Intervention through Somatic Inkblot Series and CBT in a case of Gender Identity Disorder
Satyadhar Dwivedi and Richa Verma
(SIS Journal of Projective Psychology & Mental Health, (2018):25:2, 177-180).
This case demonstrates the use of cognitive behavioural therapy in the treatment of gender identity disorder. An 18-year-old male presented with complaint of feeling of discomfort with his sex organ for several years. He had taken treatment for it with no relief. The Somatic Inkblot Series was administered to understand the underlying psychopathology and conflict of his gender dystopia. The Cognitive Behaviour Therapy was administered in 12 sessions along with pharmacological treatment. The periodic assessments including follow ups indicated substantial change and improvement in his condition which is being maintained even after six months of follow up. The case is presented to highlight the effectiveness of CBT.
Body image is a complex multifaceted construct including physical characteristics, psychological traits, and societal norms (Cash, 2004). Body image can be studied through the assessment of body-related satisfaction, feelings, ideals, and quality of life. In people with gender dysphoria (GD), body dissatisfaction-resulting from the discrepancy between “assigned” sex at birth and experienced gender—often leads to seeking medical care. Earlier research has shown that body dissatisfaction of people with GD at admission is high and often reaches beyond the characteristics of sex (Grift at al., 2016; Becker at al., 2016). Because not all body parts are affected by treatment, it is uncertain whether medical transition can completely dissolve body dissatisfaction. The diagnosis of gender identity disorder (GID) is dependent on two components. The first, in adults, a strong and persistent cross-gender identification; and in children, various behaviours like the insistence that they are the opposite sex, a preference for cross-dressing, and a preference for playmates of the opposite sex. The second component involves persistent discomfort with his or her sex or a sense of inappropriateness in the gender role of that sex (Karasic & Drescher, 2006).
Transgender people may be sexually oriented in attractions, behaviours, and identities toward men, women, other transgender people, or any combination (Grant et al., 2011; Iantaffi & Bockting, 2011; Nuttbrock et al., 2011). The present case study aimed to re-educate the client towards resolving his identity issue. The SIS-II was administered to find out the underlying psychological trauma, if any, leading to such behaviour and the therapeutic intervention with the help of Cognitive Behaviour Therapy.
Brief Clinical Description:
Index patient is 18-year-old male, un-married, studying in B.Sc. First year, Hindu, Hindi speaking, hails from urban area of Agra and belongs to lower-middle socio-economic background. He was apparently doing well until he ran away from home without informing anyone. Three months later, with the help of Police, he was in Delhi while moving with a group of Transgender in Delhi, dressed up like a girl. His parents got shocked after seeing their son dressed up like a female. They took him back home and enquired about everything. The patient told them that he feels good while living with transgender and it provides his Identity and as he always felt being trapped in a male body. When asked if getting a chance, ever, would he change his gender, he replied ‘Yes’. While living with trans-genders, he took injections to develop breasts and complete all rituals to become a transgender. He started going out with other group members and earned money by dancing in marriages and trains.
The patient adopted feminine mode of carrying himself and clapped like transgender. He further said that it always fascinated him to interact with transgender individuals right from his school days. For three months when he was away from home, his parents got to know from one of his friends that the patient used to meet the transgender group of local area daily and spent one to two hours interacting with them after his tuition classes. Patient’s parents reported that he always liked to spend his time more with girls rather than boys in school days. Dancing, cooking and grooming himself like girls were always his hobbies. When he was brought to home from Delhi, he tried to run away several times, but was caught by his uncle and brought to Institute of Mental Health and Hospital, Agra for treatment.
Cognitive Behaviour Therapy in Gender Identity Disorder:
Psychological treatments deal with responses of the individual to stressors related to the social experience of Gender Dysphoria. Talking with the psychotherapist helps process through one’s feelings of fear, anxiety, sadness, shame. Cognitive Therapy has been shown to be an effective treatment for psychological stressors.
Twelve sessions of CBT were administered with the objective to convince him to be as "Male". The first four sessions were taken on alternative days, the next four sessions were administered twice a week, and last four sessions were administered once a week.
Session One: Started with psychoeducation about his nature of problem - prevalence, incidence, psychological and pharmacological treatment facilities available in India for GID. During the session he was sensitized about side effect of such treatment and was asked to rethink about his decision.
