Hello! Fantastic questions on today’s Q&A episode. I am always amazed by your honesty and vulnerability when sending these in.
Long story short, I am a transgender male, I’ve been medically transitioning for the past 4 years. I have noticed over the years that though testosterone has helped my dysphoria in so many ways, I’ve also felt that it has enhanced dysphoria in other ways. Especially when I am being intimate with my partner. We have great communication of boundaries and what is/isn’t okay, but my mind can drift off and I get so in my head about my body. I’ve had top surgery and would ideally like bottom, but it’s not practical in my life anytime soon. I often feel a huge disconnect from my lower body and I feel inadequate, like I’m defected. I also feel like I’m letting her down. It’s an awful feeling and it makes me never want to be intimate for the fear that I’ll get dysphoric during.
How can I escape my own mind to just enjoy what is supposed to be a beautiful, fun, and loving connection with my partner? I apologize if this was too long or too much information. But thank you for all the work you do, I sincerely mean it from the bottom of my heart – you’re awesome man!
Thanks for the honest and vulnerable question. Let’s clarify some terms. Many of you probably know this information, but someone who is transgender was born with a biological sex that does not match their gender. This isn’t necessarily dependent on their gender expression or physical look. At their core, they know that there is a mismatch between the gender that they are and the body that they were born with. This can cause gender dysphoria, which is basically just the sense of discomfort that comes from this mismatch.
So if I’m reading this correctly, this is a person who is male in gender, but was not born with a standard male body, so they are trying to transition to make their body match their gender.
Using hormone is one way to adjust the body and they also received “top surgery” which means refers to surgical modification to the chest. They have not yet been able to get bottom surgery, which would be what many people call a “sex change” though that term is not totally precise. This is a really tough spot to be in and I’m proud of you for pursuing these avenues to help become who you feel that you really are. It’s hard to be in the middle of the transition, though. It’s one of those “so close, but so far away” kind of things and that can be super frustrating. First off, getting some support is really important. Making sure that you have people who understand what you are going through that can empathize and talk about their experiences. If you don’t have local organizations in your area, you might be able to find some good online communities that can help to fill that need.
I will say that regardless of sex, gender, etc. sex is something that often involves a lot of expectations both internal and external. The tendency is to apply a lot of pressure to perform and self-judge based on what happens. It may be helpful to slow down a little bit. It’s clear that your partner cares about you, is on board, and wants to be intimate with you. That’s fantastic. You could treat this situation as a prompt to try out some different approaches to sex that can be beneficial regardless of whether you are fully transitioned or not. There are a couple approaches that you could look into a bit more called sensate focus and mindful sex. Sensate focus is something often used in sex therapy where you go through in a structured way and build up very slowly rather than just diving head first into sex. So you actually go day by day, week by week, and limit the type of interaction that you have. Maybe the first day is just touching and caressing over clothes. And you stop there. No further. Then you involve more kissing and heavy petting. Maybe you take tops off or get to underwear. Then you could be nude, but no penetration of any kind. Etc. etc. until you build up to whatever the most intense level that you desire is. Along the way you try to be fully present and immersed in the sensations and the experience. It has a few different functions. It helps to shift the focus from being on the performance element and you’re able to focus more on the experience. It also helps to loosen up the definition of “sex”. We tend to have a somewhat rigid view of what having sex means. It also gives you an opportunity to sort of desensitize. Instead of having a huge build up to a single moment of intensity, which can be anxiety provoking, you are able to naturally transition and work through these steps in a way that is super tolerable. In the end, it can make you more comfortable with the higher intensity intercourse that you are working toward and also super hungry for it because you’ve been holding yourself back all this time.
The mindful sex thing is very similar, but not necessarily working through a protocol over time. It’s just about changing the pace and the focus of sexual interactions. Here is a great TED talk about it. Basically it’s about slowing down, focusing on the sensations, and increasing and decreasing intensity during a longer session rather than building and building to the ultimate goal of orgasm.
Try not to beat yourself up and feel too guilty for having a hard time with this. It’s okay that you’re struggling a bit. It doesn’t mean that it’s not worth it or that you’re doing something wrong. You are practicing and learning. Keep communicating and trying to keep an open mind. You have time to continue tweaking and figuring this out.
I re-recorded the audiobook for Hardcore Self Help: F**k Anxiety. It’s better quality with updated content. Check it out here!
I have a quick question that’s been weighing on my mind recently. I’m seeing a psychiatrist for generalized anxiety with panic attacks. He’s been trying to have me switch medications when I complain that the anxiety is high. I have been very sensitive to medication changes in the past (worsening anxiety, etc.) I’m afraid to ask if I can just try an increased dose of the current medication I am on. I guess I’m afraid I’ll overdose and do serious harm to my body by accident. Can I trust myself and my psychiatrist if we decide increasing the dose is appropriate?
PS the medication is Klonopin and I currently take 1.5 mg a day. It definitely takes some of the edge off, but I’m not where I want to be.
