New Clinical Guidelines Offer Therapeutic Alternative To ‘Affirming’ Gender Dysphoric Youth
A network of mental health professionals wrote a new set of clinical guidelines 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 guidelines advocate 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 guidelines read. “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.
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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 guidelines read.
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 guidelines. “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 guidelines’ 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 guidelines 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 guidelines explain. 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 guidelines tackle the affirm-or-suidice myth,
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