Transgender care: The push for psychotherapy for gender dysphoric kids

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New York City-based psychotherapist Paul Garcia-Ryan heads an organization of mental health providers, Canadians among them, that doesn’t support the model that conceptualizes children and teens with gender dysphoria as having been “born in the wrong body” and that changing the body via hormones or surgery is necessary to relieve their distress.

“When a mental health professional doesn’t view gender dysphoria through a gender-affirming lens, they can begin to conceptualize the case more broadly and see other factors that are also contributing to the distress,” said Garcia-Ryan.

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Garcia-Ryan was gender non-conforming as a child. “When I was 15, I came to believe that this meant I was born into the wrong body” and a doctor and therapist affirmed that theory, he said. He detransitioned when he was 30.

Garcia-Ryan’s group, Therapy First, advocates for psychological approaches as the most appropriate first-line treatment for the spike in youth gender dysphoria. Puberty blockers and cross-sex hormones for children and teens, by contrast, are, in their view, experimental and should be avoided “if possible.”

It’s a controversial approach that’s gaining some momentum, with a new paper by two Canadian authors arguing that children and teens are being locked onto a path of medical transitioning without exploring why they’re feeling the way that they are.

To alarmed critics, it’s a de facto repackaging of conversion therapy, a criminal offence in Canada punishable by up to five years imprisonment. While couched as psychological support, some academics and activists say it’s more akin to an “inquisition,” that the goal is “desistance from trans” and that a trans identity is seen as something pathological that needs to be “corrected,” a throwback to the harmful days of “reparative therapies,” when therapists tried to make gay people straight.

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In Canada, gender-affirming care has been endorsed by numerous medical groups, including the Canadian Paediatric Society.

“Is the person going to have to wait a year before they can access their hormones? Will they ever be granted access to hormones or surgery,” said Dr. Jesse Bossé, a psychologist and spokesperson for the Canadian Psychological Association.

Who is responsible for being that gatekeeper?

“Who is responsible for being that gatekeeper? Is it the psychotherapist or the psychologist who decides at some point that, ‘Yes, we’ve done enough exploratory psychotherapy, now you can access this treatment?’”

Conversion therapy is defined as any attempt to change a person’s sexual orientation to heterosexual or their gender identity to that of their sex at birth.

The authors of the new paper, however, argue that psychodynamic (exploratory) psychotherapy isn’t conversion therapy, that the purpose isn’t to discourage or encourage transition and that it takes a “neutral” approach that isn’t based on the assumption that one gender identity is preferable to another.

Canada’s conversion law is so vague and broad, they said, “almost any departure from a strict affirmative approach” is being misconstrued as a conversion practice.

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Psychotherapy “treats gender related distress, like any other form of distress, as something which emerges in a context which must be explored and understood,” Dr. Joanne Sinai, a clinical associate professor and psychiatrist at the University of British Columbia, and retired Winnipeg lawyer Peter Sim wrote in the Journal of the Canadian Academy of Child and Adolescent Psychiatry.

Under the gender-affirming approach, psychotherapy “plays little or no role,” they said. “In Canada, psychological assessment prior to hormonal therapy is typically minimal.”

Medical transition can begin once puberty starts, with drugs that block the physical changes of puberty. Older teens can receive cross sex hormones so that they develop the physical features more in line with their gender identity. Gender reassignment surgeries are restricted to patients 18 and older, though mastectomies have been performed on younger teens.

One study found that only four of 10 gender clinics in Canada required a psychiatric or psychological assessment before prescribing puberty blockers or cross-sex hormones. One clinic sometimes did and five did not.

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While the evidence supporting talk therapy for gender distress is lacking, the evidence supporting the use of puberty blockers and hormones is also “remarkably weak” and “built on shaky foundations,” a major British review recently concluded.

You go with the one that has less harm, which is psychotherapy

Given the two options, “You go with the one that has less harm, which is psychotherapy,” Sinai said. The effects of puberty blockers and cross-sex hormones are frequently irreversible and can have lifelong consequences, such as infertility.

But the focus on puberty blockers and hormones has overshadowed the possibility that psychotherapy “can empower youths to make decisions that are fully informed,” Sinai and Sim wrote.

Exploratory psychotherapy recognizes that “gender identity is often fluid and may change during therapy,” Sinai and Sim wrote. It may help “elucidate patients mislabeling internal experiences as gender dysphoria, when they may represent something else.” Gender dysphoria, for example, “could be related to a history of sexual abuse and/or internalized homophobia,” they wrote.

Therapy takes time, “it’s not a quick fix and it’s labour intensive,” Sinai said. Psychotherapy is also underfunded in public systems “and some youths might not agree to it,” she added.

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“If it’s all about gender-affirmation, the expectation is that you are going to be given medication. ‘This is who you are, this is innate, and you need to get your medication,’” Sinai said.

“The truth is some people during the course of (psychotherapy) who started off thinking that they wanted to transition medically may change their minds, but other people may go ahead and do it,” she said.

