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A Gender Based Intervention with an Adolescent – Case history
 
By Pia MP Granjon

Introduction
 
This case study is about ‘A’, a 16 years old, born and identified as a female at birth. Current pronouns of choice: she, then he - iel in French [contraction used in French for non-binary people]

The mother contacted me about A, with the authorisation of the patient.
 
·         Mother wants support because A. is not following school classes regularly, nor doing all his homework and as parents, she and husband, struggle to manage this at the moment.
 
·          Teachers contacting parents regularly about this.
 
·         Parents are aware of the gender questioning of their child, which is not the expressed therapy aim by them, nor by the teenager.

 
Discussion on confidentiality and its limits. A,’s and parents agree on this.

During the 1st session, A. talks about
 
·         A’s therapy's aim that day is: they want to feel happier. No refining is done then, purposely.
 
·         Homework: A. says he is  too tired to do them b/c not enough sleep.
 
·         A. is using the feminine gender with me at that stage, which will later switch to the masculine  [which I am using for this case study presentation], He will later on, after the therapy has finished, move on to one that states non binary in French.
 
·         Sleeping issues and nightmares on the theme of: ‘how will I die ?’
 
·         Anxiety is self-evaluated at 9/10 and focuses mainly on the world being a dangerous place dangerous for a girl. Topic we hear in the mother’s statements.
 
·         Assessments:
      • GAD7 assessment, A. scored 13= severe anxiety
      • PHQ9 assessment, A. scored 19 = severe depression
      • suicidal risk evaluated = resources > risk of acting on ideation
 
·         A. shares several sexual touching he experienced as a child when identifying as a girl. No more is shared on this day, purposely.

Between Session 1 and Session 2
 
 
·         Assessments of depression, anxiety and suicidal ideation are shared with parents; A’s made aware prior to doing it.
 
·         Discussion with parents and with A. around contacting a medical professional + seeing a psychologist in addition or instead of my interventions: their choice.

 
Background of the case

A. is very creative and highly analytical.
He has a cis gender (gender identification with sex at birth) male sibling 2 years younger than him; mother and father, both cis gender,  living together with the children.
The family is expatriated
They belong to the dominant white culture of their host country and have a good economical level.
Both parents work.
Parental education is shared by the 2 parents; they are open minded, supportive and respectful of A.
The family and each of its members has a local social network and are in contact with their family in their home country + professional and social network in the host country.

Working around the question of A.’s gender has not been a clear stated 1st goal for the therapy; it came along naturally and was expressed, whilst working on the symptoms he experienced.
The symptoms A. is presenting are recognised as being common for people going through gender search/questioning:
 
·        Social isolation
 
·        Severe depression
 
·        Severe anxiety which for A. was both generalised and targeting specifics around risks of sexual assault, kidnapping, death
 
·        Body dysmorphia
 
·        Suicidal ideation / self-harm ideation

 
A. is also experiencing:
 
·        episodes of potential hallucinations of beasts running on his skin
 
·        nightmares
 
·        psychogenic spasms
 
·        aggressivity
 
·        A. asked his family to change their way to call him: first name was changed twice, pronouns became masculin: he/him

This grieving process was particularly difficult for the father and the younger brother.
A. has been for a while highly critical towards men [except men from his family] who were described as violent and potential sexual predators.

The whole family dynamic was shaken as going through
  • what can be considered as normal phases of  adolescence of A.
  • heightened by
      • gender search / questioning
      • mental health issues related to gender and non related to it
 
 
Challenges with this client

  • finding the balance between safety and risk to make sure A was safe
  • the risks:
      • hallucinations
      • suicidal ideation / self harming ideation
  • to be sure I was clear on the limits of my intervention; distinguishing between* gender related issues
      • mental health issues. some related to gender issues and some not directly related to gender issues, among them the hallucinations and the self harm ideation.
      • ‘normal’ adolescence issues eg. some degree of emotional manipulation towards his parents, aggressivity, self-awareness quest
      • I took on a (already wanted) training in working with the LGBTQ+ community), read, listened to talks, looked at youtube videos
      • I am not a doctor nor a psychologist / hallucinations
  • Systemic work, working with the adolescent, the parents and the family as a system, without the younger brother [family’s choice].
  • Supporting each member of the family system in editing and sharing their own feelings and fear so projections are updated: warning parents on worrying points they were not aware of, as well as reassuring them on other points they were fantasising gravity about. parents’ own anxiety was nourishing A.’s + A.’s fear of adding his to his parents’ anxiety
  • Factors increasing the symptoms: social isolation increased due to covid-19 situation + not going to school => not many social connections outside of home.
  • Difficulties to ‘read’ A’s mind and body states: remote work and camera off during several therapy sessions: A’s did not want to be seen at first.
 
