Gender-Affirming Model of Psychotherapy: What is the Therapist's Role?
The Gender-Affirming model of therapy seems to be an increasingly popular psychotherapeutic modality used in the treatment of Gender Dysphoria in children and adults. In 2018, the American Academy of Pediatrics published a gender-affirming approach to ensure the “comprehensive care and support for Transgender and Gender-Diverse children and adolescents.”
Gender-Affirming care is an alarming trend in the treatment of minor children for a variety of reasons, not the least of which is it often leads to unquestioned life-altering and irreversible medical procedures including puberty-blockers and procedures such as Transfeminine and Transmasculine surgeries. These “gender-altering” therapies are rife with complications, can cause life-threatening issues, and require life-long medical treatment.
Among the side effects are infertility, cardiovascular disease, blood clots, breast disease, liver dysfunction, and cancers can—some of which require lifelong medical treatment. Most alarmingly, these gender-affirming therapies are being offered outside of clinical trials. It is enormously difficult for a woman to get an elective hysterectomy for example, but in some cases, certain doctors and clinics are performing hysterectomies on gender-dysphoric individuals with relatively little pushback.
The focus of this column will center on the psychotherapeutic “model” called Gender Affirmation therapy. As a trained master’s level therapist who was licensed as a Marriage Family Therapist in 1989, I can tell you a lot seems to have changed. I did, however, take classes at the time in “aberrant” Human Sexuality where discussions centered on the growing list of gender identities. Even at that time, there was tremendous pressure on therapists to affirm the denial of one's biologically determined sexuality when seeing certain clients.
In a conversation on “The Trouble with Transing Kids" Psychoanalyst, Lisa Marchiano discusses the identity model that often drives gender-dysphoric individuals to make poor decisions. Marchiano is also featured in a brand-new documentary entitled, “Affirmation Generation: The Lies of Transgender Medicine.”
Marchiano says the “identity model” can be tyrannical because the “rule is that people get to claim their own identity…The rule is you can’t question them.” She also explains the true role of the therapist is to help the individual better understand and contextualize his/her distress and the path to healing, not to merely affirm one’s gender without question.
“The identity model tells us that when someone comes into our office explaining that they think they are transgender or that they’re a boy trapped in a girl’s body, or however they phrase it, the rule is that people get to claim their own identity. No one else gets to do that for them. The other rule is that you can’t question them. If you question someone’s identity, you’re not validating them — you’re not believing them. There may be some validity to that in some spheres, although I would say it’s not really my job to validate a person. If you tell me you’re a great knitter, it’s not my job to affirm that for you. But you can have that, even if you’ve never knitted. You can identify as a great knitter — you’re not hurting anybody."
"I would say there’s a kind of tyranny that goes along with an identity model. In the case of transgenderism, it tyrannizes people because you cannot question, explore, or suggest there might be alternative reasons for these feelings. You cannot suggest there may be alternative ways of dealing with them, because doing any of that is tantamount to invalidating someone’s identity. And that is not allowed. Somehow, this agenda has got hooked on really well to the gay and lesbian rights movement; I think through liberals."
When we ask a young woman with dysphoria who is claiming she is transgender, how it is she thinks she is a boy, the shot that gets fired back is, “This is conversion therapy! You’re trying to make me be something I’m not.” But, in fact, they couldn’t be more different." Marchiano continues, "I would say, “Who’s trying to convert whom to what here?” Patients that come to therapists looking for treatment such as hormones or surgery are looking to be converted. And it is absurd to think that a therapist wouldn’t explore that and want to ask some questions about it. The kind of social justice/identity approach that privileges the self-diagnosis of the person sitting across from us runs completely counter to the way a mental health model has always worked, where we take in the information about a person’s lived experience, not necessarily the conclusions they’ve drawn about it. We listen, assess, and consider different possibilities, then we share with them what we think is going on and what they might want to do about it.
Affirmation Generation shows that in 2011, 0.1 to 0.3% of the U.S. population was estimated to be transgender. In 2021, according to the documentary, “in a study of 5000 public school teens, 9% claimed a transgender identity.” The NYTimes explored Transgenderism in young people in a June 2022 column citing a report that shows a “sharp rise in Transgender” youth in the U.S.
There is even a term for this alleged sharp rise in Gender Dysphoria with its own acronym, "ROGD, or Rapid Onset Gender Dysphoria", a term coined by doctor and scientist Lisa Littman in her 2018 study. Littman says children were identifying as being gender dysphoric in “numbers that greatly exceeded what would be expected. It was apparent that these kids were all from the same friendship group.”
Littman says children were identifying as being gender dysphoric in “numbers that greatly exceeded what would be expected. It was apparent that these kids were all from the same friendship group.”
