Queerer way of being: how trans people are failed by medicine and therapists alike. By Sam Hope

Content note – mentions abuse, misdiagnosis, trauma, oppression

This article is a revised version of one I wrote for the late, lamented site Spooniehacker. I wanted to reshare it in conjunction with my keynote speech I gave at tPCA’s GSRD Conference: Queerness in the Person-centred Approach. The recording of this can be purchased here.

When I wrote the original article, at the start of the pandemic, I did not realise I was about to become a case study for what I was writing about. After getting covid twice in 2022 despite strict shielding, my underlying health conditions deteriorated to the point that I began to need a mobility scooter to get around, had to significantly reduce my workload, and things have not substantially improved from there. I find my marginalisations (as an autistic trans person) interfere with communicating with healthcare professionals in multiple ways and are a barrier to me receiving help. Medical gaslighting and dismissal is constant, a theme I also hear repeatedly from clients.

The quirky population cluster we need to be aware of

Trans people experience health inequality because we are a marginalised group. We face barriers to healthcare because of systemic discrimination and the oversimplistic binaries that exist within our legal and healthcare structures. We also know that stress is devastating to the immune system and can exacerbate and even cause health problems. But in addition, there is a known overlap between being LGBTQA+ and autistic, and being autistic and having connective tissue problems, so even in a perfect world we would still experience higher levels of disability. Chronic stress can deteriorate our physical health and trigger flare-ups of autoimmune problems we’re already more susceptible to. It’s no surprise, then, that so many trans people are disabled.

Trans people exist within a quirky population cluster that also contains a number of disabling conditions. As I say in Person-centred counselling for trans and gender diverse people:

“A number of divergent traits cluster together in the population – non-heterosexuality, left-handedness, joint hypermobility, genius, synaesthesia, ME/CFS/fibromyalgia, physical conditions like EDS and POTS, gender variance, certain facial features, dyslexia, ADHD, high sensitivity, autism, dyslexia, dyspraxia and other body and brain quirks.”

Having one of these traits increases the odds of having another. So, not all trans people are left-handed, but they are more likely to be left-handed than cis (non-trans) people.

Some traits in the cluster are seen as positive – perfect pitch and giftedness are in the cluster, for instance. Some, like left-handedness or synaesthesia, (e.g. the ability to smell colours), are generally treated with neutral curiosity. Some are marginalised identities, and some disabling conditions.

When I run training, I invite attendees to reflect on how they think about each of these differences and consider how they might complicate trans people’s experiences. I invite the reader to do so now – what is pathology and what is natural human diversity? What was caused and what is just how some humans are?

For example, the link between transness and autism is widely speculated on in current society, in the context of a concerted campaign to undermine and pathologise trans identity. While nobody speculates as to how left-handedness could cause somebody to be trans, considerable research is devoted to speculating what it is about autistic people that causes trans traits. Sometimes “gender confusion” is listed as an autistic trait. Anti-trans campaigners cite the high incidence of autism in trans youngsters as a reason to block their transition, which is patronising towards trans and autistic people. Meanwhile, the autism overlap also occurs with gay people, but there is less pathologising and infantilising scrutiny to this overlap, because we’re closer to a place in our culture where we understand gay is just something people are, we don’t need to look for a cause.

Using the social model of disability

A social model approach helps here – an approach that looks at disability in terms of how society accommodates it rather than the individual’s medical needs. A beautiful illustration of this is research published in The Lancet. In a nutshell, this and other research found that trans people’s mental health problems are related to how we are treated – assault, bullying, isolation, discrimination take their toll on our emotional wellbeing, a phenomenon known as minority stress.

In response, the WHO finally took “Gender Identity Disorder” out of their list of mental illnesses in 2019, something they did with homosexuality in 1990.

The clear message is: Not accommodating trans people creates mental health disability.

Add in the cluster phenomenon, and trans people’s lives become increasingly complicated, our social environments more and more disabling. If society shrugged its shoulders and said “oh, some people are just quirky in multiple ways – that’s how some folks are,” these differences would not be such a burden. Yet it is a burden currently: holding multiple differences can complicate our interactions with the world in far-reaching ways.

