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Interview with Sage DeRosier and Liliana Ramos
Liliana: Welcome! We appreciate you doing this interview. Would you please introduce yourself, tell us about your specialties, certifications, and training.
Sage: My name is Sage DeRosier. I'm a trained holistic psychotherapist; I started practicing in 2008, became licensed in 2012, and in private practice since 2013.
I contribute in the world by loving people unconditionally while engaging in creative, experiential therapeutic relationships that help my clients heal from profound and overwhelming hurts and step into their innate power, potential, and wisdom. I help people move through developmental stages with increased youth and efficacy, learn skills , tools, and practices to more effectively navigate within our global milieu of intergenerationally-layered trauma compounded by curated ignorance and misinformation. I help people perceive the possibility of our species finally evolving beyond perpetual emotional retrogression toward creating systems, supports, and social structures that end unnecessary fear and instead nurture kindness, connection, inclusion and diversity.
My specialties include my niche area supporting gender expansive youth and their families, which is the intersection of three deep interests. Interest #1) Death and dying, bereavement, complex loss, grief work. Interest #2) Working with children, using play and art therapy. And Interest #3) Anything having to do with the full range of gender and sexual orientation identities as well as expansive relationship configurations. I was trained at the Process Therapy Institute as a process therapist. I also trained with the founder of Accelerated Resolution Therapy (ART), an incredibly effective trauma resolution modality. ART uses bilateral stimulation, sensory processing of the brain's playful and creative powers to decouple traumatic memories from hijacking the physical and emotional body. I'm trained in and I've trained other clinicians in clinical applications of polyvagal theory. Also, I'm also a graduate of the 50-plus hour San Francisco Sex Information Sex Education (SFSI) Training. I was also trained in and have a certificate in commercial mediation.
Liliana: That is quite an accomplished list. What are the intricacies of doing therapy with transgender clients?
Sage: Working with gender-expansive clients, including those who identify as transgender, gender fluid, non-binary, two-spirit, and so forth can be quite tender and complex. When a human being dares to enter into their individuation and authenticity-seeking process, sometimes they discover and learn things about themselves that flies in the face of often narrow, overly sheltered, ignorant, and or painfully rigid beliefs and childhood conditioning. I’ve come to realize that people are taught many narrow-minded beliefs, like there are only two genders — boy and girl — despite a blatant plethora of biological evidence worldwide that there are multiple genders, shared genders, changing genders among earth’s many living beings. When we enter introspection and authenticity-seeking and discover that the gender we've been brainwashed to perform is based on the genitals that define our sex, when we find our authentic identity doesn't match our conditioning, we face a primal fear. What if to belong, remain connected, safe, and supported, I must reject my authentic identity?
Many people historically have chosen to deny their authentic identity to conform and capitulate to social pressure to fit in, seem safe, and look normal. Unfortunately, that trade-off is not sustainable. Denying our authenticity is ultimately toxic, not only to relationships, but to the people who are (ironically) living in drag. By performing the role that has been projected onto them by everyone whose path they cross, nobody gets the benefits of their real, authentic, most empowered self. Refusing our authenticity results in resentment, depression, and anxiety. An inauthentic person does not have an actual connection with others. They perform for the illusion of safety; internally. they are disconnected. There are many people who live confused, perpetually asking, “why am I so depressed?” My answer: “because you've refused your authenticity, overlooking a core tenant of what it means to be fully human.”
In my practice with gender expansive people, it's my priority to meet each person where they are in their process: in pre-contemplation some haven't even thought about their gender. Maybe they're contemplating, exploring possibilities. Maybe they've started experimenting with identity shift. They might have already explored or tried coming out, or might be in physical, social, legal, or medical transition of some sort and navigating, gender identity shift in their meaningful relationships. For example, with kids, many start with coming out to close friends at school because there's a closeness and it’s not as risky as starting with parents in some cases. Nobody makes this decision on a whim. It requires a new vocabulary, explaining stuff to people. It's really uncomfortable. It's potentially vulnerable. You expose yourself to harsh judgment, exclusion, the potential of violence.
Liliana: What should therapists be aware of when working with transgender clients who are neurodiverse?
Sage: There’s a lot of overlap between gender expansiveness and neurodivergence. Neurodivergence is more common than most people think. Humans are adaptable and have a strong instinct to survive, so we're quite capable of masking and showing others what they demand to see. For most people, their only exposure to neurodivergence is extreme autism spectrum disorder (example behaviors include yelling/screaming, continuous stimming, primary communication is nonverbal and others) which can make some people panic. A lot of other neurodivergent presentation exists on the spectrum. Neurodivergence shows up quite differently from person to person. So, if I'm autistic, I won’t exactly match anybody else who's autistic. There might be some overlap, but the general public is not aware of this. And most of the historically well-known organizations that purport to deal with neurodivergence are about forcing behavioral conformance on people who are neurodivergent so they “fit” into neurotypical cookie-cutter patterns. To me, a lot of our social norms are overly simplified and don't account for or fully value the beautiful diversity of humanity. Essentially, neurodivergence is more common than people suspect. A lot of neurodivergent people have learned to mask, ignore their neurodivergent inclinations. Most my clients who identify as neurodivergent are on the autism spectrum or are diagnosed with ADD, or ADHD.