Session Two: This session was started with taking feedback of last session and about his final decision about sex transformation. He was 100% sure to go for hormonal and surgical process for transformation of sex. In this session he was asked to think about different role of sex in society and whether he is a good fit in such roles and social norms.
Session Three: This session started with discussion about female sex and how much he is comfortable to be a female in society. He came to know that after sex transformation, he may lose productivity as a male and may not be able to be a father or mother in future.
Session Four: He was not willing to come in this session as he was conformed to his individual decision, but he was brought by an attendant of the respective ward for session. During this session he was sad and did not want to stay in inpatient setting of the Hospital.
Sessions Five to Eight: He was motivated for not undergoing sex transformation; instead stay at home and follow the norms of the family and society. He was further discussed issues from where he developed this interest. He narrated the history about his interest, playing with girls during his early childhood and preference of female play/game rather games played by boys and was happier to wear the cloths of girls.
Sessions Nine to Twelve: His family was called and counselled about how they can help the client. They were also advised to develop new interest in life and not to lock him at home.
Somatic Inkblot Series-II:
The Somatic Inkblot Series (SIS) is a structured, projective, diagnostic procedure and is an adjunct to psychotherapy. It is based on spontaneous, individually generated responses to semi-ambiguous figures, which elicit intra-psychic associations specific to the person presented with them. The Somatic images evoke symbolism and meanings unique to the responding individual. These can be differentiated from typical and atypical peer norms and can be analysed according to internationally recognized diagnostic criteria. The procedure is an adjunct to therapy because responses can be further explored to create a more effective treatment plan, and can be re-addressed in later discussions, providing opportunities to elicit deeply defended material. During the administration of the SIS procedure, clients may abreact emotional conflict raised to consciousness by the images, which can be a therapeutic experience (Cassell & Dubey, 2003).
The SIS images use the language of dreams, visual imagery, and symbolic thought, the most basic forms of thinking and expression. It is also the language of repression which brings whatever is buried in the mind closure to consciousness, accessible for processing. Expression stimulated by ambiguous imagery can be used in therapy to test insight and to help measure treatment progress (Dubey, et al,2014).
A few significant responses relevant to this case are analysed below:
A1: " looking like lungs, ugly looking." This indicates low body imagery and a kind of low self.
A5 (Image 3 of SIT): "Cartoon and looks good" may indicate his desire to keep smiling and happy. The common response on this image is ""happy man"
A7 (Image 5 of SIT): "Funny picture of a girl" though the dancing lady is the most common response on this image. Avoiding perceiving dancing lady may indicate his conflicting behavior and role particularly in female domain which he is not sure to accept forever.
A9 (Image 6 of SIT): "half pictures" . He has again avoided perceiving two persons particularly a male and female, may further bring the gender conflict already brought on earlier image A7.
A10: Preponderance of " X-Ray of Stomach" on A10 “ultrasound of Stomach on A14, A15, B10, B11, X-Ray of Lungs and intestine on A17, and A19 suggested his preoccupied bodily anxiety probably due to thinking of changing the sex and adopting new roles in life. Many such responses may further suggest somatization tendency (Klopfer, 1954).
A27 (Image 17 of SIT): Despite perceiving Breast on this image he has seen "Ladies sandal" which may indicate severe conflict with mother particularly during oral state of development when mother could not take proper care of the child during early life. This was also confirmed during personal interview with mother.
A31 (Image 18 of SIT): "Two faces looks happy" is a good response though he could not perceive whether they are male and female. This again indicates gender conflict.
B4 (Image 19 of SIT): "Two good looking faces of women" on this image where people perceive two males may indicate his liking for females and the fantasy/attitude he has to change to a Female in future.
B17 (Image 22 of SIT): "Heart, sad feeling" may indicate his pensive mood and uncertainty.
B28 (Image 28 of SIT): "One woman;" “avoiding child with mother” on this image brings back the conflicting mother-son relationship particularly during childhood which was also indicated on A27.
B31: "One family –mummy, papa, son and daughter" is very good response on the last image of the test. It further indicates his feelings towards happy family and sign of good prognosis.
Discussion
A useful feature of the somatic inkblot test is the inclusion of structured images capable of stimulating male and female body imagery. Case of gender identity was taken to assess the sexual conflict of the client, and it brought out on surface underlying unconscious conflict particularly in relationship area. He gave more somatic percept on SIS indicating having anxiety and somatic preoccupation. CBT was found useful in this case, helped in reducing anxiety and develop new strategies cope with his gender identity issue.
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