Therapy for gender dysphoria

I wrote this piece to encourage therapists to work with gender dysphoria; parents might find it helpful to share with therapists working with their kids. All thoughtful comments very welcome.

The extraordinary increase in the number of children and young people seeking support due to their gender-related distress continues to escalate, and with it, the number of parents feeling entirely at sea as they attempt to comprehend their distressed child.

This is a controversial field. Some people believe in gender identity theory as a way of making sense of gender-related distress. This theory originated with clinicians such as Dr John Money and Dr Robert Stoller as a consequence of their work with children. It was Dr Stoller who first hypothesised that every person has an unidentifiable, invisible element inside them and this element motivates the individual to behave in certain ways and subscribes to certain gender norms and expectations. Dr Money agreed and stated that “Gender identity is the private experience of gender role, and gender role is the public manifestation of gender identity.” Akin to the religious concept of a soul, this identity has no identifiable existence and so it is unverifiable and unfalsifiable. According to this theory, some people’s gender identity is mismatched with their physical body and therefore tend to recommend a treatment approach that offers a series of medical interventions to create a body that aligns with the individual’s gender identity.

In recent years Dr John Money’s work has been discredited due to his unethical treatment of the Reimer family. Bruce Reimer was born the elder of identical twin boys in August 1965.  When they were six months of age, Bruce and his identical twin, Brian, were both diagnosed with phimosis, a condition which means the foreskin of the penis cannot retract, thus inhibiting regular urination. Bruce underwent a circumcision for this condition but the clinician made a catastrophic error and severely injured the baby’s penis. The parents removed permission for this surgery to then be performed on Brian and his phimosis healed naturally. Some months later, in a deep depression about what had happened, the parents heard Dr Money expound his theories of gender identity on TV and they wrote to him explaining their plight.  Dr Money worked with the parents to raise Bruce as a girl called ‘Brenda’ as he believed gender identity was mutable until an infant was two years old. Although Dr Money spoke at conferences across the world for many years describing the experiment as a great success, in fact it was a disaster. Dr Money encouraged the twins to engage in ‘childhood sexual rehearsal play’ and Brenda hated the appointments and eventually refused to attend the appointments. ‘Brenda’  presented in a very masculine way and finally, when ‘she’ was fourteen ‘her’ parents took pity on ‘her’ and explained the truth – that he was born a boy. ‘Brenda’ reverted to presenting as a boy and chose the name ‘David’. However the fallout was devastating. Both twins went on to have extremely difficult lives and died in their thirties; Brian took an overdose and David died by suicide two years later.

Other people believe that gender-related distress arises as a consequence of an influx of hormones that occur to the body – perhaps while it is still a foetus in the mother’s womb. This is similar to the understanding of depression as a ‘chemical imbalance in the brain’. Although there is no scientific evidence to support this theory, yet, just like the chemical imbalance theory, it makes intuitive sense to many people.  Neuroscience shows us that some people’s brains gravitate towards more stereotypically feminine behaviour while others towards what is considered stereotypically masculine behaviour. Gay, lesbian and bisexual people are more likely to disproportionately display the behaviour of the opposite sex compared to heterosexual people. Nobody seems to have figured out why this is and the subject continues to be a topic for debate. A major argument against medical interventions for children is that many gender nonconforming children will one day grow up to be gay, lesbian or bisexual as long as they experience the sexual awakening that follows their biological puberty. Puberty blockers halt puberty and this is one of the reasons why a growing number of organisations – including, most recently, the NHS – reject the use of puberty blockers as a way to treat gender-related distress.

The third most common theory that attempts to understand gender dysphoria is a developmental model of understanding. This theory suggests that some people develop gender-related distress as a maladaptive coping mechanism during their development. There has always been a small number of young children – roughly 6% - who present as the opposite sex, if their parents accept this behaviour. The below photo of me as a gender nonconforming nine-year-old girl (all dressed up for my brother’s confirmation, wearing a white stripey t-shirt and blue jeans) in the 1980s shows that I was one of those kids.

I was fortunate as my parents were comfortable with gender nonconforming children, however some parents tend to worry about this, especially in the context of gender nonconforming boys. Society has long been affectionate towards tomboys, especially pre-pubescent tomboys; the image of the self-assertive tomboy who likes to play with the boys tends to raise a smile among most people. However it is notable that feminine boys seem to generate less comfort among many people. According to the studies,  the vast majority of gender nonconforming children who were brought to gender clinics in the 1960s through to the 2000s were mostly boys. This was perhaps more homophobically motivated than many realise as reports of parents who wanted the clinicians to somehow ‘fix’ their feminine son demonstrates the typical unease of some parents who correctly intuited that this was a sign that they would be likely to one day come out as gay, lesbian or bisexual, who were uncomfortable with their gender nonconforming children and wanted the therapist to try to ‘convert’ the child to being heterosexual.