Sinai said she isn’t advocating for mandatory psychotherapy but believes puberty blockers and hormones should only be offered under research protocols or in extenuating circumstances, like the direction Sweden, England and other countries have taken. Britain’s Cass review also recommended a more “holistic” approach that emphasizes psychological assessment and support.

The danger of delaying access to gender-affirming treatments “is that (critics) will say these children will try to kill themselves, but I think there’s now enough out there about suicide to say this just is not true,” Sinai said. The Cass review concluded that there is insufficient evidence about the effects of puberty suppression on a child’s mental wellbeing.

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Canada’s law banning conversion therapy exempts practices that relate to “the exploration or development of an integrated personal identity,” such as a person’s gender transition, provided there is no assumption a particular identity is preferred over another.

But it’s not entirely clear “how judges would interpret concepts like development of an integrated personal identity,” Sinai and Sim wrote, and “no therapist wants to be the defendant in the first test case.”

Very few people do any kind of psychotherapy for people with gender dysphoria

“Very few people do any kind of psychotherapy for people with gender dysphoria,” Sinai said.

Psychodynamic (exploratory) psychotherapy involves “a very careful assessment,” she said. “You really want to get lots of details about who the person is, the context of their life, the kinds of relationships they’ve had, their memories, their dreams.”

“So, if they told you that they are natal male identifying as female, you’re going to have questions: ‘When did it begin? What is it related to?’”

Someone who may have suffered sexual trauma as a younger person “may not want to be in a female body because it makes them feel vulnerable,” Sinai said.

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Some natal males are pushing back against “toxic masculinity,” she said. “They don’t want to be that kind of a man.

“With some of the natal girls it’s not necessarily they want to be a man. They don’t want to be a woman with all the vulnerabilities.”

Some gay and lesbian youth can experience gender dysphoria when coming to terms with their sexual orientation. “Homophobia has deep roots and exists even today, even in liberal places,” said Garcia-Ryan, board president of Therapy First, formerly known as the Gender Exploratory Therapy Association.

The group “rebranded” when Garcia-Ryan stepped in, over concerns that “some new form of therapy” was being created, he said, “when really my view, and the view of the organization, is that all therapy at its heart is exploratory.”

Sinai said she and Sim wrote the article “hoping that it would introduce the idea in Canada that this therapy is valid and hoping that more of the mental health community and the medical community will be engaging patients and parents in discussions about it.”

“You cannot really have informed consent if you don’t understand your subconscious or unconscious motives,” Sinai said.

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But others worry that delaying medical interventions risks exacerbating a child’s gender distress. There’s no time limit for how long talk therapy should last. Therapy First says exploratory therapy requires an “extended period of regular contact,” not a handful of sessions, and some therapists avoid using the youth’s preferred and affirmed name and pronouns.

Therapy First also “does not encourage the obfuscation of biological facts,” according to its guide for therapists working with gender-questioning youth. “Some young and vulnerable people believe that they can fully change sex and that medical and surgical treatment will transform them entirely into the desired sex.”

The sudden interest in exploratory therapy has coincided with a flurry of attempts to restrict or criminalize gender-affirming care for trans youths, Canadian academic, activist and University of Alberta law professor Florence Ashley wrote last year.

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“Although couched in the language of exploration, gender-exploratory therapy seems more akin to interrogation or perhaps even inquisition,” Ashley said.

Among the “questions for clinicians” Ashley offered is, what happens if the child or youth refuses to engage in gender exploration therapy? “Do you refuse them gender-affirming care, even if it may be necessary to their well-being?”

It also places “undue weight on the risk of transition,” Ashely wrote. “Imposing gender exploration on clients seems manipulative or coercive, and incompatible with patient-centred care,” Ashley wrote.

“Being trans is not undesirable and should not be approached as if it were.”

Under the gender-affirming model, children and youth can seek psychosocial support, “If they want to, if they feel the need for that,” said Bossé, of the Canadian Psychological Association.

“Being transgender is not a mental health issue,” Bossé said. “If we make mandatory assessment a thing for people who are transgender, we are pathologizing normal gender diversity.”

Underpinning psychotherapy is the belief “that there is a way, through rigorous assessments, through exploratory psychotherapy, to discern who is ‘really trans’ and to prevent de-transition, to prevent ‘mistakes’ — people who ‘mistakenly’ think they are trans who are not,” Bossé said.

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“The problem with that is that there is no empirical evidence that gender assessment or gender exploratory therapy can accurately predict or prevent de-transition or regret.”

Psychotherapy provides people an opportunity to carefully reflect on identity, Garcia-Ryan said. “The exploration is going to look different for each person” that comes into the therapy room, he said.

According to its mission statement, Therapy First rejects treatments that set out to change a person’s gender identity. Garcia-Ryan said he has had patients who have transitioned medically “after a therapeutic process,” once they reached adulthood. “Whether that will serve them in the long run is yet to be seen.

“But really, it’s not about determining who is trans and who’s not trans and more about avoiding medical harm.”

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