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Working with trans and gender questioning people: some basic principles.



A trans woman in her thirties with shoulder length wavy pink dyed hair and a light brown top on smiles broadly to the camera

There has been a colossal amount of misinformation, much of it spread for political or ideological reasons, about trans people in the UK. For therapists this extends to questions about how best to work with trans and gender questioning clients. Some therapists may feel scared to even approach the area as it has been infested with culture wars rhetoric.


But there’s a way through, if, as a therapist, you can approach your client with an open heart, putting aside your privilege or your anxiety and acting with compassion, a lack of preconceptions and always focusing on your client’s best interests. There’s no place for your prejudice or presuppositions, whatever direction your work takes you both.

 

I’ll start with a story about someone I know. Assigned male at birth, they grew up through a childhood in which they always felt somehow different, and apart. From an early age, they couldn’t understand how it had, weirdly, turned out that they had to live as a boy, because, inside, they knew that they were a girl. And I mean knew it.  Bullied for years at their boy’s school, they realised that their feelings must never be revealed to others, or the abuse would only get worse. As a result of their treatment at school they never really learned how to make friends and at 18 went onto university having had many miserable, isolating years.


University was scarcely better. They weren’t getting punched, but they hadn’t developed the social skills to find their place and the loneliness was powerful. Eventually, after a failed attempt to get any meaningful help from the university counselling service, they found their way to a psychiatrist and decided, at last, to share a deep truth that they had, by this point, been carrying alone for almost 20 years. “I’m a girl” they said. The psychiatrist, qualified and respected and in the eyes of my friend someone who, finally, might have the training and experience to actually help, said (I paraphrase for brevity, but it amounted to this), “I doubt it. What you need is a good screw. Find yourself a woman to go to bed with. That’ll sort it out.” My friend, desolated, left the consulting room in pieces. This was a trained medical professional to whom they had finally, anxiously, revealed all. Surely, they thought, this man must know what they were talking about? And his take was that my friend had been suffering under a simple delusion and that the answer was plain to see. The psychiatrist, with his doctorate and his certificates, had spoken. Have sex with a woman, that’ll fix you. Now, off you go. There followed for my friend over 15 years of deepening loneliness and pain. They didn’t want to have sex with a woman. Or with a man, for that matter. Not while they had to do so with this pretend ‘male’ persona, this body that did all the wrong things sexually. They longed to be close to someone, physically and emotionally, but despite what that psychiatrist had said, and despite all the attempts they made, unless it could be as the woman they knew themselves to be, it just didn’t make any sense – and it simply wasn’t going to happen. And it didn’t. My friend remained alone, the energy they poured into their work mirrored by a sad and deep sense of brokenness inside. Until finally, in this person’s late 30s, they’d had enough. They found a therapist to whom they said the words “I am a woman; I have known it all my life. I want to live as a woman”, and that therapist said “Well, why aren’t you then?”. Thus began a journey that has finally helped my friend find her place in the world. After all the wasted years, she transitioned, found a partner and a deep love, and she is happy. “Every year is better than the last, these days,” she told me.


The damage that psychiatrist caused that day is clear. It’s impossible to speculate about his professional abilities more widely, especially from all these years later. Was he any good? We cannot know in any professional sense. Like all fields, mental health included, there are those whose skills and prowess are self-evident, a few who, frankly, should be sacked, and many, many others strung out along the competency spectrum between the two.


But there’s one conclusion we can draw.


He had a presupposition


Whether this was based on homophobia, transphobia (this was years ago now, the word had barely been coined), or a wider blindness to the richness and diversity of human experience based on his own vaunted self-image as a respected, culturally powerful figure, we have no idea. But we can say that he was basing his judgement on a pre-formed conceptualisation in his head, likely, for him, a so-called ‘medical’ model, impervious to the data in front of him in the form of human being and a life. He didn’t listen. He knew better. He assumed, for some reason, that my friend hadn’t wondered – for years - about whether she was gay, or whether all this was just about lack of sexual experience with a woman...or a man. It hadn’t occurred to him that she had spent years reflecting painfully on the knowledge that it wasn’t about any of that, that it was something deeper and more profound that went to her very essence. Quiet and deferential, my friend tried to accept what this status-laden psychiatrist had said, but his diagnosis was a disaster for her. Call it incompetence, call it wilful ignorance, maybe. Or call it conversion therapy. Because that is what it amounted to. And, like all conversion therapy, it didn’t work.