Neurodivergent folks may show up as a little different, quirky or more literal than average. Their relational skills may seem a bit different. There are some autistic folks who have learned how to “pass” as “normal” sort of like how some transgender people can “pass” as cis-gender. That's because they're putting an inordinate amount of energy into passing. I think of how ducks seem to glide smoothly on the water. But underneath, they’re paddling really fast. And we don't see the fast paddling of most neurodivergent folks. So, what happens after a while, is many get very tired, depressed, anxious. Some start developing maybe physical symptoms – they get sick. For a lot of people who are overworking to keep up with what is expected, at some point it catches up. For example, a person finds a place to work so they can be self-supporting. It's usually fine: “Somebody is working with my quirky self and they're able to get benefit out of my contribution. At some point, my manager takes another position or leaves the company and somebody else becomes my manager who didn’t hire me, doesn’t know me, and doesn't have a relationship with me. And they are really bothered by my quirkiness. My job gets much harder, or even threatened.”
With gender expansiveness and neurodivergence, anxiety and depression can sometimes enter the equation. Anxiety is our fancy word for afraid. And human-curated fear is, in my humble opinion, the core of what gets in the way of our species evolving. Fear has a very basic, quite useful purpose, which is help us survive imminent danger. My body is hardwired to rapidly pick up potential danger via neuroception, a subconscious system for detecting threat and safety. Being perceived as different coupled with a real fear of not being welcomed and included ups our odds for anxiety, sometimes enough anxiety to be diagnosable.
Depression is a type of “stuckness,” a lack of energy. If we look at polyvagal theory, our initial state from birth is dorsal vagal: rest and digest. Once we've rested and digested, then we can move up to our next level, which is sympathetic vagal: excitement and/or fear. If I'm threatened, I get that jolt of energy to do something to survive. But, if cannot escape the threat, if I’m barely surviving, or if I'm still feeling threatened after my adrenaline has run out, I drop back down into dorsal vagal: into rest and digest. And it's a hard and difficult rest and digest, which takes much more time to get enough energy to come back up to sympathetic where I can try again. And so I can get stuck in a loop, unable to access the next level, ventral vagal: safe connection and creativity. That lower loop is the depressive loop. I have not enough energy to get unstuck from this loop of agitation and exhaustion. Depressed people don't feel alive and don't feel creative or connected. They ask: “What’s the point; why am I here?” When we're different, neurodivergent, or somehow not fitting into the narrow gender norms that have been imposed upon us, we experience disconnection, which can leave us anxious, depressed. So, there's a common root.
Liliana: Yes, that makes lots of sense. Thank you. Are there any other issues that are prevalent since we're talking about how they're all connected?
Sage: One of the most important issues in my opinion is the bane of most people's existence in the United States, which is insurance and affordable quality health care. Insurance often acts like an authoritarian gatekeeper. It prevents care that physicians and their patients agree upon. Insurance providers will lure us in with clever marketing schemes about building bridges and better health and better life and like a good neighbor and thrive and helping. Well, a good neighbor doesn't shut the door in your face when you need medical assistance. Functional medicine is actually much more competent, but insurance doesn't cover it, which is interesting. The things that are outside of the narrow business lines of western medicine don't get covered. So a lot of insurance companies deny care. They make it super difficult to get coverage for hormone therapy and gender-confirming surgeries. I worked with a client a while back who was the parent of the transgender youth who had passed the age of majority, and they got a big run-around with the insurance company about paying for gender-affirming care. The issue with insurance companies: who gets to decide what is necessary, what's a necessary procedure. How do we help the client get what they need to decrease their gender dysphoria?
When we tell an individual with neurodivergence that they need to figure their identity out quickly, it creates unnecessary pressure, anxiety. I imagine that a person who hears impatient demands from somebody else will feel jangled, perhaps frightened or overexcited and may not stop to say “let me think this through.” So, there's the pressures coming from a lot of people around us when we're just questioning what's going on with me? How come I'm having a harder time playing this gender role than my friends? How come I'm not able to look other people in the eyes and they're able to look me in the eyes? How come other people get sarcastic jokes and I don't quite get it? It gets complicated.
Liliana: I'm wondering, what made you get into this work and decide to work with this community?
