A network of mental health professionals wrote a new clinical guide for adolescents struggling with gender dysphoria, offering an “exploratory” alternative to “affirming” a minor’s chosen transgender identity.
The Gender Exploratory Therapy Association (GETA) developed “A Clinical Guide for Therapists Working with Gender-Questioning Youth” to present mental health professionals with a new therapeutic technique to help minors who experience distress about their gender. The guidance advocates for an approach to explore possible underlying factors that may be causing their dysphoria.
“The exploratory approach outlined here stands in contrast to the ‘gender-affirmative approach,’” the introduction to the guide reads. “The affirmative approach assumes that minors presenting with a wish to live in a gender role different from their sex are transgender, and that the primary role of the therapist is to help minors transition.”
Therapists who abide by the affirmative approach often facilitate a social transition, which usually includes a name change and new pronouns. Although social transition is commonly portrayed as a benign way to allow children to express their “true selves,” there are good reasons to doubt this narrative.
All available research suggests that this seemingly innocuous act of support is an active psychosocial intervention that may greatly increase the likelihood of a child persisting in the rejection of their bodies. Gender-affirming therapists frequently provide their clients with letters of support to pursue medical transition.
Medical transition, which includes puberty blockers, cross-sex hormones, and surgeries comes with significant risks. “These risks include compromised bone density and brain development, cardiovascular complications, neoplasms, and other dangers,” the guide reads.
In addition, children who begin taking puberty blockers during the first signs of puberty and go on to take cross-sex hormones, which constitute the vast majority, will have permanent loss of fertility and sexual function.
“This means that children as young as 9-12 may be waiving their future right to sexual function and reproduction long before they are mature enough to comprehend the importance of these functions,” says GETA. “This is especially alarming since gender-related distress is a common developmental phase of many pre-gay youth who may not discover their sexual orientation until they are more mature.”
GETA believes in a more “patient-centered” and “whole-person approach” that “does not favor any particular outcome.”
“Just like any other patient, gender distressed youth deserve individualized treatment that leaves room for a full therapeutic process and doesn’t come with any fixed agenda,” said Lisa Marchiano, a licensed therapist who co-authored the new guidance. “Good psychotherapists already have the skills to offer this. They just need a reminder that what we do with gender questioning youth is the same way we would approach any other patient—with compassion and curiosity.”
Along with Marchiano, the new guides’ contributors include Sasha Ayad, Dr. Roberto D’Angelo, Dr. Dianna Kenny, Dr. Stephen B. Levine, and Stella O’Malley, the founder of Genspect, an advocacy group that strives for an evidence-based approach to gender distress.
“In view of the heavy medical burden and risks associated with medical transition, the uncertain long-term benefits, and low-quality evidence base, a growing number of public health authorities internationally are recognizing that less invasive approaches, such as exploratory psychotherapy, should be the first line treatment for youth with gender distress,” the guidance read.
The international authorities that have departed from the gender-affirming model of care were outlined in the guide. After conducting systematic reviews of the evidence for the use of puberty blockers and cross-sex hormones in treating pediatric gender dysphoria, health authorities in Sweden, Finland, and England have decided to abandon the “gender-affirming” model, finding the costs far outweigh the benefits. Royal Australian and New Zealand College of Psychiatrists published a position statement on gender dysphoria last year distancing itself from the gender-affirming model.
England’s National Health Service (NHS) has proposed new guidelines for treating trans-identifying youth and warns that adolescents identifying as transgender may be experiencing a “transient phase” and that doctors should not encourage them to change their names and pronouns. “Social transition,” the NHS said, is not a “neutral act” and could have “significant effects” in terms of “psychological functioning.”
In the United States, there are few alternatives to “affirming” the identity of a child who believes themselves to be transgender. Over 20 states passed laws in recent years banning “conversion therapy,” which now includes any attempt to dissuade someone of their “gender identity.” They succeeded in the ban by equating “watchful waiting” with the discredited practice of trying to get gays and lesbians to “convert” to heterosexuality.
“Current thinking about treatment for gender dysphoria is structured by a binary that considers only two possible approaches: affirmation or conversion,” the guide explains. Gender-exploratory therapy provides a third option that is “not constrained by the affirmation-conversion binary but is open to a range of outcomes, including gender outcomes.”
The guide tackles the affirm-or-suidice myth, debunking the narrative that implies that medically transitioning adolescents will prevent them from committing suicide.
“The ‘transition or die’ storyline, in which parents are informed that they must choose between a ‘live trans daughter or a dead son’ or ‘live trans son or dead daughter,’ is not only factually inaccurate but, also, ethically questionable,” says GETA.
Much of the hype around trans-identified youth at increased risk for suicide relies on online surveys of self-reported “suicidal thoughts,” which may not be the best measure of suicidality. Although thoughts of suicide are concerning, GETA says that completed suicides are equally important measures of suicidality.
GETA cited data from the largest pediatric gender clinic in the world, the recently-shuttered Tavistock Gender Identity Development Service in the U.K., which reported a 0.03% rate of completed youth suicides over a 10-year period. This amounts to an annual rate of 13 per 100,000, GETA noted.
“Although this rate is higher than that observed in the general population of adolescents, it is far from the epidemic of trans suicides described in headlines and public discourse,” said GETA. “In fact, there were just four completed suicides in this very large sample.”
Additionally, short-term studies of improved mental health after medical transition may not be a reliable indicator of long-term outcomes. GETA cited a longitudinal study from Sweden that followed study participants for over 30 years and found that adults who underwent surgical transition were 19 times more likely than their peers to commit suicide. Female-to-male participants were 40 times more likely to commit suicide than the expected rate.
GETA believes that the “transition or die” storyline is “worse than mistaken; it is unethical.”
“Unquestionably, any increased suicidality and suicide risk is worrying, and any at-risk adolescents should be carefully evaluated and treated by capable mental health professionals,” asserts GETA. “But we aver that the hyper-focus on heightened suicide risk promulgated by clinicians and the media may create an injurious nocebo effect, inadvertently exacerbating suicidality in vulnerable youth.”
The 120-page clinical guide is available for download on GETA’s website. GETA also offers membership for therapists who are dedicated to providing care “without pushing an ideological or political agenda” and a database for clients to access their services. “We believe that skilled, ethical exploratory therapy is appropriate for those with gender dysphoria, their families, and detransitioners,” the website reads.
If you or someone you know is struggling or thinking of harming themselves, please call or text the 988 Suicide & Crisis Lifeline at 988.