Our quirkiness can complicate other’s perceptions of us

Autism can make us stand out more than society wants us to. For example, a trans woman who cannot cope with the texture of make-up or feminine clothes due to sensory differences might be seen as not “making an effort” with transition, a notion backed by misogynistic and cissexist standards about how women should look, of course. A non-binary person who cannot cope with ticking clocks and fluorescent lights might be labelled fussy and over-demanding, which might be used to undermine their non-binary identity. If they also sense things others do not – hear the fluorescent lights, for example, their perception of reality might even be questioned. A trans guy who struggles with voice loudness or conversation turn-taking might be perceived as domineering or aggressive.

Physical disability can also complicate matters. A young trans person who needs to use a cane or wheelchair to walk due to hypermobile joints or Ehlers Danlos Syndrome might be seen as attention-seeking. EDS is a connective tissue disorder that’s very common in our community. Postural Tachycardia Syndrome (PoTS) is also common in this population, and the symptoms – dizziness, chest pains, fatigue – can be put down to anxiety or depression. These emerging conditions often go undiagnosed, frequently described as “Medically Unexplained Symptoms (MUS)”, a term that often implies an illness is psychologically based.

It is not unusual for someone to have a combination of neurodivergent traits (like autism, ADHD and dyspraxia), which often go undiagnosed within marginalised groups, and also some physical “Medically Unexplained Symptoms” as well as an LGBTQA+ identity. Someone who is this different is also more likely to have a trauma history – unfortunately, both disabled and LGBTQA+ people have a much higher risk of being targeted for abuse by others due to vulnerability, stigma and isolation. Predators seek us out as easy targets, in other words, precisely because we are cared about less and disbelieved more.

All too frequently, I see people with this cluster of differences labelled with “personality disorder” and every trait is seen through that lens – their transness is interpreted as impulsive or attention seeking or “identity confusion”, their neurodiversity goes undiagnosed and labelled “problem behaviour”, their worsening physical condition is assumed to be “all in the mind”. Despite the research emerging that it is reasonable to assume trans people will have other unconnected but commonly co-occurring conditions, the medical profession favours models that causally link all a patient’s differences, in pathologising ways.

How therapists respond to quirky clients

Therapists are also guilty of this. The tendency is to roll all those traits up into “trauma response”. Sadly, there are still many therapists who believe LGBTQA+ identity is caused by childhood trauma or other pathology, that we’re not part of natural diversity but something that “went wrong” or that we are mistaken about ourselves due to poor mental health or cognition. It is very telling what is treated as a part of humanity’s richness, and what is treated as a problem that we need to find the cause and cure for. We are no less common than redheads, and yet nobody is asking “what went wrong to make someone red-headed?” We are in the same cluster as left-handers but nobody is asking anymore how we can fix left-handedness, although my grandmother was subjected to her left-handedness being trained out of her in quite traumatising ways. Perceptions of difference can change a good deal over time.

LGBTQA+ identities, neurodivergences, physical differences all become “symptoms” instead of being understood as unique and discreet patterns in a naturally quirky population group. Such unsophisticated approaches to therapy or diagnosis can do real violence to sensitive, divergent people in desperate need of understanding and acceptance.

My Keynote Speech is designed to help therapists and other workers to unlearn these unhelpful ways of viewing natural human diversity, giving a helpful framework and insight into the accommodations us quirky folk require.

We don’t need studies finding out what causes us to be us, we need a society that accommodates us, gives us the healthcare we need but more than that, celebrates us in all our rich diversity.  

Sam Hope, counsellor, supervisor, trainer and author of Person-Centred Counselling for Trans and Gender Diverse People. Sam draws from clinical, personal and community experiences as well as their learning from being the PPI Lead and co-author of the mental health report on Integrating Care for Trans Adults, a major NIHR-funded trans healthcare project.  Sam is autistic, trans, non-binary and a mobility-impaired disabled person. Their website is: sam-hope.co.uk

If you would like to purchase Therapist Encounters with Autistic Trans People by Sam Hope you can do so using the link. The cost of the recording is £10.00.