Holding the Space for Exploratory Therapy with Gender-Questioning Clients
By Peter Jenkins
The Cass Review for the UK NHS has sharpened wider awareness of the ongoing controversy over exploratory therapy for gender-questioning clients. Normally, this would just be a topic of interest mainly to therapists, and probably only to bitterly opposed minorities even then. The Cass Review has trodden a careful path between these directly opposing positions. On the one hand, there are the supporters of gender-affirming care, including the use of preferred personal pronouns, and validation of the client’s internal sense of gender identity. On the other, there are supporters of exploratory therapy, without adopting a fixed view of the client’s experience of gender, or of their preferred outcome in terms of future social or medical transition.
Psychological Support
Hilary Cass clearly sees this binary approach as unhelpful to the debate. However, she does emphasise the need for evidence-based psychological support for children and adults with gender distress. And within this psychological support, there is a clear need for exploratory work within the therapy: “The intent of psychological intervention is not to change the person’s perception of who they are but to work with them to explore their concerns and experiences and help alleviate their distress, regardless of whether they pursue a medical pathway or not.” (Cass, 2024: 150. Emphasis added: PJ).
This approach tallies with the experience of Keira Bell, a detransitioner who brought a landmark legal case against the UK’s Tavistock Gender Identity Development Service (GIDS) in 2020: “I should have been challenged on the proposals or the claims that I was making for myself. And I think that would have made a big difference as well. If I was just challenged on the things I was saying” (Holt, 2020).
Conversion Therapy
However, this is a fiercely contested issue. For trans activists, it seems that therapy which is not explicitly geared to affirming the client’s sense of gender identity is, almost by definition, going to become a form of conversion therapy. Conversion therapy is a clumsy and inaccurate term, seemingly based on the parallel metaphor of enforced religious conversion. Therapy of any kind relies on the client’s willing consent, so conversion therapy i.e. coercive therapy, is a contradiction in terms.
Exploratory therapy for gender issues is either barely tolerated by opponents of conversion therapy, or roundly condemned as a stalking horse for conversion, equivalent to practising therapy via deceit. Activists lobby strongly against the use of exploratory therapy, using undercover taping of suspected exploratory therapists to prove their point. However, this runs up against a critical point in understanding the core issues at stake here. All mainstream therapy uses exploration as a joint therapist-client process, within therapeutic work. All mainstream therapy therefore includes an element of exploratory therapy.
The logic of this conclusion is that activists are opposing and seeking to curtail not just conversion therapy, not just exploratory therapy, but all mainstream therapy. The paradox here is that practically all therapy associations now strongly support a criminal law ban on conversion therapy. In effect these associations are loudly pushing for their own future demise, rather like the French nobility wholeheartedly voting for the guillotine.
Exploratory Therapists
So how are therapists who offer exploratory therapy for their gender-questioning clients surviving? This was the question we set ourselves to answer, via an online survey for therapist members of Therapy First. This is an international association of practitioners working mainly in the US and UK, and other countries across the globe. From a sample of 89 participants, we found that half of the responses described experience of working in a hostile professional environment. One third of responses referred to experience of a complaint or threat of a complaint. One half of responses referred to anxiety about undergoing a complaint.
However, this fear of complaint was not leading to widespread professional flight from the field of work. Therapists seemed highly motivated to work with this gender-questioning client group, in some cases choosing to focus on work with detransitioners, or with young people. Hence, one responded: “I believe this is about protecting children.” For another, “I’m interested in working with detransitioners because I focus on trauma-informed care and recognize the trauma this population has endured.” Personal and biographical factors were also a strong factor in some instances: “I am a transman with 20 years of lived experience. What we are witnessing right now is nothing short of a contagion.”
In all, we found this to be a community of resilient and dedicated practitioners, working under appreciable pressure, in an often hostile professional environment, to offer exploratory forms of therapy to their gender-questioning clients.
References:
Cass, H. (2024) Independent review of gender identity services for children and young people. https://cass.independent-review.uk/home/publications/final-report/
Holt, A. (2020) “NHS gender clinic ‘should have challenged me more’ over transition”. BBC
News. 1st March. https://www.bbc.com/news/health-51676020
Article download:
Peter Jenkins and Dwight Panozzo. “Ethical Care in Secret”: Qualitative Data from an International Survey of Exploratory Therapists Working with Gender Questioning Clients. Journal of Sex & Marital Therapy. (2024).
Article download via: https://doi.org/10.1080/0092623x.2024.2329761
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