 

Conversion therapy - the practice of working to make a gay person straight, or a transgender person cisgender, in a 'therapeutic' setting, continues to roll around the news. The British government has been discussing its banning (as it is banned in some other countries) and trans people's inclusion in that ban, or not, for many years. Most recently it has kicked its plans deep into the political long grass as trans people turn out to be much more exploitable as scapegoats to monster for votes than as a group to support. Hard right political agendas have come together in an unholy alliance with elements of the left, the latter rooted originally in radical (but never mainstream) feminism, to create a culture war frenzy, complete with all the typically deranged hatreds and ideological underpinnings. In this trans people are the victim group-that-just-keeps-on-giving...newspaper headlines, fear-stoking policy announcements or online witch-hunts.

 

Against that backdrop, we as therapists need to look at exactly what conversion therapy is. Because if therapists are going to avoid doing it, they really need to know what lies at its heart. And it’s the same thing that lies at the heart of much oppression of minority groups in society. The popular conception of conversion therapy – if one exists – is perhaps of the religious zealot sitting with a young person in turmoil and trying to ‘pray away the gay’. The client in this scenario may be there under duress (explicitly, or more subtly, through social or family pressure), or see themselves as a collaborator in the process as they are despairingly trying to rid themselves of some ‘wrongness’ within. Though these dreadful scenarios are less common than they once were, there’s no doubt that such practices exist still in some communities, together with their secular equivalents. Alongside that picture, a historical image also exists of even more barbaric practices – electric shock or emetic [1] aversion therapy administered to gay or trans people until well into the later part of the last century, for example.

 

But conversion therapy also exists in a far more subtle form, one that is very much still around and if we are not alert to this, it will return. It shares with some of its more obviously reprehensible precursors a family similarity. It too is founded on the belief that the person coming for help is sick, that their assertions around their sexual or gender identity are symptoms of that sickness but not the sickness itself, and that the clinician’s job is to reveal the deeper condition and to cure it. The intended result? A client who more closely resembles the therapist, in sexual or gender identity perhaps – the implicit threat that they represent to the therapist’s own self-construct, or the self-construct of the societal group within which the therapist feels secure, now eliminated. Despite any claims of altruistic motivation, conversion therapy is at its heart an exercise in making a client in therapy more like the therapist, because the therapist represents what is acceptable and valued in the world and the client does not. That value is rooted in being cisgender, not trans; a model of supremacy and power with close similarities to those that drive racist or heteronormative power narratives in society too.

 

The row about all this has flared up badly again within the therapy community recently, its latest iteration coming from something that happened eight years ago. In 2016, a group of mental health organisations, including the major professional therapy bodies, the NHS and others, came together to sign a Memorandum of Understanding (MoU) condemning the practice of conversion therapy for adults and young people alike. This agreement, created partly (though it turns out unsuccessfully) to lobby the government to act, was renewed in 2022 and now includes 25 major organisations as signatories, including NHS England and Scotland, The Royal College of GPs, Mind, the Royal College of Psychiatrists, and most of the major psychotherapy professional organisations.   Last week, the UKCP, one of those major psychotherapy organisations, unilaterally pulled out of the MoU, without consultation with its members and with immediate effect, accompanied by some pretty confusing and, to the minds of many, very unconvincing justifications. You can read their statement here, and object to their stance here. It’s a move that feels like it has been on the cards, as the organisation has for about six months seemed to have been moving towards a position in line with anti-trans agendas and the views of so-called ‘Gender Critical’ actors, who oppose the acceptance of trans identities in UK society. Some have speculated that it's been influenced by a court case last year, or the imminent arrival of the Cass Review report this week (more on this below), which has been anticipated with unease by the many in the trans community lest it feed even more ammunition to those who wish trans people (in the case of the Cass remit, trans kids) gone from UK society. Whatever its motivations, which remain foggy, I and many others in the profession consider the UKCP’s decision a major mistake, not least in the way it was done.  Some have called its language disingenuous (or much worse), but even with the most charitable reading it’s confusing (it expresses, for example a ‘belief’ about the problems of conversion therapy but has now removed all the regulatory teeth within its Code of Ethics to prevent a UKCP registered therapist actually doing it). So, if you are a therapist who wants to do the best you can for a client who presents with questions of their gender, what should you do?*


