Psychedelic-assisted therapy and reclaiming identity

True affirmation must first come from within.

When Mikayla learned that psychedelic-assisted therapy with psilocybin mushrooms could help with depression, she wondered if mushrooms could help her too. She had been struggling with gender dysphoria and related suicidal thoughts since early puberty, often falling asleep wishing she would wake up as a cisgender person – or not wake up at all. Mikayla found articles describing research exploring whether psychedelics could “cure” gender dysphoria. Unable to find a clinical trial to join, she took psilocybin mushrooms on her own. During her experience, she was not freed from what she saw as the burden of being trans. Instead, she had a profound realization that there was nothing wrong with her. She wept with gratitude and mourned the years she lost hating herself. For the first time, she saw clearly that she was surrounded by people unable to see beyond their own limited perspectives of gender. With the help of the mushrooms, she saw herself as a beautiful, magical human connected to an infinite lineage of past, present, and future humans who live beyond the binary.

Psychedelic-assisted psychotherapy (PAT) has received tremendous attention in both the popular press and scientific literature in recent years. PAT includes the medically supervised use of psychedelic medicines such as MDMA, psilocybin, LSD, and ketamine, in conjunction with psychotherapy that is specifically designed to optimize the mental health benefits of these medicines. Heralded as a breakthrough treatment for several mental health issues including depression, anxiety, post-traumatic stress disorder, and addiction, it represents hope for people who have tried traditional treatments that have failed them. However, despite growing evidence of efficacy and safety, PAT is largely not available to the people who need it the most.

As a clinical psychologist and researcher focused on healthcare for transgender people, I know how often individuals like Mikayla feel they must navigate this complex terrain alone. Both psychedelic experiences and transgender identities have been medicalized and pathologized - even criminalized - by the Western medical model. Despite a promising line of psychiatric research and no evidence that these medicines are addictive, psychedelics were categorized as Schedule I substances in the early 1970s as part of the War on Drugs, deemed to have no medical benefits and high potential for abuse. In fact, psychedelic medicines have been used in healing practices for over 5000 years. Outlawing psychedelics in the United States led to mass incarceration and the suppression of further research into their mental health benefits for more than four decades.

Also in the mid-20th century, Western medicine began to develop treatments for trans people with the assumption that being transgender was a mental disorder that needed to be cured. At that time, Western scientists also developed conversion therapies to turn queer and trans people into straight and cis people, and even studied the potential use of psychedelics for this purpose. Unfortunately, researchers today continue to publish accounts of attempts at conversion therapy, despite its documented harms. This was the research that Mikayla happened upon when she sought to “cure” her transness using psychedelics.

Currently, PAT (excluding ketamine) is only accessible legally within the context of clinical trials. There are long waiting lists of people who hope to enroll in these trials, and long lists of criteria for which most people will be excluded. Trans and gender expansive people are vastly underrepresented in all clinical research, and trials of PAT are no different. This means that, like Mikayla, most people working with psychedelic medicines today do so outside of the medical context. This has been true throughout all human history and in cultures around the world. Even here in the United States, underground therapists have been offering these medicines safely and effectively to people who have experienced transformative, sometimes even lifesaving, benefits.

While PAT does not eliminate structural barriers to optimal care, its promise does represent a unique hope for transgender people. PAT can increase gender affirmation in multiple ways. While many people like Mikayla experiment with psychedelics on their own, in an ideal situation people will have a trained therapist to guide them during the session. With a gender-affirming therapist, the client will experience connection and affirmation from the therapists. The client may experience increased affirmation of themselves, as psychedelics have the capacity to increase one’s self-compassion and unconditional self-love. Psychedelic journeys that result in a mystical or unity experience can result in a sense of “divine blessing”, described as the experience of having one’s higher power communicate affirmation of the highest order. PAT can increase one’s sense of trust and connection, and for trans and gender expansive people who describe experiences of feeling like an outsider, these medicines may provide a pathway for reconnecting with oneself and others. In addition to increasing access to gender affirmation, PAT may also reduce the need for gender affirmation from other people. As a client experiences renewed connection with their body and self-compassion, they often come away with a visceral understanding that true affirmation must first come from within.

Offering optimal care to people requires us to continuously challenge medical control of the human experience and the ways we’ve internalized this control. We must continue to create safe, supportive spaces where trans people can express themselves fully, collaborate with each other, and build solidarity across different communities. In this way, we all can experience more freedom, both individually and collectively. There is much internal work to do alongside the external work of navigating and transforming these systems, but as we do so, we reclaim the right to healing for all. We all must reclaim the right to make choices about our own bodies and futures. This includes embracing all healing modalities – including psychedelic experiences – that offer hope. In this way, people like Mikayla will not have to navigate this terrain alone.