5 things to know about transgender depersonalization

“…I was a dispassionate observer of my own life. The person who went through the motions wasn’t the observer-me. Whenever the acting-me felt any emotions, the observer-me recognized the emotions but didn’t feel them herself.”

1.

Chronic depersonalization is a distressing dissociative condition characterized by feelings of “unreality” or “no self”, and it occurs at an elevated rate among trans people. Also known as depersonalization disorder or depersonalization-derealization syndrome, sufferers of this condition perceive themselves as emotionally distanced and separated from their experience of self and their perception of the world [1]. While their grasp of reality is intact, they perceive themselves as not truly feeling their own emotions, and have a sense that the world is flat, lifeless, or lacking in meaning or depth. Depersonalization disorder is chronic and unremitting; most individuals experience its onset in adolescence, while others report it being present since their childhood [2]. Studies have found that trans people are anywhere from 3 to 18 times more likely to experience this chronic syndrome compared to the general population [3], and depersonalization has been a theme of numerous personal accounts and memoirs of trans people for decades [4, 5].

Those with depersonalization often experience their self as separated into an outer participant in the world and a detached and emotionless inner observer, and they can feel that a kind of “veil”, “fog” or “glass” has interposed itself between them and the world around them. They may find spontaneity to be difficult or elusive – with little sense of agency or investment in life, they often feel that they are a “robot” or a “zombie” who is simply “going through the motions” [6]. Sufferers may also ruminate or obsess over existential questions about reality and the self. Despite their experience of emotional numbing, those with depersonalization typically find this to be a “painful absence of feeling” and a highly distressing condition [7]. The elevated prevalence of these serious symptoms among trans people make depersonalization an item of special concern to us.

2.

Chronic depersonalization is not just depression or anxiety. Because depersonalization alters the texture and sensation of subjective experience on a very deep and even pre-verbal level, sufferers often find it challenging to explain or convey these symptoms to others; living with depersonalization disorder has long been recognized as notoriously difficult to describe in any way other than metaphor [8]. While inexperienced clinicians may misdiagnose the chronic syndrome of depersonalization as instead being symptoms of depression or anxiety alone, studies have found that depersonalization disorder represents a symptom cluster distinct from depression or anxiety [9].

3.

Chronic depersonalization can have a severe and wide-ranging impact on mental health and well-being. The distressing experience of unremitting depersonalization is typically not an innocuous or harmless syndrome. Individuals with depersonalization disorder are more likely to experience comorbid mental health conditions, such as depressive disorders, anxiety disorders, suicidal ideation and attempts, and avoidant personality disorder [10]. As a result of these interlocking struggles, sufferers can face difficulties and impairments in employment, personal relationships, academic achievement, independent living, positive coping strategies, cognitive function and focus, and overall social engagement [11].

4.

Depersonalization symptoms can be successfully treated via transition, particularly hormone therapy. Clinical studies repeatedly find that trans people who’ve medically transitioned have decreased rates of chronic depersonalization and its symptoms, similar to the general population [12]. Much as hormone therapy has been found to have a positive effect on depressive and anxious symptoms in trans people, HRT is also associated with a measurable reduction in depersonalization among both trans women and trans men [13].

5.

Trans people can benefit from greater awareness and screening for depersonalization. Existing guidelines recommend that providers assess trans people seeking transition care for co-occurring mental health conditions [14, 15]. Unfortunately, even among the general population, depersonalization disorder is “poorly recognised and under-treated” [16], and there is “a dramatic neglect of DP in clinical routine” [9]. It is typical for sufferers to experience the symptoms of chronic depersonalization for 7–12 years before receiving a diagnosis, and some have lived with this for half of their lifetime [17]; they may even have had depersonalization for so long that they’ve become “habituated to it as ‘normal'” [6]. Those with depersonalization can find relief in simply knowing that their symptoms have a name and are part of a recognized condition, and that they are not alone in this experience [16].

Given the potentially severe impact of untreated depersonalization on mental health, recognition of these symptoms among trans people is of urgent importance. When considering their medical options, trans people should be aware that transition may provide relief from depersonalization, and that those struggling with this condition may benefit from additional medications or psychotherapy focused on these symptoms [17]. Emergence from the fog of depersonalization can be a highly rewarding and life-enriching experience for trans people, with many reporting a sense of feeling truly alive for the first time and a transformative improvement in their ability to be engaged with the world around them. By being aware of these symptoms in trans people, healthcare providers can play a key role in helping us become our fullest selves. ■

References

• [1] American Psychiatric Association. (2013). Depersonalization/derealization disorder. In Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
• [2] Medford, N. (2012). Emotion and the unreal self: depersonalization disorder and de-affectualization. Emotion Review, 4(2), 139–144. [Abstract]
• [3] Elevated rates of depersonalization in gender dysphoria (Gender Analysis)
• [4] In our own words: transgender experiences of depersonalization (Gender Analysis)
• [5] Themes of depersonalization in transgender autobiographies (Gender Analysis)
• [6] Steinberg, M., Cicchetti, D., Buchanan, J., Hall, P., & Rounsaville, B. (1993). Clinical assessment of dissociative symptoms and disorders: the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). Dissociation, 6(1), 3–15. [Abstract] [Full text]
• [7] Enlightenment’s Evil Twin (The Atlantic)
• [8] Sierra, M., & David, A. S. (2011). Depersonalization: a selective impairment of self-awareness. Consciousness and Cognition, 20(1), 99–108. [Abstract] [Full text]
• [9] Michal, M., Glaesmer, H., Zwerenz, R., Knebel, A., Wiltink, J., Brähler, E., & Beutel, M. E. (2011). Base rates for depersonalization according to the 2-item version of the Cambridge Depersonalization Scale (CDS-2) and its associations with depression/anxiety in the general population. Journal of Affective Disorders, 128(1–2), 106–111. [Abstract]
• [10] Psychosocial impact of depersonalization: depression, anxiety, and suicidality (Gender Analysis)
• [11] Psychosocial impact of depersonalization: social and occupational impairment (Gender Analysis)
• [12] Depersonalization in gender dysphoria: widespread and widely unrecognized (Gender Analysis)
• [13] Colizzi, M., Costa, R., & Todarello, O. (2015). Dissociative symptoms in individuals with gender dysphoria: is the elevated prevalence real? Psychiatry Research, 226(1), 173–180. [Abstract]
• [14] Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., . . . Zucker, K. (2011). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism, 13(4), 165–232. [Full text]
• [15] Byne, W., Bradley, S., Coleman, E., Eyler, A. E., Green, R., Menvielle, E. J., . . . Tompkins, D. A. (2012). Report of the APA Task Force on Treatment of Gender Identity Disorder. American Journal of Psychiatry, 169(8), 1–35. [Abstract] [Full text]
• [16] Simeon, D. (2004). Depersonalisation disorder: a contemporary overview. CNS Drugs, 18(6), 343–354. [Abstract] [Full text]
• [17] Hunter, E. C. M., Charlton, J., & David, A. S. (2017). Depersonalisation and derealisation: assessment and management. BMJ, 356, j745. [Abstract]