My thoughts here are general, they do not represent copper-bottomed guidance in any individual case of course. They are built on my professional practice, my (ongoing) training, my integrative way of working, and, in fact, my life. It's not a list of terms you need to understand, what the letters in various acronyms mean, nor a primer on how not to be accidentally offensive. I don't want you to get stuck on these questions (much used in the popular culture to make trans people seem strange, sensitive or unapproachable) and whilst they certainly can be important, these questions are really not that complicated. Plus there's plenty of material on the internet and a growing literature elsewhere that you can use to find the answers [2]. My focus here is more grounded in first principles, in your basic human goodness and in how to be with someone who may be describing a self-concept or a life that might feel strange or even destabilising to you. You probably got trained in some, or all, of the principles I discuss below in some way. Trans and gender questioning deserve to see and feel you putting them into practice in your work with them, just as much as every other client does:

 

1.       Listen

If this sounds obvious, read the word again and reflect hard on what it truly means. Really listen. Listen to what your client is telling you about their experience, what it feels like for them, what it means to them (clear or unclear), what it means to be them. If they are talking about their relationship with their inner self, their sex or their gender identity, you might find that your inner conversation fires up. Maybe a whole lot of questions and feelings are coming into the room that you've not faced before? How, as the saying goes, does that make you feel? Anxious? Out of your depth? Scared? Angry even? Stay with that. Keep listening, to your client, and to yourself. Would it be easier if these feelings didn't arise inside you? Is something telling you to try and make them go away, perhaps by guiding your client onto ground in which you feel more secure, personally, professionally, instinctively? Then do number 2.

 

2.        Park your assumptions

 

You might think of this as bracketing. The work is not about what you think the right or the best outcome is in your work, it’s about what’s best for your client. Shedding presuppositions, especially perhaps the ones constructed to help you not face difficult or confusing feelings, has to be at the heart of any good therapist’s work; working with people who experience the world in different ways to us and being absolutely ok with them doing that is central to what we do. My view is simple. Our job is to help people to be as happy as they can be with who they are, helping them to find and grow the parts within themselves that nurture and feed them and to take down the barriers that may have built up to cause distress or unhappiness.

 

That doesn’t mean in your work with a trans or gender questioning client (or anyone else for that matter) being oblivious to the possible signs of some kind of serious psychopathology, or another significant condition. You wouldn't do that with any client, if you are any good at your job, and this situation is no different. But it does mean not starting with the belief that one is inevitably present and at the root of everything going on. I'll come back to this below.


And if you do suspect an additional condition, check in with yourself before you assume that condition is somehow causative of your client’s gender narrative. If you do, it is a great way to not hear or see them fully. What you have hypothesised might simply accompany that narrative, as parallel aspects of our personality sit alongside each other for us all, not create it. Or, going further, your client’s inner gender identity and need to express themselves might actually be causative of the other difficult features of their life. For example, they might struggle with loneliness, social anxiety or isolation because they haven’t been able (or allowed) to deal with their inner questions of gender, or because in the past they have been abused when they became visible – not the other way round. In that sense, helping them through their gender journey, if that’s what they need you to do, may be a way to actually deal with all sorts of other distresses in their life too, as the story of my friend at the start of this piece illustrates.


