Missteps in Treatment: Confronting the Limits of My Knowledge
By Dwight Panozzo
In Part 1, therapist Dwight Panozzo reflected on how he broke his silence on Gender Identitarianism (GI) too soon, without taking the time to thoroughly research what it actually represented. In this second part of his journey, he recounts the professional missteps that followed his public support for gender self-identification.
At Genspect, we value clinicians who confront their errors with humility, as Panozzo does here, offering insights that can guide others in navigating the complexities of gender-related care. In this second post, he recounts the professional missteps that followed his public support for gender self-identification and his experiences treating transgender patients.
Read the full series: Part 1: From Respect to Understanding | Part 3: Recognizing Gender Identity as a Belief System
Treatment of Two Transgender Patients
I had no idea that my speech was a form of advertising, which was remarkably naïve, given that my psychoanalytic supervisor of 20 years had taught me that all public talks were a form of “ethical advertising.” Soon, two transgender patients sought my care.
While I thought I understood what ethical psychotherapy treatment was and how to provide it, and had benefitted from training — a two-hour lecture and Q and A with a transman in a graduate class, and I had reviewed the standards of care in the WPATH manual—I see now that I was unprepared.
One patient sought a hormone letter and later a double mastectomy letter; the other, less engaged in therapy, sought hormones with a compelling narrative of gender dysphoria. The first patient gave evidence of the need for a hormone letter, which was followed a year later by a letter for a double mastectomy. The second, who was comparatively less engaged with anything in life beyond seeing friends or avoiding work, was strikingly cogent and convincing in their description of the heartache they suffered from regarding their gender dysphoria. The dichotomy in engagement in life and needing hormones for this patient was utterly striking. It was only later that I learned that many people in the transgender community share narratives with each other to then perform for therapists to get letters.
It is impossible to know if that is what I was exposed to with either or both patients, but the possibility looms large in my mind. Both left treatment against clinical advice with numerous unresolved life challenges and did not return. In retrospect, I deeply regret those letters as one patient deepened their use of an illegal drug while the other experienced a descent into substance abuse and prostitution. Even if their gender dysphoria was reduced, their overall level of life functioning clearly decreased.
Wandering in the Wilderness
These experiences made me wary of treating gender-related issues. The gatekeeping role imposed on therapists—writing letters to protect patients from hasty decisions—got in the way of providing quality care to them. It also became clear that the small sample of people who did present might have wanted some assistance with some psychological issues, but my role was diminished to that of a letter writer, not a psychotherapist. Transactivists see therapists as gatekeepers preventing free expression. Gender critical activists see them as providing prescribers and surgeons with a level of protection from malpractice lawsuits. Ironically this puts therapists at risk for malpractice suits from dissatisfied patients.
I decided to refuse further inquiries from transgender patients, believing I had parted ways with GI. My lack of curiosity about its underlying dynamics was a failure, echoing Socrates’ warning: we err not on what we don’t know, but on what we think we know.
Called In, Twice
During the COVID-19 pandemic, a patient introduced me to Abigail Shrier’s book. Initially, I dismissed it, certain she was wrong. Months later, I revisited it, grappling with its implications. A second opportunity came when I was asked to join a library panel discussing Helen Joyce’s book, Trans. Through engaging with Joyce and clinicians like Stella O’Malley, Sasha Ayad (Gender — a Wider Lens), and Lisa Marchiano in their book, When Kids Say, They’re Trans, I realized my training was steeped in ideology rather than depth psychology. My review of the literature, which spanned hundreds of hours, revealed a weak theoretical foundation for GI; studies claiming to validate it often failed to control for variables such as sexual orientation. It crumbled under scrutiny.
My missteps taught me the dangers of acting without understanding. In the final post, I’ll explore GI as a potential New Religious Movement and propose ethical pathways forward.
Continue reading: Part 1: From Respect to Understanding | Part 3: Recognizing Gender Identity as a Belief System
Dwight Panozzo, PhD, licensed clinical social worker with 30+ years’ experience and Beyond Trans therapist directory member.
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