The Gender Identity Development Service (GIDS) in the United Kingdom (UK) reports a “several thousand percent increase in referrals for Gender Dysphoria in teenage girls. The ratio is about, 80 percent girls, and 20 percent boys with Gender Dysphoria,” according to Endocrinologist, Dr. William Malone who is also featured in the documentary. These types of referral numbers are also showing up in the U.S., according to Malone.
Affirmation Generation references data that suggests that autistic children and foster children are highly susceptible to thinking that gender-affirming therapies are the answers to all of their problems. In fact, they may just be experiencing depression because they are socially awkward outcasts or have a troubled history. We are exploiting some of our most vulnerable children in the name of helping them come to terms with who they are.
How Can Therapists Help Individuals with Gender Dysphoria?
Admittedly, my bias is toward a more systemic approach to therapy. That means that the family unit— and parents in particular— are critical participants in the child’s healing process—as complicated and conflict-ridden as that process might prove to be. Change is very difficult and fearful individuals are often surprisingly resistant to meaningful change.
Human beings are naturally social creatures and the parents and the family unit—whatever that unit might look like—is a critical foundational structure in the child’s life. Human beings are contextual beings, not biological islands. Children and even adolescents are profoundly influenced by their families. Children are developing beings who are enormously vulnerable to the opinions and attitudes of the influential people in their lives—including their peers, teachers, parents, coaches and, at times, their therapists and doctors.
While even the most experienced therapists can fail to engage the family unit successfully around the best interests of a distressed child, the goal should almost always be to solicit and join with family/parental support and interest. Children always benefit when the significant adults in their lives are meaningfully engaged—even if the participation is often fraught with conflict and distress. Conflict and distress do not always have to end in more conflict and distress. In fact, the change that comes from distress can often result in great growth and healing.
One of the most important characteristics I look for in an ethical, artful therapist is his or her ability to appropriately challenge a patient’s belief systems. Clients often show up in great distress or they probably wouldn’t be seeking care. Individuals seek therapists because despite their best efforts they failed to alleviate the stress on their own.
The solutions individuals employ to alleviate their distress are often simplistic and/or ineffective and circular. They find themselves hitting the same brick walls over and over, often coming up with “magical solutions” to their problems that in the end only cause more problems and distress. Gender dysphoric individuals OFTEN reach these kinds of simplistic conclusions based on what they are feeling at the time. The worrying part, however, is a growing culture of practitioners who are either educated to affirm or too afraid to question their clients’ logic for fear of doing something wrong or hurting someone’s feelings. Our culture today is arguably pushing therapists to refrain from common sense or compassionate discernment.
Our culture today is arguably pushing therapists to refrain from common sense or compassionate discernment.
In the case of gender-affirming care, whether it is a psychotherapeutic or medical treatment, gender dysphoric individuals—especially children—often tend to think far too simplistically about the solutions to their problems. They allow their profound distress, depression, anxiety to make them believe that all their problems will be solved if their chosen gender is affirmed. Rarely do they turn out to be correct. Unfortunately, the price of being wrong is often unbearably high. A report from the Journal of the American Academy of Child and Adolescent Psychiatry in 2013 showed 84% of children change their minds about changing their gender.
Many individuals, especially troubled children, are highly influenced by their peers and their families. Sometimes they express suicidal thoughts. They are often depressed and are acting out at home and in school. These behaviors are highly distressing to parents and families, causing a great deal of understandable fear. However, a good therapist with a confident, curious mind may be able to help the child put his or her feelings in perspective. Therapists are there to help individuals better understand their feelings and resulting behaviors. The gender-affirming approach may not leave room for the kinds of therapeutic exchanges that lead to “aha moments" and significant, healing breakthroughs.
In addition, listening and hearing are two very different things. Listening means your ears are functioning. Hearing means you are taking in and helping the individual to interpret their feelings. A good therapist can help individuals connect the dots by showing them how to link their attitudes and emotions with their behaviors and choices.
Clients tell therapists many things—things that may or may not be true. It is the therapist’s job to take a good biopsychosocial history with the help of the parents. The therapist can help the child explore his feelings, beliefs, and choices in age-appropriate ways. Some of the most successful therapists engage the parents, joining with the family to formulate a plan that makes sense for the child and the family.
Gender-Affirming therapy does precisely the opposite of the type of therapy explained above. Gender-Affirming therapy is often incurious and merely relegates the therapist to the role of agreement with the client exactly as he presents himself.
Therapists are Being Misled and Therefore Misleading Clients
LMFT, Stephanie Winn, spoke about the Gender-Affirming model in a February 23 interview on American Thought Leaders with Jan Jekielek. Winn was also one of several therapists featured in Affirmation Generation. The documentary is well worth the watch. It is a fulsome look at gender-affirming care from psychotherapy to medical interventions for gender dysphoric individuals, including individuals who made life-altering decisions as minors they later regretted as adults. The film examines the belief systems surrounding gender dysphoria, gender-affirming care, and the treatments available to minors, sometimes without clear parental consent.
