One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria

"Ethical Care in Secret": Qualitative Data from an International Survey of Exploratory Therapists Working with Gender-Questioning Clients

This is a mixed methods international survey of therapists (n = 89) belonging to Therapy First, an organization supporting the use of exploratory therapy, rather than gender affirmative therapy, with gender-questioning clients. The method used was an electronic questionnaire, producing a 33% response rate from members. Responses were analyzed using thematic analysis. This article reports qualitative responses relating to therapists' experiences of anxiety in working in a hostile professional environment, and their adoption of strategies to minimize risk of allegations of conversion therapy. Therapist strategies included refining existing marketing approaches to serve preferred client groups, and reliance on proven therapy models.

Detransition and Desistance Among Previously Trans-Identified Young Adults

Persons who have renounced a prior transgender identification, often after some degree of social and medical transition, are increasingly visible. We recruited 78 US individuals ages 18-33 years who previously identified as transgender and had stopped identifying as transgender at least six months prior. On average, participants first identified as transgender at 17.1 years of age and had done so for 5.4 years at the time of their participation. Most (83%) participants had taken several steps toward social transition and 68% had taken at least one medical step. By retrospective reports, fewer than 17% of participants met DSM-5 diagnostic criteria for Gender Dysphoria in Childhood. In contrast, 53% of participants believed that "rapid-onset gender dysphoria" applied to them. Participants reported a high rate of psychiatric diagnoses, with many of these prior to trans-identification. Most participants (N = 71, 91%) were natal females. Females (43%) were more likely than males (0%) to be exclusively homosexual. Participants reported that their psychological health had improved dramatically since detransition/desistance, with marked decreases in self-harm and gender dysphoria and marked increases in flourishing. The most common reason given for initial trans-identification was confusing mental health issues or reactions to trauma for gender dysphoria. Reasons for detransition were more likely to reflect internal changes (e.g., the participants' own thought processes) than external pressures (e.g., pressure from family). Results suggest that, for some transgender individuals, detransition is both possible and beneficial.

Supporting autonomy in young people with gender dysphoria: psychotherapy is not conversion therapy

Opinion is divided about the certainty of the evidence base for gender-affirming medical interventions in youth. Proponents claim that these treatments are well supported, while critics claim the poor-quality evidence base warrants extreme caution. Psychotherapy is one of the only available alternatives to the gender-affirming approach. Discussion of the treatment of gender dysphoria in young people is generally framed in terms of two binary approaches: affirmation or conversion. Psychotherapy/exploratory therapy offers a treatment option that lies outside this binary, although it is mistakenly conflated with conversion therapies. Psychotherapy does not impose restrictive gender stereotypes, as is sometimes claimed, but critically examines them. It empowers young people to develop creative solutions to their difficulties and promotes agency and autonomy. Importantly, an exploratory psychotherapeutic process can help to clarify whether gender dysphoria is a carrier for other psychological or social problems that may not be immediately apparent. Psychotherapy can therefore make a significant contribution to the optimal, ethical care of gender-dysphoric young people by ensuring that patients make appropriate, informed decisions about medical interventions which carry risks of harm and have a contested evidence base.

The Importance of Non-Probability Samples in Minority Health Research: Lessons Learned from Studies of Transgender and Gender Diverse Mental Health

Non-probability sampling methods utilize nonrandom research participant selection, which may generate study samples that are not representative of the general population. Non-probability sample studies are often regarded as inferior due to uncertainty about their generalizability and external validity. In reality, non-probability sampling offers advantages that make this method particularly valuable for minority health research. In this perspective article, we review the strengths and limitations of probability and non-probability samples, examining three landmark survey studies used to study transgender and gender diverse mental health. We conclude that both types of studies provide important and actionable data about mental health inequities experienced by minority populations.

Gender detransition: A critical review of the literature

Gender detransition is the act of stopping or reversing the social, medical, and/or administrative changes achieved during a gender transition process. It is an emerging phenomenon of significant clinical and social interest.

Interrogating Gender-Exploratory Therapy

Opposition to gender-affirmative approaches to care for transgender youths by some clinicians has recently begun to consolidate around "gender exploratory therapy" as a proposed alternative. Whereas gender-affirmative approaches follow the client's lead when it comes to gender, gender-exploratory therapy discourages gender affirmation in favor of exploring through talk therapy the potential pathological roots of youths' trans identities or gender dysphoria. Few detailed descriptions of the approach's parameters have been offered. In this article, I invite clinicians to reflect on gender-exploratory therapy through a series of questions. The questions are followed by an exploration of the strong conceptual and narrative similarities between gender-exploratory therapy and conversion practices. Finally, the ethical dimensions of gender-exploratory therapy are discussed from the lenses of therapeutic neutrality, patient-centered care, loving attention, and therapeutic alliance, suggesting that the approach may be unethical.

