Question 1

How and which of the core processes of ACT help with gender dysphoria or feeling at war with your body?

Alex Stitt · Accepted Answer

Instead of viewing acceptance, cognitive defusion, present-based-mindfulness, viewing the self as context, values, and committed action as sequential or even separate processes, it’s important to remember that ACT is an integrative, nonlinear modality.

Consider a client who avoids their gender dysphoria by burying their feelings in the proverbial closet. They want to face their dysphoria, but they fear their life may unravel if they do. If they're willing to proceed, they may need to affirm their most salient values, and explore how to apply them contextually to the present moment in order to defuse the cognitions telling them not to accept their feelings. Simultaneously, they must also be present with their thoughts and feelings in order to accept them, view them in context, and defuse from what’s no longer helpful in order to make enough room for value commitment.

Trace the Hexaflex model and you will see that each process is interconnected. If a client is stuck in one process, they may actually need to address another. This is important to keep in mind since gender dysphoria can present very differently depending on the unique social, physical, or cognitive distress a client may have. If a client is uncomfortable in their body, it does no good to force them into it, or center all their sessions around it. Indeed, many gender dysphoric clients dissociate from their physical experience in order to get through the day, sidestep emotional distress, and all the self-deprecation spiraling around their internalized cissexism. Given so many landmines, it may be worthwhile to defuse from some of the more explosive thoughts amplifying their distress. Or, it may be worthwhile to identify their values in order to shift from avoidance strategies to self-actualization strategies. Or it may be worthwhile to focus outwardly, in order to develop a safe environment conducive to self-exploration, before unpacking their dysphoria.

Question 2

What processes of ACT would help someone who feels hooked on needing validation from the outside world in relation to their sexuality or gender?

Alex Stitt · Accepted Answer

This depends entirely on the client and what’s most important to them. If a client wants to empower themselves as an act of self-reliance, then they may need to defuse from any cognitions demanding social approval. However, if a client keeps returning to external validation then there may be unmet needs to address. Trans and nonbinary people who experience intense isolation, alienation, and social intolerance often long for connection, community, and social acceptance – the fundamental building blocks of a healthy social life. So when a client appears ‘hooked’ on the need for validation, it may be time to inventory who already gives them support, who they want support from that may be open, and who they want support from that may be closed. There may be loss, estrangement, and grief to accept. In turn, value congruent action can help a client expand and engage new social support groups that embrace their authenticity.

As always, the more engagement one has with people who actively understand where one’s coming from, the more one feels validated. Now let’s say a client is doing this already, yet still feels like there’s something missing. Dive deeper into the nuances of social connection, since there are many different kinds of relationship and, therefore, many different kinds of gender validation. They may have the validation of their friends, but not their family, or vice versa. They may have the validation of an active sex life, but not a romantic connection, or vice versa. They may have the validation of being good a mentor, but have never found someone to guide them, or vice versa. The hook may have a very specific kind of bait, and they're hungry for it.

Question 3

For someone who is naïve beyond the two cisgender boxes, can you explain what is gender identity and why is it important?

Alex Stitt · Accepted Answer

Gender identity is an aspect of the self that exists at the crossroads between one’s mind, one’s body, and one’s social performance. It incorporates one’s self-concept, but it’s far more than just a thought. It incorporates one’s physical sex, but isn’t defined by anatomy. And it incorporates the social performance of gender, but isn’t limited by them. This is why gender identity is very personal, since there are as many ways to experience gender as there are people on earth.

For some, their experience of gender is rigidly defined. For others it’s fluid and changing. For some, their experience of gender has remained constant throughout their lives. For others it has evolved a great deal. For some, their experience of gender is central to their identity. For others, it’s irrelevant and practically nonexistent. Understanding this, transgender and nonbinary are umbrella terms encompassing a wide array of trans, genderqueer, genderfluid, agender, and xenogender identities. Furthermore, there are many indigenous cultures which have a completely different experience of gender that does not fit a binary worldview.

Question 4

How might ACT help someone who feels stuck in a gender role? What general advice would you give for feeling this way?

