicide risk, approximately 21% are at moderate or high risk for suicide. Mental health clinicians who are not trained in working with vulnerable populations may assume that this elevated risk is an indicator of psychopathology, however, research among vulnerable populations suggests psychosocial stressors resulting from being in a minority group (minority stress) influences risk factors for suicide. From a schema perspective, one could hypothesize that it’s the persistent unmet core needs and the coping response style that influence the observable behaviors. Data from a study that I am working on publishing suggests, that if we hold all schemas constant, self-sacrifice, failure, and social isolation are associated with an increase odds of being classified for current suicide  risk; interestingly, dependence/ incompetence is a protective factor for current suicide risk. Further, while holding all 18 schemas constant among those with current suicide risk, emotional deprivation schema is associated with severity of suicide risk (i.e., increased emotional deprivation is predicts severity of risk for suicide). Schema modes were not associated with current suicide risk. 


Gender-Affirming Schema Therapy
Currently there are no controlled studies to exam whether gender dysphoria is associated with a specific schemas, however, if there were, the influence of minority stress would likely make it difficult to examine this relationships. The goal of engaging in gender-affirming schema therapy is not about healing schemas in order to modify gender identity – rather, the goal is to facilitate healing through countering minority stress experienced in an unsupportive sociocultural environment that values the gender binary. Really, the goal of gender-affirming schema therapy is the same as with any other schema therapy goals which is to help patients identify, weaken, and break schema-driven maladaptive patterns in order to build a health adult that experiences autonomy, belonging, and competency in their everyday life. The only difference is that our focus is on working with the patient to help them counter negative messages about themselves, to help them explore the gender identity and expression that is most congruent with them, to help them navigate the complex medical systems that can oftentimes perpetuate maladaptive schemas, and to provide affirmation. One of the most affirming interventions one can provide an individual is to simply ask what their preferred name and gender pronouns are. From a schema perspective, this helps communicate to the patient that you want to understand them for who they feel they are, without any conditions. In sum, you can think of gender-affirming schema therapy as schema therapy with an added awareness and understanding of the basic assumptions that we as a society have about gender stereotypes. 


Case of Adam (pseudonym used)

Sex Assigned at Birth: Female
Gender Identity: Male


“Adam” is the name that the patient chose – he asked that I use masculine pronouns – he/him/his. 


Adam was referred to me because he had recently moved away from his home and was seeking to start hormone therapy in order to masculinize his body – his physician needed a letter of support from a mental health professional to initiate testosterone. During the first appointment with me, Adam reported to me that he recently left his home state after his father attempted to strangulate him over a disagreement about Adam not dressing in the manner that the family preferred. Adam tearfully recalled his father screaming the words, “You are bringing shame to this family and I would rather have you be dead.” 


In our appointments, Adam would frequently recall his childhood being filled with what felt like riddles and involved questions about whether he should engage in the rituals of gender expression. Should he wear the dress that he was told he should wear? Should he play with the toys that he liked, or the ones that he was told to like? He recalled that just before puberty he tried to “act like a girl”.  “I tried so hard to wear the dress, it was during this time that my mother was the proudest of me. But even when I was in a dress, my mom would tell me: ‘You have a masculine body – you will have to stay at home because no man or their family will want you’”. Through the first few sessions Adam would repeat the words, “I tried, I tried… I tried liking wearing dresses and makeup, but it was not me.”  He recalled that he had felt different about himself since the age of four and it wasn’t until he was an adolescent did he attempt to present in a more stereotypic masculine appearance. It was during this time that family arguments became common. Adam reported that it wasn’t until he went away to college reported that he felt relief from the constant family discord - even then, when he would post on social media his parents would ask him to remove pictures of himself with friends because he appeared “too masculine”. Adam learned to tell lies about himself in order to appease his parents. It wasn’t until Adam graduated college that he felt empowered to inform his family that he identified as male and that he had the goal of transitioning to a masculine sounding chosen name and pronouns. This is when his father attempted to strangulate him and he left to another state under the guise that he would be going away to graduate school. 


Adam’s schemas included mistrust/abuse, defectiveness, subjugation, abandonment/instability, emotional deprivation, social exclusion, and self-punitiveness. In addition, throughout our therapy sessions we discovered the role of enmeshment/undeveloped-self. Adam’s frequent modes were the vulnerable child, angry protector, detached protector/self-sacrificer. 


Gender Affirmation in Imagery Rescripting

During a therapy session that focused on the role of culture and rituals and the expectations that come with them, Adam and I engaged in imagery rescripting. The emotional trigger as an adult was seeing pictures from his friend’s Facebook post about his family being at a party and recalling that he was not there with them because of the way he expressed his gender. 


I engaged Adam in an imagery exercise linked to this trigger and he recalled that the memory was when he was about 5 years of age and he had family coming over for a party. He recalled that his mother called him into her room and showed him a pink dress that she had bought for him to wear to a family photo. Adam recalled persistently asking, “Can I change now?” after each click of the camera. It was at this time when he recalled that his mother took him upstairs and “mom beat the crap out of me”. 


During the imagery rescripting, as Adam’s schema therapist,  I had to decide what would be most affirming to Adam – my first thought was that I should use Adam’s birth name, “Sofia” along with feminine gender pronouns – it wasn’t until I was in the image with little Adam that he informed me that he needed to hear from his mother that she loved him the way that HE was, and she would allow for him to wear jeans to the family picture, instead of a pink dress. It was during the imagery rescripting exercise that I affirmed Adam’s gender – “A child should not have to worry about being themselves” – after a warm hug and affirmation in the imagery all Adam wanted was to go down a slide while wearing a Spiderman outfit – “You are so special – a special child- you are allowed to be yourself- I will accept you no matter what- you can dress up like Spiderman anytime you want.”  


I worked with Adam for over 2 years now. He has gone on to receive surgery to remove his breasts- he has been on hormone therapy and has set limits with his parents; he has developed his self by changing his name and gender marker on his identification. Adam is currently navigating the developmental milestones of dating and throughout this has developed a sense of stability for himself by joining a transgender affirming church and building a chosen family. 


Adam’s parents have informed him that they will only meet with him if he transitions b
ack to presenting female.

Why Schema Therapy?

Schema therapy has been extensively researched to effectively treat a wide variety of typically treatment resistant conditions, including Borderline Personality Disorder and Narcissistic Personality Disorder. Read our summary of the latest research comparing the dramatic results of schema therapy compared to other standard models of psychotherapy.

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