Obligatory Psychotherapy for People with Gender Dysphoria in Iran

Gender dysphoria (GD) is described as a distressing and persistent conflict between one's at-birth-assigned sex and gender identity. Treatments used for transsexuals are composed of a set of psychiatric assessments, as well as hormonal and surgical procedures, resulting in changes in physical appearance and the function of sexual organs for facilitating the transition to the opposite sex (1). GD is a society and culture-related issue. It is required to take the approval of the Court (e.g., Italy) or the Health Ministry (e.g., Sweden) in some countries, and gender surgery is not allowed in most Islamic countries (2). In Iran, sex reassignment surgery (SRS) has been accepted religiously for transgender people since 1987 (3).

In general, transgender people receive psychotherapy before initiating any medical procedure to explore gender identity, expression, and role; address the negative effect of stigma and GD on mental health; improve peer and social support; promote resilience; and enhance body image (4). Psychotherapy is associated with more optimal outcomes after surgery (5). Mental assessment is not mandatory in many countries. For example, it is not required by law in England and many other countries (2). However, some argue that individuals seeking these procedures due to GD need to be referred to a mental assessment (6).

In Iran, the forensic medical organization issues a license for sex reassignment if the person has undergone psychotherapy for one year, and psychotherapy is mandatory. If the person has undergone SRS, they can change their birth certificate and documents according to their gender identity. The photo of the documents must match the person's clothing for many actions, such as getting a loan, credit card, and driving license. Therefore, people with GD who have changed their clothing but have not had surgery are restricted from many social activities, including driving. The issue of mandatory hijab for women in Iran adds to this complexity.

In this article, I would like to share my experiences of group psychotherapy with people with GD. People with GD are referred to a psychiatric hospital by the forensic medicine organization of Mazandaran province (located in the north of Iran) to undergo a one-year course of psychotherapy and then get a license to change gender. Different approaches to psychotherapy are used in various centers in Iran, including individual psychotherapy, group therapy, cognitive behavioral therapy, and support therapy. In previous years, at Zare hospital in Sari, individual psychotherapy was mainly performed supportively and based on problem-solving. In the last three years, the number of clients increased, and the number of individuals trained to work with people with GD was insufficient. Therefore, it was decided to use group psychotherapy.

Those who requested SRS joined the group. They were referred to the Forensic Medicine Commission of Mazandaran Province, where they were diagnosed with GD. Twelve people joined the group, all of whom were over 18 years. Some had started hormone therapy, and some had not, and all were participating in the group in the guise of the opposite sex. Some group members came from nearby cities because this hospital was the only center approved by the forensic medicine of Mazandaran province. The supportive group psychotherapy was mainly formed with a problem-solving approach. The group was closed, and the number of participants remained constant throughout the year. The leader of the group was a psychiatrist and psychotherapist. Weekly group sessions of 60 min were held. As a group psychotherapist, I faced various challenges.

A challenge we faced was gender segregation in many official spaces in Iran. However, in the case of a group whose most crucial issue was gender identity, we decided to create a mixed group of seven transgender men and five transgender women. A heterogeneous group helped these people to get to know the experiences and expectations of the opposite sex better and empathize with each other and help each other better in solving issues related to gender roles. In research in Turkey, a homogenous group was held to avoid gender-related conflicts (7).

The dominant theme in the sessions was the impact of gender stereotypes on careers, interpersonal relationships, family and partner problems, and discrimination. Group therapy helped the psychiatrist gain a better understanding of each member and their interaction with the family. Some members talked about not being accepted by the family. In some cases, individual meetings were held to educate the family members. The group members shared many common experiences, realized they were not alone in terms of problems in society or family, and got help from other members to solve the problem. This issue caused empathy and cohesion in the group. Our experience is in line with research conducted in Turkey (7), which showed that individuals stigmatized and excluded by society must share their experiences and problems with others.

One of the problems was the mandatory course of psychotherapy for one year. Some studies have reported the helpful effect of group therapy for individuals with GD to share their experiences and talk about their doubts and other feelings in a safe environment. However, no study has addressed mandatory psychotherapy. In previous investigations, patients were not forced to undergo a year of group therapy, and the person with GD decided on the duration of presence in the group (8, 9). Therefore, in the group I ran, anger at coercion was felt in the group. At the beginning of the group therapy, people did not talk about their doubts and concerns because they were worried that the psychotherapist's opinion about their gender change would be affected. Gradually, a sense of trust was created among the members and between the members and the therapist. However, resistance was observed in the mandatory group until the end of the course.

In the mandatory group therapy, dropout was zero, unlike other types of group therapies that report 30 - 40% dropout (10) because people needed to have a certificate of participation in a one-year psychotherapy group to change their gender. In addition, these people had to pay for psychotherapy for one year. They had to spend their time and money on a mandatory stage so that they could get a license for SRS, and then they could drive, be employed, and perform other normal activities in society. Although the purpose of psychotherapy is for people with GD to talk about the problems and discriminations created for them in society and find solutions, mandatory psychotherapy is also a kind of considerable discrimination and is in contrast to the patient's autonomy.