3.        Believe your client, and believe in them

 

Whose life experience matters most here? Yours, or theirs? When a client shows up with a conviction about their gender or sexual identity, it’s usually not great to kick off by not believing what they are saying about themselves. This is their truth, in their life, not yours. You may be operating with a set of parallel truths that work in your life, or your practice, and these may, or may not, resemble those that resonate for your client. Unless you gain a well-formed and not prejudged belief that you are dealing with someone with a major, problematic psychopathology (which will likely be rare), it’s what makes sense and works for your client that most matters here. We need to treat our clients with respect and avoid exploiting the unequal power relationship that a few in our profession sadly seem keen to exploit, knowingly or unknowingly.


4.        Explore your client’s life with them, not for them

 

This might come as a surprise to read. Not everyone who turns up suspecting that they may be trans is going to take a journey to change their gender expression, or their body, or whatever. And of course, not everyone's going to have it 'all worked out' when they arrive to see you. Some may be bringing the possibility that they are trans and, genuinely, as you work in good faith with them, they might reach a point at which they understand their experience differently. That choice is for them. But – and this is vital – accept that amongst the potential ways forward, some kind of journey around gender expression (in any number of ways), legal recognition, or even medical intervention might eventually be a fully appropriate way forward for them.

 

Explore their life, their inner world with them. Let them guide you through it. Don’t draw the mental map of it beforehand, based on a stance of anything but actually trans and work from it. No matter how subtly you do it, if you are operating with a frame of mind in which you pre-emptively discount the genuine possibility that your client is trans, if you find yourself searching over and over for some other explanation simply to resist that conclusion and to keep on resisting it, then you could be crossing the line into conversion therapy.

 

5.        Get properly trained and listen to therapists from the LGBTQI+ community

 

You’re not going to get much of this stuff on a standard therapy training programme, sadly. Although things are changing, slowly, in some places, the forces of backlash have been at work too, trying to restore the profession to a kind of pathologising status-quo-ante (as they are also doing, hard, in our wider society). Sign up for ad hoc training where you can and draw on the experience of therapists whose lived experience as an LGBTQI+ person has something to say (full disclosure, I am one). Pink Therapy does some good work.

 

6.        Don’t get drawn in by soundbites or culture war rhetoric

 

Alas, the culture wars have arrived in the therapy profession and whilst all therapists would (hopefully) claim to be acting in their client’s best interests, their positions and the language of a few can sometimes bear an uncanny resemblance to the anti-trans rhetoric and dogwhistles that saturate the British press and political discourse. One area in which this is taking hold is in the use – and misuse – of two terms to describe types of therapy: ‘Affirmative Therapy’ and ‘Exploratory Therapy’. You might come across them, so let’s look at what these two terms actually mean...

 

In the context of working with trans and gender questioning people, Affirmative Therapy (AT) is essentially the commitment to accept that your client has the right to find an inner truth about who they are (specifically, their gender definition) for themselves, that no answer to this question is somehow 'better' or 'worse' than another, other than which one makes sense and brings peace to our client. It never starts with the assumption that a client asking for help must have some sort of deeper, causative psychopathology of which they must be 'cured'. AT involves working with your client to help them find their best understanding of their own experience, for them, and one which helps them lead a happier life.

 

You’ll use their preferred name and pronouns (simply a matter of respect), but AT is categorically not, as those who oppose it sometimes absurdly claim, some kind of blind agreement with everything your client says as you push them unthinkingly onto a fast-track travelator towards a full gender transition. Working in an affirmative way must always involve helping the client to explore their life in the round, helping them to make sense of their experiences, feelings or backstory, without a predetermination of where that will lead. It doesn’t avoid any of this, in fact it must not. It is – as I see it – a commitment to affirming your client’s life and their truths as you jointly, and deeply, explore them together. It is, despite the adoption of the word by its opponents, profoundly exploratory.