[Transgender care in the USA, advances and setbacks, and how it impacts Europe]

What is happening in the United States in terms of support for trans people, as in other areas, is regularly observed and a source of inspiration at the international level; the recent political turmoil around affirmative trans care in some States, especially for minors, has a tremendous impact in Europe, being regularly used by the "camps" that argue today on this issue. However, the political context and the organization of the health and health insurance system color this support in a very specific way in the United States, and omitting these aspects or simplifying them is a source of erroneous interpretations and misinformation. Understanding these determinants is essential to define what belongs to the medical field, and to put back at the center of the discussions the interest of the people concerned, the principles of beneficence, non-maleficence and equity. In this article, we will therefore discuss the organization of care and recommendations for good practice, but also, from "non-scientific" articles and references, the political and social climate and its impact on trans health and care, including in Europe.

Editorial Perspective: Medical body modification in youth with gender dysphoria or body dysmorphic disorder - is current practice coherent and evidence-based?

In recent decades, there has been a steady increase in the number of people, including adolescents, undergoing medical body modification (MBM) to alter their physically healthy bodies in invasive and nearly irreversible ways through medical treatment (e.g. surgery). While MBM is often recommended for youth with persisting gender dysphoria (GD), in body dysmorphic disorder (BDD) it has been considered contraindicated. Here, we outline the current controversies surrounding MBM practice and recommendations in adolescents with GD versus those with BDD in order to better understand under what circumstances we may or may not support adolescents who want to change their bodies medically and often irreversibly. We compare the two disorders in terms of the overlap and uniqueness of their behavioural and psychological features. In doing so, we discuss limitations of the existing (often low-quality) evidence for and against MBM in young patients. We conclude that the currently available evidence is too preliminary and far from conclusive to make any robust recommendations in terms of benefits and harms of MBM in youth with persisting GD or BDD. However, we strongly recommend further urgent scientific discussions and systematic research efforts into more robust evaluations and the identification of more precise psychological characteristics that may serve as decision criteria for or against MBM - particularly in those adolescents who did not respond to non-MBM, that is, psychiatric/psychological treatment and psychosocial support, if available at all. This will greatly benefit youth healthcare professionals in their challenging clinical practice of making decisions regarding MBM today and in the future.

Supporting young people to manage gender-related distress using third-wave cognitive behavioural theory, ideas and practice

The Gender Identity Development Service (GIDS) supports gender diverse young people, and their families but currently does not provide weekly psychological therapy as part of its core work. In addition, local Child and Adolescent Mental Health Services (CAMHS), may feel deskilled in providing support for this population. We, a group of three Clinical Psychologists, aim to share some common themes and observations gained from our work in GIDS. We talk about how existing Cognitive Behavioural Therapy (CBT) models can be relevant and helpful for the challenges facing gender diverse young people, without pathologising, or aiming to change a young person's gender identity. An illustrative case study is presented, based on an amalgamation of young people we have worked with highlighting how third-wave cognitive behavioural theory, ideas and practice can be used to support young people to manage gender-related distress. Further reflections on the broader socio-political context, and implications for clinical practice and future research are discussed.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Commentary: The Signal and the Noise-questioning the benefits of puberty blockers for youth with gender dysphoria-a commentary on Rew et al. (2021)

This commentary is a critique of a recent systematic review of the evidence for the use of puberty blockers for youth with gender dysphoria (GD) by Rew et al. (2021). In our view, the review suffers from several methodological oversights including the omission of relevant studies and suboptimal analysis of the quality of the included studies. This has resulted in an incomplete and incorrect assessment of the evidence base for the use of puberty blockers. We find that Rew et al.'s conclusions and clinician recommendations are problematic, especially when discussing suicidality. A key message of the review's abstract appears to be that puberty blockers administered in childhood reduce adult suicidality. However, the study used for the basis of this conclusion (Turban et al., 2020) did not make a causal claim between puberty blockers and decreased adult suicidality. Rather, it reported a negative association between using puberty blockers and lifetime suicidal ideation. The study design did not allow for determination of causation. Our commentary concludes by demonstrating how the GD medical literature, as it moves from one publication to the next, can overstate the evidence underpinning clinical practice recommendations for youth with GD.

Commentary on Levine et al.: A Tale of Two Informed Consent Processes

This commentary compares two recently published informed consent recommendations for gender dysphoria. One key difference identified is in their assessment of the strength of the evidence base for the gender affirming treatment model. An evaluation of both authors' citations supports the claims of a weak evidence base for the use of puberty blockers and gender affirming hormonal treatments in youth with gender dysphoria. This commentary then reflects on the implications of this. In particular, it asks whether it would be best practice to provide gender affirming treatments for youth only under clinical research conditions, rather than as routine clinical practice.