 
Solutions (which techniques )

The 3 phases of a therapy, that overlapped at times

Stabilisation

  • Strong rapport based on trust + common discoveries :
      • A. taught me how it is for him to go through the quest of one's gender. I stated that to him and we shared good laughter when I kept using the wrong pronouns for him at the beginning of our work together.
      • Stating he can but never has to answer any of my questions but better answer honestly to himself if he wants our work to be efficient.
  • Psycho education on PolyVagal Theory / neuroplasticity / construction and impact of beliefs …
  • Risk assessments: suicidal ideation, self harm, anxiety and depression
  • Self helping tools
      • breathing techniques taughtS
      • elf-awareness built
      • How to use expressive art: A draws beautifully.
 
Change

  • much work on A.’s awareness of his tenancy to generalise Vs ability to regain control in addressing precise points: ‘what is fantasy Vs what is real and how can I know ?’
  • fluid time anchoring to conceptualise past, present and future in cognition and emotion, using the polyvagal theory frame
  • SID: mental boundaries, hypnosis
  • we did several ‘deals’ regarding his symptoms management to get his responsibility and control back
  • The work was massively about listening to A. expressing himself freely and me sharing my views when he was seeking them.
  • having the role of
      • a clear reassuring adult A. could share anything with, without any fear of psycho-affective blurriness / manipulation / anxiety triggering …  me, never stepping on the parents’ domains or criticising them: each member had their recognised space.
      • discussion on how to differentiate reality and fantasy topics were on:
      • his sexual assaults that seemed to be sexuality explorations between toddlers + 2 teen boys from school looking at his female body shapes.
      • gender / sexuality, a quest for many adolescent and adults
      • What does A. want and why: real need, fantasms or provocation ?
For Example:
wearing binder
getting surgery
selling his female eggs
how to interact socially
risks of being sexually assaulted / kidnapped / dying

  • Visualisations
  • to create resources - conversational hypnosis
      • for body dysmorphia - conversational hypnosis
  • mindfulness for thoughts looping, kindness meditation to approach body dysmorphia
  • several sessions with parts work on different intrusive as well as on helpful emotions & thoughts
  • Expressive art therapy via drawing
  • checking what outer resources he has:
      • favourite soft toy, integrate its reassuring power: hypnosis
      • his parents: how, when, for what: conversational hypnosis & role play
      • friends & frenemies: who to keep and who to have distance with and why
      • coaching  / socratic process regarding
      • school homework organization: when / how much
      • relationship with teachers and other students
      • what are his potential preconceptions and how it affects his life and mental health
      • Taking the role of a mediator between A. and his parents in setting sessions with the three of them
      • getting consent from A., prior to those sessions, what would he wanted to share and for which purpose
      • re visiting the extend of what is requested from A. by the parents
      • discussing what was important for A. at a moment in time and how it affected his parents: wearing a binder / selling one’s eggs / going through transgender surgery at the age of 16.
      • what is parents’ own anxiety and not A.’s and how this affected A’s life

  • Supervision

Consolidation

  • When appropriate, soliciting A.’s reflection on what he was learning about himself, his family and the world; what implications this may have for him for his future / how he could create the  life he wants, bouncing from what he learned from each session
  • This phase was not ‘finished’ in this therapy, as A. requested to have a face to face therapist, which was welcomed as good news as this is what was needed at that moment.
 
 
Results

  • Open discussion on genders and the search of who A. is: history and cultures differences of the representation of genders as well as what gender search evolution is in A.’s life
  • normality of
      • notion of fluidity / no rush in opinions to have : ‘who am I / who are the others / how is the world and where do I stand in all of this’
      • acceptance and kindness towards self and others
  • massive shift around body dysmorphia towards self acceptance and self love
  • back to increased controlled and chosen social life
  • gained tools for critical thinking around: what is fantasy and what is real
  • self helping tools
  • redirecting A. to face to face local to them psychotherapist + medical consultation; for potential hallucinations and spasms
  • back to being more present at school and looking for universities: future orientation w/ hope and excitement

End of Work:
  • No more hallucination
  • GAD7 = 7: mild
  • PHQ 9 = 8: mild
  • nightmares gone and sleep normalised
  • back to sport
  • no more self harming ideation
  • no more suicidal ideation
  • pride to be different - I told him he represents our societal future on human’s rights
  • stop worrying about his parents' anxiety, opening to them about his fears leading to nightmares and self harm ideation and now counts on their parental support
  • back to better attendance at school and solution discussed with parents around realistic homework organisation
  • parents buying non binary clothes, feeling at peace at using the masculin pronoun and accepting the second new first name
  • much less generalisation, more happiness felt and shown within family setting, much less burst of anger
  • kept high awareness on LGBTQ+ community + human rights without anger and fear attached
  • resources: back to sport,  musique and horse riding
  • A. asked to end the therapy and continued for a while with a local psychotherapist
  • news received end of December 2021: A. changed again his 1st name and is doing great: mother’s words.
  
Scope of work

  • gender and sexuality journey
  • A. felt being a lesbian, then transgender, then  aromantic.
  • He is now defining himself as non-binary and potentially asexual
  • He has resources: youtube channels, local groups … parental support
  • continuing to be aware of his needs to manage his learned tendency to catastrophise the state of the world
  • being aware of his sadness tendency

We can see that this kind of therapeutic work was wider than ‘only’ working on gender issues.



Pia MP Granjon PG Dip (Clin Hyp), MBSCH


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