On psychological interventions for gender dysphoria

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

Roberto D’Angelo, Ema Syrulnik, Sasha Ayad, Lisa Marchiano, Dianna Theadora Kenny, Patrick Clarke

Turban, Beckwith, Reisner, and Keuroghlian (2020) published a study in which they set out to examine the effects of gender identity conversion on the mental health of transgender-identifying individuals. Using the data from tihe 2015 U.S. Transgender Survey (USTS) (James et al., 2016), they found that survey participants who responded affirmatively to the survey question, “Did any professional (such as a psychologist, counselor, religious advisor) try to make you identify only with your sex assigned at birth (in other words, try to stop you being trans)?” reported poorer mental health than those who responded negatively to the question. From this, Turban et al. concluded that gender identity conversion efforts (GICE) are detrimental to mental health and should be avoided in children, adolescents, and adults. The study’s conclusions were widely publicized by mass media outlets to advocate for legislative bans on GICE, with the study authors endorsing these calls (Bever, 2019; Fitzsimons, 2019; Turban & Keuroghlian, 2019).

We agree with Turban et al.’s (2020) position that therapies using coercive tactics to force a change in gender identity have no place in health care. We do, however, take issue with their problematic analysis and their flawed conclusions, which they use to justify the misguided notion that anything other than “affirmative” psychotherapy for gender dysphoria (GD) is harmful and should be banned. Their analysis is compromised by serious methodological flaws, including the use of a biased data sample, reliance on survey questions with poor validity, and the omission of a key control variable, namely subjects’ baseline mental health status. Further, their conclusions are not supported by their own analysis. While they claim to have found evidence that GICE is associated with psychological distress, what they actually found was that those recalling GICE were more likely to be suffering from serious mental illness. Further, Turban et al.’s choice to interpret the said association as evidence of harms of GICE disregards the fact that neither the presence nor the direction of causation can be discerned from this study due to its cross-sectional design. In fact, an alternative explanation for the found association—that individuals with poor underlying mental health were less likely to be affirmed by their therapist as transgender—is just as likely, based on the data presented. Read more

Psychotherapy for Gender Identity Disorders

Az Hakeem

This article describes a special adaptation of group psychotherapy as a psychological treatment for people with a variety of gender identity disorders. It can be used as an alternative to or concurrently with hormonal and/or surgical interventions for transgender people. It is also suitable for individuals whose gender identity disorder remains after physical interventions. The article draws from a UK specialist pilot for such a treatment service and describes the explicit aims of the psychotherapy, the specialist adaptation of therapeutic technique required and observed thematic features relevant to working in this specific field.

Although many clinicians are familiar with transgender individuals and the physical treatments available to them, many will be unfamiliar with the psychological treatment options available for other gender identity disorders. Eden and colleagues have detailed the role of the gender specialist when offering assessment and physical treatments in the forms of hormone therapy and surgery to transgender patients (this issue: Eden 2012Wylie 2012). In this article I outline the specialist adaptation of psychotherapy as a treatment for people with gender identity disorders that do not neatly fit into a transsexual diagnosis or for whom physical sex (gender) reassignment is not a suitable option. The recommendations here are based on findings from a specialist psychotherapy service for patients with gender identity disorders that operates in the UK within the National Health Service (NHS). Read more

Development and validation of a measure for assessing gender dysphoria in adults: The Gender Preoccupation and Stability Questionnaire

Az Hakeem, Rudi Črnčec, Mona Asghari-Fard, Fintan Hartee, and Valsamma Eapen 

Available clinically useful questionnaires for people with gender dysphoria incorporate outdated binary male/female gender stereotypes. Moreover, no tools assess for gender dysphoria, a construct applicable to a gender-diverse population. This study’s purpose was to develop and validate an instrument that overcame these shortcomings: the Gender Preoccupation and Stability Questionnaire (GPSQ). Method: The 14-item GPSQ was developed through consultation with patients with gender dysphoria and experts in the field. The scale was administered to three groups of participants: those seeking treatment for gender dysphoria and Control Groups 1 and 2 with no gender dysphoria. 