Attitudes in the U.S. Toward Hormonal and/or Surgical Interventions for Adolescents Experiencing Gender Dysphoria

In order to align with their inner sense of gender identity, adolescents suffering from gender dysphoria are increasingly being treated with cross-sex hormones and irreversible surgeries to alter their bodies. The present study is the first to examine attitudes about these recently emergent medical practices in a national population. We used data from the 2018 Post-Midterm Election Study, a survey representative of adults in the USA ages 20 to 65 years (N = 5285), to examine the social factors associated with approval or disapproval of hormonal and/or surgical interventions for adolescents seeking medical treatment for gender dysphoria. Higher fertility, race/ethnicity (in this case, black), sex (male), and heterosexual self-identity were each robustly associated with disapproval. Nested regression models revealed that a range of religion measures were statistically significant (toward disapproval). However, all but evangelical self-identification were no longer significant after accounting for support for abortion rights, the spectrum of political self-identification, and voting behavior. These findings, prompted by a high percentage of variance explained, led us to consider perspectives on medical transitions for adolescents as fitting the "culture war" framework, largely polarized between a "progressive" worldview of bodily autonomy and an "orthodox" worldview of bodily integrity.

Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults

In less than a decade, the western world has witnessed an unprecedented rise in the numbers of children and adolescents seeking gender transition. Despite the precedent of years of gender-affirmative care, the social, medical and surgical interventions are still based on very low-quality evidence. The many risks of these interventions, including medicalizing a temporary adolescent identity, have come into a clearer focus through an awareness of detransitioners. The risks of gender-affirmative care are ethically managed through a properly conducted informed consent process. Its elements-deliberate sharing of the hoped-for benefits, known risks and long-term outcomes, and alternative treatments-must be delivered in a manner that promotes comprehension. The process is limited by: erroneous professional assumptions; poor quality of the initial evaluations; and inaccurate and incomplete information shared with patients and their parents. We discuss data on suicide and present the limitations of the Dutch studies that have been the basis for interventions. Beliefs about gender-affirmative care need to be separated from the established facts. A proper informed consent process can both prepare parents and patients for the difficult choices that they must make and can ease professionals' ethical tensions. Even when properly accomplished, however, some clinical circumstances exist that remain quite uncertain.

Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners

The study's purpose was to describe a population of individuals who experienced gender dysphoria, chose to undergo medical and/or surgical transition and then detransitioned by discontinuing medications, having surgery to reverse the effects of transition, or both. Recruitment information with a link to an anonymous survey was shared on social media, professional listservs, and via snowball sampling. Sixty-nine percent of the 100 participants were natal female and 31.0% were natal male. Reasons for detransitioning were varied and included: experiencing discrimination (23.0%); becoming more comfortable identifying as their natal sex (60.0%); having concerns about potential medical complications from transitioning (49.0%); and coming to the view that their gender dysphoria was caused by something specific such as trauma, abuse, or a mental health condition (38.0%). Homophobia or difficulty accepting themselves as lesbian, gay, or bisexual was expressed by 23.0% as a reason for transition and subsequent detransition. The majority (55.0%) felt that they did not receive an adequate evaluation from a doctor or mental health professional before starting transition and only 24.0% of respondents informed their clinicians that they had detransitioned. There are many different reasons and experiences leading to detransition. More research is needed to understand this population, determine the prevalence of detransition as an outcome of transition, meet the medical and psychological needs of this population, and better inform the process of evaluation and counseling prior to transition.

Reflections on the Clinician's Role with Individuals Who Self-identify as Transgender

The fact that modern patterns of the treatment of trans individuals are not based on controlled or long-term comprehensive follow-up studies has allowed many ethical tensions to persist. These have been intensifying as the numbers of adolescent girls declare themselves to be trans, have gender dysphoria, or are "boys." This essay aims to assist clinicians in their initial approach to trans patients of any age. Gender identity is only one aspect of an individual's multifaceted identity. The contributions to the passionate positions in the trans culture debate are discussed along with the controversy over the official, not falsifiable, position that all gender identities are inherently normal. The essay posits that it is relevant and ethical to investigate the forces that may have propelled an individual to create and announce a new identity. Some of these biological, social, and psychological forces are enumerated. Using the adolescent patient as an example, a model for a comprehensive evaluation process and its goals are provided. The essay is framed within a developmental perspective.

A Typology of Gender Detransition and Its Implications for Healthcare Providers

Gender detransition is an emerging yet poorly understood phenomenon in our society. In the absence of research, clinicians and researchers have applied the concept of detransition differently, leading to inconsistencies in its use. The article suggests a typology of gender detransition based on the cessation or the continuation of a transgender identity to address this issue. Implications of this typology for healthcare providers are discussed, emphasizing the increasing necessity of developing clinical guidelines for detransitioners. Finally, the article reflects on the possibilities of preventing detransition, which underlines the challenges that clinicians face when treating individuals with gender dysphoria.