Sage: At the end of my graduate studies, I had sort of an aha moment. I had to choose a niche, so I kept going back to my three interest areas. One, the working with children and youth by using play therapy, art therapy. Second, the death, dying, loss, bereavement, and grief work. Third, the non-traditional identities that involve gender, sexual orientation, and relationship configuration. I was not willing to let go of any of these three. So, I let them intersect. I wondered, what if there's a kid who's thinking, “I don't know if the gender that you've assigned me is true.” That sets off a whole pattern of loss for everyone around them, especially their family. So then, we're dealing with grief work, the death of hopes, fantasies. “My daughter's not going to get married and have babies because my daughter is now a son.” Or, my son's now my daughter... And what does non-binary mean? And who are they? And how's it going to look? So much grief comes out of that process of exploring identity. Then, the next question that a lot of parents ask is about sexual orientation. For example, “well, are you gay now? Because you were our son and you were dating girls… so if you still date girls, aren’t you a lesbian...?” So gender exploration can hook into sexual orientation. And there have been several clients who realized they're not really monogamous, that they're more polyamorous or want to be ethically non-monogamous.
Here's the overlap. Gender-expansive youth and their families, hit all three of my interest areas. That's what made me decide to work with this niche population.
Liliana: That’s beautiful. Do therapists need special training to do gender affirming work with gender-expansive clients?
Sage: Well, I think there are a lot of things that aren't necessarily taught in grad school. But I would say that no matter what your niche ends up being. I support the basics of what we're encouraged to do, which is having your own therapeutic supports, consulting regularly, continuing your education. There are a lot of LGBTIQ+ classes and program certifications available. There are quite a few competent teachers and opportunities for continuing education. I would encourage people who want to work with this niche community to be aware of peer consultation groups in their area and facilitate access; make sure you're affiliated with at least one regular consultation group to have a dynamic referral network. I'm part of the Gender Identity Awareness Network, G-I-A-N, a consulting group of colleagues who work with gender-expansive youth and their families. I'm aware of Mind the Gap, which is up in the East Bay. And there are organizations like WPATH for documenting standards. And every summer, there’s a continuing education weekend put on by Gender Spectrum, in the East Bay.
I strongly encourage all of us to be aware of any preconceived notions, biases. Notice if there's repulsion or you feel like pulling away, feel disgusted, or judgmental. Those things will be key in the self-selecting process. If I feel repulsed, disgusted, if I’m pulling away from somebody, I'm not going to be able to serve them. It takes a level of courage to look at the unpleasant stuff that's going on in one's organism in reaction to somebody else's organism and how they are showing up. In retrospect, I look back at when I was a youth and I experienced that ignorant reaction. To work effectively, I encourage nurturing unconditional love for each person striving to find their authentic self.
Liliana: You did. Thank you. And what would the takeaway, if you want one thing for other therapists to remember about this whole article?
Sage: If you're interested in working with people who identify as gender expansive or exploring their gender and/or people who identify as neurodivergent or are exploring whether they might be neurodivergent, it's important to ensure that you have supportive colleagues with whom you can consult. We're not supposed to do this alone. The reason we exist is relationship. I'm not an expert. I'm a person who wants to practice loving and supporting other people in learning how to love and support other people. So having consultation has been vital. Having resources who have experiences that are different than me, so that we can share them and enlighten each other. This is vital!
Liliana: Thank you. I think that's a good point. Is there anything else that I should have asked that I didn't?
Sage: I think we covered a lot of the main stuff. One thing is, if you're reading this and you know somebody who is questioning their gender or wondering if they might be neurodivergent. check around your community for additional resources: a community center organization that is LGBTQ+ and other places to get more information, referrals, leverage support groups. There are so many aspects of society in this day and age that push us into loneliness and isolation, and we human beings do not thrive in isolation. Even though we have the internet, which is a great bridge for connections and information – it also spews tons of misleading information. Help clients by knowing quality resources, including low fee and sliding scale therapists. Many queer-identified and neurodivergent-identified people lack and need loving connections. I have found that in-person connections are often more nourishing to us than those that are electronically mediated. It's important to lean into the discomfort of getting some kind of proximity to others. So going to a community center for social events, or going to meet with a potential therapist, or even logging onto a teleconference gives us more of that warm connection and, in polyvagal theory terms, gives us access to the ventral, that good feeling of mutual connection, which is the baseline, the core of mental/emotional wellness. We must feel safe to have nourishing connection. For me, proximity, repetition, and play are vital to human wellness, thriving. If I'm just typing messages to somebody, I might have play and we might have repetition, but we don't really have proximity.
Liliana: Thank you so much for this valuable information. We appreciate your passion and expertise in this field. Thank you for all the people that you are helping in the gender expansive and neurodivergent communities.
Sage earned a master's degree in holistic counseling psychology from John F. Kennedy University. JFKU’s holistic studies program goes beyond the requirements for clinical psychology to include transpersonal psychology (spiritual focus) and somatic psychology (physical focus). Sage has been joyfully and successfully practicing holistic psychotherapy-for 15 years and finds the more inclusive model provides a solid foundation for effectively working with the human mind-body-spirit connection and empowering clients. More about Sage
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