 According to every study carried out on these gender nonconforming children, the vast majority end up becoming comfortable in their own skin and don’t seek medical transition. A small number of people become fixated upon the idea of medical transition as a way to alleviate their mental distress and when they are adults they can be prescribed cross-sex hormones as well as undergo medical interventions such as mastectomies and/or genital surgeries. An added complication is that some men – mostly middle-aged men – have a paraphilia called autogynephilia which is a male’s propensity to becoming erotically fixated on the idea of themselves as a woman. These males also seek medical transition and are likely to hide the existence of their paraphilia and instead present as a person who believes they have an immovable gender identity within them that needs medical interventions as soon as possible.

A new cohort that has never been seen before in the medical literature has suddenly arrived into this mix in the last decade or so. These are mostly teenagers and mostly girls, who suddenly identify as trans without ever demonstrating gender nonconforming behaviour prior to their trans-identification and typically come out as trans after spending an extended period of time online and often following some sort of trauma.

(Source: www.segm.org)

Reports show that these young people are often very vulnerable, with a notably elevated prevalence of co-morbidities including ASD, ADHD, OCD, eating disorders, anxiety, and depression. The physician-researcher Dr Lisa Littman described this phenomenon as ‘rapid-onset gender dysphoria’ and in a world where acronyms rule the day, many refer to this cohort as ‘ROGD’. Pro-affirmative clinicians tend to believe that the ROGD cohort is simply a rebalancing of the numbers that has come about as a result of society accepting medical transition. However, with a rise in the numbers as high as 4000%, and 5200% among females, viewing this as a recalibration does not make statistical sense – if this were the case, it is statistically likely that many clinicians working in the field in the decades prior to the existence of the ROGD cohort would have come across more examples. Also, if this were the case, the numbers from other cohorts, such as middle-aged men and women, should also be undergoing a recalibration.

The social psychologist Jonathan Haidt has suggested that social contagion is the underlying issue and the fact that trans-identification occurs in clusters in schools and colleges across the world suggest that this is the most likely explanation for this recent phenomenon.

Meanwhile parents are often lost and confused. Driven by love they seek the best care for their child, but often they are unaware of the competing theories within the field. They do not know that the role of the gender-affirmative clinician is to be child-led, rather than child-centred, and to facilitate medical transition as soon as the child seeks it. A child-led approach provides the child with the freedom (and the responsibility) to decide how they wish to live. It can be used in educational programmes where the child decides what/how/whether they wish to learn and also with food intake where the caregivers follow the child’s decision about how much food they may wish to eat.  The gender identity affirmative model is a novel approach that is built upon gender identity theory however there is no long-term research to support it. The wide gap in the difference between gender affirmative care and more standardised psychotherapy which offers a more challenging therapeutic process can be discombobulating for parents who often believe that there is little difference between one mode of therapy and another.  

As a psychotherapist working in the field, I recommend that therapists consider inviting parents of adolescents to join every four or five sessions. This approach is valuable because it keeps parents informed about the process and prevents triangulation, as discussed below. While it is important that the adolescent knows the therapy is their sacred and confidential space, yet it is also important that both the minor and the parents learn about the complexities of gender dysphoria and medical transition. If the adolescent is non-communicative then how can the parents know what is going on?

The discourse online is polarised, the research is extremely limited and deep reflection is seldom to be found on social media. Not only that, but not many parents have experience of gender-related distress. If we consider the parents of anorexic children in the 1960s and 70s, or bulimic children in the 1980s, self-harming children in the 1990s, then we can properly understand how bewildered and uninformed these parents are.

Therapists working with adolescents should always be aware of susceptibility to Karpman’s drama triangle. If the young person perceives themselves as the victim, they can be quick to assign the role of the saviour to the therapist and the persecutor to the parent. This is profoundly unhelpful in a multitude of ways and it can be valuable to use some psychoeducation to explain this issue to both the teen and the parents if there is a danger of triangulation occurring.

Haidt’s latest book The Anxious Generation: How the Great Rewiring of Childhood is Causing an Epidemic of Mental Illness as well as Abigail Shrier’s Bad Therapy: Why the Kids Aren't Growing Up both explore the impact of today’s current emphasis and elevation of victimhood and oppression on today’s generation and therapists need to carefully balance these issues in order to maintain compassionate curiosity as well as a deeper understanding of the underlying factors at play.