First off – good for you for seeing a psychiatrist. It can be really hard to take that leap and get help. Proud of you for that. One thing that I will say is that out of any type of medical provider, a psychiatrist is going to be most well equipped to help you with medication adjustments. They have likely seen all sorts of people with similar issues and different sensitivities to medications.
Most important thing is that you communicate with your psychiatrist. Your goals and your reservations. Make sure they know where you are at before making changes.
In terms of Klonopin – I did a quick search and it looks like you are in the range with the most research support for anxiety. You can go as high as like 3-4mg, though the research support isn’t as strong for that dose level. It may be more appropriate to switch or add an adjunct medication to enhance the effect. However, I’m not a psychiatrist, so I wouldn’t be the appropriate person to advise you on that. I know that some people do succeed on higher doses of klonopin. It’s just up to your psychiatrist to make that call for you in particular. You psychiatrist will not let you overdose. If you are using the medication as prescribed and not abusing it, you should be fine. You can definitely have side effects and other thing that you don’t want, but those are just things to bring up to your psychiatrist and you can always call and make adjustments if they are too bad.
The other side of that I want to address is – are you also in therapy? Medications are efficacious for treating anxiety, but they don’t actually change much for you in the long run. Research shows that therapy and medication together is more effective than medication alone in most cases. If you aren’t building good coping skills, building a tolerance to anxiety, and adjusting your lifestyle to better support your recovery, you can still be fighting an uphill battle, even with the medication. Do what works for you. Certainly no judgment if medication alone is the approach that fits with you right now. It may be that a medication adjustment is necessary to get you at the right level, but just consider the other stuff as well. It all fits together.
Hello Dr. Duff, After a great deal of bullying and harassment from an administrator who found out I deal with mental illness, I resigned from my career in the spring to focus on recovering from several mental health conditions, including PTSD and BPD. Between April and June I was hospitalized five times, the last for attempted suicide. After being discharged from the hospital, I tried following through with the social worker, therapist, and IOP they had set up for me, but NONE of them called me back. I just lost my psychiatrist of seven, for three of which he was also my therapist, as well. I have tried looking for other work in my field, but despite an impressive resume and several job offers, I found out that the organization for which I worked made it so no one else can hire me until January. My harmful thoughts and symptomatic behavior are returning, and PTSD symptoms have worsened again. And for the first time, I can’t think of a reason to stay alive. I don’t care anymore. What’s holding me back is that I’m a little scared of doing it, but I have a pretty concrete plan. The therapist I just started seeing, and the two psychiatrists I’m trying to decide between, are aware of my situation, so I’m not asking you to give me a reason to live. But if others out there feel this way – only alive so that others don’t have to feel bad that you died – what would you advise us?
I’m so sorry that all of this has happened to you. You have had some really bad luck and that’s super unfair. I totally understand why you have come to a place of feeling like your situation is hopeless. It’s been a bad break. Just don’t forget that things can spiral downward so quickly, but they can also do the opposite. Things can really improve in a short amount of time. I wonder if a big change is necessary instead of trying to force the current situation to work. For instance, could you move to somewhere totally different with better resources and start fresh?
Have you explored treatments like ECT or Ketamine infusion? In particular, Ketamine infusion may be something that you would greatly benefit from. It seems to be particularly effective for people who are in your situation and have treatment resistant mental health issues and a great deal of hopelessness. If you are suffering through this alone, aside from your mental health team, I would suggest that you at least make some of your personal connections aware of the situation. If you have a solid plan, you may need help in restricting your access to the most likely means and in developing a safety plan. You don’t have to want to live right now, you just have to help yourself stay alive in order to give yourself the chance to feel better.
I’m glad you’re alive and I’m glad that you’re listening to this podcast. The fact that you have been doing so much to address this situation. Fighting to find a therapist and a new psychiatrist, writing into the podcast etc. tells me that you have some fight in you and at least a part of you wants to continue living and get back to a place that you are more comfortable with. I believe that you can do it. You absolutely have the capacity to. You are allowed to feel shitty and hopeless and frustrated that all of this has happened AND you are allowed to keep living.
Don’t forget to do the other things that recharge you and nourish your soul. Focusing so much on treatment and the problem at hand can sometimes cause the things that are actually good to fall out of focus. Make an active point to do more of the things that have characteristically brought you joy and comfort. I won’t to try to challenge you and convince you to see things a different way. I am sure that there are people out there, myself and the listeners included, that want you to live. But you may not be in a place to recognize that right now. Just focus on what’s right in front of you. Keep going through the motions with treatment, explore bigger interventions and alternatives like I mentioned, don’t go through this alone, and do what needs to be done to preserve your body and give yourself a chance to live a life that you are more satisfied with.
I have a few resources that you may want to look at if you haven’t yet. At duffthepsych.com/emergency, I have a list of emergency resources. I also did an episode of the podcast all about different intensive treatments for treatment resistant depression, which goes into more detail. That’s at: duffthepsych.com/episode107/
Good luck. I hope we hear from you again.