Participants were also administered the Gender Dysphoria questionnaire (a 27-item scale wherein gender dysphoria was based on a bipolar dichotomous identity, which is at one pole male and at the other pole female, with varying degrees of gender dysphoria existing between them). Results: The GPSQ showed acceptable internal consistency (a D .90), known groups, and convergent validity. The scale’s sensitivity and positive predictive power were 88% and 91%, respectively. Conclusion: The GPSQ was shown to be an effective, valid, reliable outcome tool to measure gender dysphoria. The tool is likely suitable to measure the effectiveness of a number of clinical interventions within this population. Read more

Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria

Lisa Littman

This descriptive, exploratory study of parent reports provides valuable detailed information that allows for the generation of hypotheses about factors that may contribute to the onset and/or expression of gender dysphoria among AYAs. Emerging hypotheses include the possibility of a potential new subcategory of gender dysphoria (referred to as rapid-onset gender dysphoria) that has not yet been clinically validated and the possibility of social influences and maladaptive coping mechanisms. Parent-child conflict may also explain some of the findings. More research that includes data collection from AYAs, parents, clinicians and third party informants is needed to further explore the roles of social influence, maladaptive coping mechanisms, parental approaches, and family dynamics in the development and duration of gender dysphoria in adolescents and young adults. Read more

Transgender medicalisation and the attempt to evade psychological distress

Bob Withers

In this paper the author argues that trans-identification and its associated medical treatment can constitute an attempt to evade experiences of psychological distress. This occurs on three levels. Firstly, the trans person themselves may seek to evade dysregulated affects associated with such experiences as attachment trauma, childhood abuse, and ego-alien sexual feelings. Secondly, therapists may attempt to evade feelings, such as fear and hatred, evoked by engaging with these dysregulated affects. Thirdly, we, as a society, may wish to evade acknowledging the reality of such trauma, abuse and sexual distress by hypothesizing that trans-identification is a biological issue, best treated medically. The author argues that the quality of evidence supporting the biomedical approach is extremely poor. This puts young trans people at risk of receiving potentially damaging medical treatment they may later seek to reverse or come to regret, while their underlying psychological issues remain unaddressed. Read more

‘Taking the lid off the box’: The value of extended clinical assessment for adolescents presenting with gender identity difficulties

Anna Churcher Clarke and Anastassis Spiliadis

As the number of young people referred to specialist gender identity clinics in the western world increases, there is a need to examine ways of making sense of the range and diversity of their developmental pathways and outcomes. This article presents a joint case review of the authors caseloads over an 18-month period, to identify and describe those young people who presented to the Gender Identity Development Service (GIDS) with gender dysphoria (GD) emerging in adolescence, and who, during the course of assessment, ceased wishing to pursue medical (hormonal) interventions and/or who arrived at a different understanding of their embodied distress. From the 12 cases identified, 2 case vignettes are presented. Implications for the development of clinical practice, service delivery and research are considered. Read more

Attachment Patterns in Children and Adolescents with Gender Dysphoria

Kasia Kozlowska, Catherine Chudley, Georgia McClure, Ann M. Maguire and Geoffrey R Ambler

The current study examines patterns of attachment/self-protective strategies and rates of unresolved loss/trauma in children and adolescents presenting to a multidisciplinary gender service. Fifty-seven children and adolescents (8.42–15.92 years; 24 birth assigned males and 33 birth-assigned females) presenting with gender dysphoria participated in structured attachment interviews coded using dynamic-maturational model (DMM) discourse analysis. The children with gender dysphoria were compared to age- and sex-matched children from the community (non-clinical group) and a group of school-age children with mixed psychiatric disorders (mixed psychiatric group). Information about adverse childhood experiences (ACEs), mental health diagnoses, and global level of functioning was also collected. In contrast to children in the non-clinical group, who were classified primarily into the normative attachment patterns (A1-2, B1-5, and C1-2) and who had low rates of unresolved loss/trauma, children with gender dysphoria were mostly classified into the high-risk attachment patterns (A3-4, A5-6, C3-4, C5-6, and A/C) (x2  = 52.66; p <  0.001) and had a high rate of unresolved loss/trauma (x2  = 18.64; p <  0.001). Comorbid psychiatric diagnoses (n  = 50; 87.7%) and a history of self-harm, suicidal ideation, or symptoms of distress were also common. Global level of functioning was impaired (range 25–95/100; mean = 54.88; SD  = 15.40; median = 55.00). There were no differences between children with gender dysphoria and children with mixed psychiatric disorders on attachment patterns (x2  = 2.43; p  = 0.30) and rates of unresolved loss and trauma (x2  = 0.70; p  = 0.40). Post hoc analyses showed that lower SES, family constellation (a non-traditional family unit), ACEs— including maltreatment (physical abuse, sexual abuse, emotional abuse, neglect, and exposure to domestic violence)—increased the likelihood of the child being classified into a high risk attachment pattern. Akin to children with other forms of psychological distress, children with gender dysphoria present in the context of multiple interacting risk factors that include at-risk attachment, unresolved loss/trauma, family conflict and loss of family cohesion, and exposure to multiple ACEs. Read more