Gender dysphoria has arrived like a rocket into the culture, it has become an extremely politicised and polarised issue and it can feel like a field filled with controversy. Notwithstanding this, there are increasing numbers of young people seeking therapeutic support for this issue and a corresponding increase in the need for therapists working with this cohort. Many therapists are wholly untrained in this field to consider working with gender distressed people. This is creating even more distress as the waiting-lists grow ever longer and the distressed people are led to believe that only specialists in the field can work with them. However any competent, educated therapist should be able to work with gender-related distress.

An issue often raised with me among therapists is that they fear the language barrier as much of the discourse in this context is underpinned by a plethora of acronyms and complex concepts such as autogynephilia, ROGD, transmaxxing and HSTS. This is a superficial barrier and a study of any good glossary will outline the meaning of the majority of these words and acronyms (there is a list of common terms listed here: https://genspect.org/resources/glossary/ ). Language can be incendiary and it is helpful if therapists first take the time to learn some of the acronyms and concepts that are often used.

It is also worthwhile for therapists to offer potential clients an information sheet about their approach where issues such as confidentiality; trust; the freedom to make mistakes; language; how a fixation on language can become a barrier to therapeutic progress; and other issues that could arise during the process.   

Even though this is a controversial field where emotions online are typically heightened, the work is often extremely satisfying. For example, before working in this area, I never had the opportunity to think so deeply about what it means to be a man or a woman, to consider how much our hormones and sexual drive might motivate our behavior, and to reflect on what makes me, me. The clients I work with value the therapeutic process, and benefit from having a space where no subject is taboo and every thought and belief is open for contemplation.

In summary, gender dysphoria is a condition that has entered the symptom pool. It’s unlikely to go away and it seems to me to be much more likely that it will remain as a culturally-bound symptom of distress. Other conditions have similarly arrived and, through social contagion became common relatively quickly. If you are a competent and experienced therapist, I urge you to consider working in this area. Children, adolescents and vulnerable adults are left stewing for years on waiting lists across the world as so few therapists are willing to work with them.

Thankfully there is an ever-increasing range of resources, workshops, conferences and other information available for therapists who may wish to work in this field. I co-authored the book When Kids Say They’re Trans: A Guide for Thoughtful Parents with fellow therapists Sasha Ayad and Lisa Marchiano (2023). This book is explicitly a pro-parent book that seeks to give support, education and guidance to parents of children who are experiencing gender dysphoria. While some parents are keen to seek out medical interventions for their distressed children, many prefer a slower, more cautious approach and in this book we explore a range of non-medicalised options that can help the gender-distressed young person. Although this is a book for parents, yet the feedback shows that therapists are also finding it an informative read.

Another resource that is helpful is Genspect. Genspect supports a service called the Gender Dysphoria Support Network and runs roughly five online meetings every week for parents of gender-distressed children. These are parent-facilitated meetings that operate along the lines of Al Anon (although we sometimes also offer therapist-facilitated meetings). Genspect also offers funding for personal one-to-one therapy for people who have detransitioned or been harmed by medical transition with our Beyond Trans service. Detransition is a process– whereby people who medically transition come to regret it and seek to reverse the medical process. Most therapists are competent at working with trauma and so they can feel confident working with detransitioners as they begin to work in this area. Every therapist that joins the Beyond Trans service agrees to prioritise a non-medicalised approach to gender-related distress and disavows WPATH’s medicalised pathway.

Finally, it is my experience that therapists are wary of delving into this debate. “The stakes are too high,” said one therapist to me when I requested her to see a trans-identified young person. This therapist feared making a mistake and somehow ruining the young person’s life. Yet personal agency is a foundational stone on which therapy is built. Ethical therapists cannot have an agenda for our clients. Rather we can work with them so that they know the options available and have developed some self-awareness about themselves about likely motivations for any patterns of behaviour. It is not the role of the therapist to influence whether the individual decides to transition – it is the role of the therapist to ensure the client is aware of why they might make any given decision and to have sufficient knowledge about the impact of this decision.  With a careful, compassionate and conventional therapeutic process, any competent therapist can carry out this work.

---

If you are a parent and would like to see the Directory of Therapists offered by Beyond Trans or if you are a therapist and would like to join the Beyond Trans service, please follow this link: https://beyondtrans.org/therapists/