Winn explains that the “generally agreeable and conscientious natures” of therapists are often “exploited.” In many cases, she says they are “lied to,” meaning they are “being [trained] and asked to do something that is actually antithetical to the goals of mental health therapy.”
“The Gender-Affirming Model of care is being sold to therapists as an actual model of psychotherapy—like other models, right?!? We have many models of psychotherapy, DBT, ACT, CBT, EMDR, etc. But models of psychotherapy generally include ways of conceptualizing and formulating our clients’ distress. They need help understanding their presenting problems, and then ways of proceeding with helping treat their distress. Gender-affirming care is actually antithetical to the therapeutic process, which always necessarily includes really getting to know our clients and exploring their life circumstances.
“With the so-called gender-affirming model, what we're told to do is not to ask questions, just to affirm, just to agree. It's a reduction of our role from the curious explorer who uses mirroring and reflection as just one of many tools to somebody who's just relegated to the role of only marrying and reflecting without probing, questioning, or discernment.”
Human Beings Want to be Accepted and Loved
In general, human beings seek affirmation. They want to feel accepted and loved. Anyone who is even the least bit aware of the interactions on social media will confirm that “likes” and “clicks” are virtual affirmations and when not delivered as expected can lead to distress and anxiety. And that is why it is so dangerous for a therapist to merely put a rubber stamp of approval on what may be a child's passing whims.
Real-life interactions are the same. People want to feel loved and heard. No one wants to be bullied or ostracized. Most children are highly motivated to fit in. Children and adolescents are in the process of developing their belief systems and their world view. If a child perceives himself as an outcast whose norms deviate from those of his peer group, the child may do everything in his power to fit in. As such children often make impulsive decisions that are based on immature decision-making processes and a lack of life experience. Children cannot always project how they might feel in the future. They often lack the ability to project how the decisions they make today will affect their lives in the future. Children need caring adults to help them navigate those tumultuous social and emotional challenges.
There seems to be a significant “social contagion” that favors gender-affirming therapies and procedures as the “most logical” or best solution to their presenting problems. There is evidence suggesting some children choose another gender because of peer pressure. Yes, there are multiple studies refuting this idea but frankly, it is very difficult to trust many research studies now given the rampant bias and cultural shifts we are now witnessing. Whether true or not, more and more children seem to struggle with their gender. And Social contagion or not, it has nothing to do with the quality of care a distressed child deserves to receive.
Affirmation Generation references data suggesting autistic children and foster children are overrepresented in mental health referrals that diagnose gender dysphoria. These two cohorts are allegedly highly susceptible to thinking that gender-affirming therapies will answer their problems. However, they may, in fact, more accurately be experiencing depression or distress because they are socially awkward outcasts or have a troubled history.
Many Gender-Dysphoric individuals experience great internal struggles with regard to their biology both mentally and physically. If they choose puberty blockers, which essentially serve to chemically castrate, or surgery, which leaves them with irreversible physical changes in their appearance and sexuality, they are often still left with depression and a feeling of confusion and isolation. Make no mistake, one’s biology will always assert itself. To add to their distress, these individuals must continue to inject themselves with chemicals to maintain their desired gender at great cost. Some go through multiple surgeries and therapies, only to find themselves even more depressed years later because of the uninformed decisions they made as young children or teens.
The saddest part is that often parents allow themselves to be convinced by their children, a therapist, a teacher, or a doctor, that their suicidal child will be “cured” with these invasive therapies. In most cases, these invasive "therapies" are far from being the cure to all of their problems.
Children will often behave in attention-seeking ways that are scary and fear-provoking. If those behaviors are dangerous to you or your child, seek qualified help to keep yourselves safe. However, keep in mind that children often do and say things to test the waters. They are testing their own boundaries and yours. A sound therapist can help individuals and their families sort those things out. Therapists should help individuals explore root causes and ensure that all solutions are entertained, not just solutions that are gender-affirming.
Parents have a responsible role in the care of their children.
A parent should never be fearful of questioning the adults who play a significant role in their children’s lives. Those adults include teachers, coaches, doctors, clergy, therapists, and even the parents of your children’s friends.
Educate yourself on the background and education of your therapist. It is entirely reasonable to interview the therapist upfront. A therapist who balks at thoughtful questions from a parent may not be a good choice.
Don’t be afraid to attend sessions with your child from time to time, even if that child is a teenager.
Trust your instincts. Most of the time they will be correct.
While fear is a natural human emotion, remember it is often one of the least constructive emotions on which to base choices and big decisions. Good support systems—clergy, therapists, extended family, and friends— can help you feel less fearful and more supported. More often than not, others are experiencing the same things you are.
Remember, it is not the job of a professional therapist to affirm your decisions without discernment. You are seeking help because you want someone else to help you make the best possible decisions with an eye to the future for you and your child.
This document lists resources for those who may have been misdiagnosed with gender dysphoria, including legal services and how to file a complaint.
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