Unconscious homophobia and the rise of transgender movement

Terry Patterson

Last year, I attended an excellent conference organised by the Birkbeck Counselling Association on  An exploration of sexuality and psychoanalytic thinking the in twenty-fi rst century . It was refreshing to hear the speakers Alessandra Lemma and Leezah Hertzmann acknowledge that the psychoanalytic world has a long history of simplistic homophobic attitudes towards LGBT people, which is now seen to be a largely outdated and shameful legacy. Until recently, the psychoanalytic training institutions excluded LGBT applicants on the basis of sexuality, seeing us as psychologically fl awed, or at least  immature . Apparently, this no longer happens, at least not overtly. This shift is to be celebrated; most right-minded people would be behind this. However, it did set me thinking about what happens when this kind of prejudice that has to be repressed to fi t with prevailing (external) social trends, when personal (internal) anxieties have not been resolved. And this brought to mind, a worrying phenomena I have recently become aware of, and that both speakers referred to, which is in the rise of the transgender movement of the unintended, perhaps unconscious intolerance of diversity that fuels demand for a quick fix to a very complex issue. Read more

To be, or not to be? The role of the unconscious in transgender transitioning: identity, autonomy and well-being

Alessandra Lemma, Julian Savulescu

The exponential rise in transgender self-identification invites consideration of what constitutes an ethical response to transgender individuals’ claims about how best to promote their well-being. In this paper, we argue that ’accepting’ a claim to medical transitioning in order to promote well-being would be in the person’s best interests iff at the point of request the individual is correct in their self-diagnosis as transgender (i.e. the distress felt to reside in the body does not result from another psychological and/or societal problem) such that the medical interventions they are seeking will help them to realise their preferences. If we cannot assume this—and we suggest that we have reasonable grounds to question an unqualified acceptance in some cases—then ’acceptance’ potentially works against best interests. We propose a distinction between ’acceptance’ and respectful, in-depth exploration of an individual’s claims about what promotes their well-being. We discuss the ethical relevance of the unconscious mind to considerations of autonomy and consent in working with transgender individuals. An inquisitive stance, we suggest, supports autonomous choice about how to realise an embodied form that sustains well-being by allowing the individual to consider both conscious and unconscious factors shaping wishes and values, hence choices. Read more

Outbreak: On Transgender Teens and Psychic Epidemics

Lisa Marchiano

Having lived through both World Wars, Jung was aware of the dangers of what he termed “psychic epidemics.” He discussed the spontaneous manifestation of an archetype within collective life as indicative of a critical time during which there is a serious risk of a destructive psychic epidemic.

 Currently, we appear to be experiencing a significant psychic epidemic that is manifesting as children and young people coming to believe that they are the opposite sex, and in some cases taking drastic measures to change their bodies. Of particular concern to the author is the number of teens and tweens suddenly coming out as transgender without a prior history of discomfort with their sex.

“Rapid-onset gender dysphoria” is a new presentation of a condition that has not been well studied. Reports online indicate that a young person’s coming out as transgender is often preceded by increased social media use and/or having one or more peers also come out as transgender. These factors suggest that social contagion may be contributing to the significant rise in the number of young people seeking treatment for gender dysphoria.

Current psychotherapeutic practice involves immediate affirmation of a young person’s self-diagnosis, which often leads to support for social and even medical transition. Although this practice will likely help small numbers of children, there may also be many false positives. Read more