Alex Stitt · Accepted Answer

When we feel stuck in a gender role we’re adhering to socio-cultural rules telling us what we ‘can’t do’ what we’re ‘not allowed to do’ and what we ‘must do’ because of our gender identity, so much so that these rules have begun to limit how we see ourselves. In order to affirm and empower a deeper sense of self, ACT mindfully expands one’s internal and external awareness to increase mental flexibility.

By observing how fallible and limiting these rigid gender roles are, it's possible to identify the actor behind the performance. Perhaps we did play a certain role on a certain stage, and perhaps we will reprise that role again should we need to, but what other roles have we played in our life? And who are we when we step off stage and leave the theater behind? Gender exploration is really about recognizing and affirming one's authenticity, and giving ourselves permission to be unscripted.

Question 5

How does ACT fit with gender affirming therapy?

Alex Stitt · Accepted Answer

ACT and Gender Affirmative Therapy share many parallels. Both help clients sit with their internal sense of self, normalize their experience, decrease emotional avoidance strategies, challenge unhelpful cognitions, and facilitate self-acceptance and self-empowerment. I discuss this at length in my article Of Parades and Protestors: LGBTQ+ Affirmative ACT, with the proviso that ACT practitioners need to integrate Affirmative Therapy into their practice if they intend to work with LGBTQ+ populations.

While ACT can be a powerful tool to help clients disempower internalized cissexism, and empower the values instrumental in their gender self-actualization, Affirmative Therapy provides the broader framework necessary to conceptualize gender diversity, and the many complex issues facing trans and nonbinary people. Affirmative Therapy also necessitates a level of self-reflection on the clinician’s part in order to check one’s own bias. On top of this, while ACT is a powerful route to self-acceptance and maintaining self-awareness, Affirmative Therapy is a powerful route to self-affirmation and maintaining resilience.

Question 6

Could you point a new graduate who aspires to work with LGBTQ+ populations in the right direction for training? What are some key starting things to know about to become a competent LGBTQ+ affirming therapist?

Alex Stitt · Accepted Answer

The big thing to know is that competency is not a finish line, it’s an ongoing process of continuing education, especially when it comes to working with LGBTQ+ populations. Not only is each letter of the acronym distinct, it is a world unto itself, comprised of international, racial, ethnocultural, spiritual, socio-economic, and generational differences.

While there are continuing education programs that offer courses in LGBTQ+ affirmative therapy, and a small handful of universities that offer gender affirmative coursework, competency begins with mental flexibility. It's important to study LGBTQ+ history, Queer Theory, and Gender Affirmative Practices in order to conceptualize the many issues sexual and gender minorities face every day, yet more-so to provide context. Every client brings with them their own unique conceptualization of their sexuality and gender identity, as well as their own unique defense mechanisms to survive the socio-political climate they find themselves in. Because of this, clinicians would do well to reframe the discussion from ‘how do I help this demographic to ‘how do I help this person?’

Question 7

What part of ACT can help a client be able to experience their own anger and rage at gender prejudice and discrimination in a way that stops them internalizing it into self-hatred?

Alex Stitt · Accepted Answer

Once again, it’s important to frame ACT as a nonlinear modality. Each of ACT’s six core processes can be helpful to access and express anger before it’s morphed into self-hatred. Internal mindfulness can help clients observe where they feel tense, or hot, or agitated in their body. External mindfulness can observe the power imbalances they’re subjected to that aren’t their fault.

Keep in mind, ACT does not encourage clients to accept intolerance, but to accept their valid emotional response to said intolerance. Cognitive defusion can help them put down the smiling mask, or the idea that they have to be composed all the time, or the worry that they'll lose control if they get angry, or the rule that they’re not allowed to rock the boat, or the reasoning that it's better to be angry at themselves than to be angry at other people.

It is not uncommon for people who are learning to empower themselves to push back against societal expectations, rebel against social norms, or speak out against imbalanced power dynamics. Why? Because a client’s anger is evidence that something very important to them is being threatened or harmed. There is a value behind their anger that needs to be voiced, albeit justice, or fairness, or passion, or dignity, or respect. To that end, the more anger is framed as a signaling system to engage value congruent action, the less likely one is to avoid it, or be carried away by it, or internalize it.

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