 

Critically, if you are sitting with a client who is working through their process around all this, and has not yet reached a conclusive sense of an answer, AF does accept the possibility that your client may be trans, has the right to be trans, that being trans is something real and ok, that it is not an illness nor the manifestation of one and that they may decide to move forward to adjust their gender presentation and how they live their life...if that's what they wish to do. And that this is as legitimate an outcome as any; one to be respected as much as any other.

 

Exploratory Therapy (ET) is a term which seems to have first arisen in the US and increasingly has support amongst anti-trans/anti-LGBTQI+ voices in southern Republican states. Many in the LGBTQI+ community regard it as a disingenuous label. Of course, on the face of it, who wouldn’t endorse something called exploratory therapy? Sadly, what ET often means is a commitment to the examination of everything but the possibility that your client is actually trans. Exploration of anything and everything except one possible answer. Its usage sometimes verges on doublethink, because in actuality, it is anything but fully exploratory. And that's because of prejudice, baked-in from the outset.

 

Advocates of ET will sometimes create long lists of pathologies for which therapists should look when working with a client who brings questions of gender identity. When the first condition cannot be found, the advice will be to move on to the next, over and over. There must be something hidden, the logic goes. Yet that list pointedly never includes one possible answer, that your client isn’t actually sick at all, but trans.


The reason that such a possibility is, axiomatically, ignored is very straightforward. At the heart of the ET is a core belief that trans people do not exist. That they are little more than a culturally-produced delusion, a product of social media contagion perhaps, or a range of illnesses, conditions or past trauma that makes then delusional. Why search for something that isn't real? That trans people do, self-evidently, exist (one is writing this piece) and have done so in many cultures for millennia, is difficult to reconcile with this approach – except by asserting that those who live in the world as trans must be acting out some massive, chronic delusion which has not yet been treated and for which trans people should be pitied, or worse, feared.


Alas, it doesn’t take long before the position exposed by all this merges with a toxic Daily Telegraph headline or a witch hunt based on a claim that trans people, especially trans women, are concealing some threatening mental illness that makes them a danger to others, especially to other women or children, and must be vilified, separated from society or shunned.


7. What about working with young people?

 

In my practice, I work only with adults, so I claim no direct clinical experience here. Working with children and teenagers requires specific training and I do not claim to have it. So I offer these thoughts chiefly from my own personal experience, though also from the deeply-held ethical standpoint that underpins why I work as a therapist. Apart from actually being a trans kid myself once, I have personally known a number of trans children and their families over the years. If you haven't, that may not be surprising because for some families in this situation keeping their child safe from the real, physical danger they may face if their identity and location becomes widely known can be a priority. I have seen the prejudice these children and their parents face. I have heard the stories about their families being hunted by newspapers, the social media monstering, even the death threats [3]. I know the stories of the suicide attempts some of these children have made, after being put through relentless bullying at school - by fellow pupils, teachers, or even other parents - and how their desperate families have done everything they can to try and keep them safe. I have recently read the UK government's education proposals that would, if enacted, even more deeply isolate and stigmatise trans children in schools – proposals of breath-taking cruelty and embedded, shocking, bias, condemned by teaching unions and the NSPCC. I’ve known one family whose 14 year old child started asserting their inner gender when they were 3. And, I mentioned, I was a trans kid myself once – in an era when, like the friend of whom I wrote at the start, I was terrified of revealing anything of my identity at all.


How are we to help such children and their families? I believe that, in essence, the principles outlined above hold true for them too. Much has been made of how children’s brains grow and develop, and this point is entirely valid. Equally, media and political commentators point to ostensible social media or peer pressure. Some, using a reheated trope previously levelled at people of colour, Jewish people and gay people at one time or another, accuse the trans community of trying to ‘trans’ kids, a predation narrative with a stink of the so-called ‘great replacement’; a smearing of trans people (who are not, in this narrative, real, but in the grip of a sinister ‘ideology’), by saying that they are trying to ‘erase lesbians’.


Were this last claim not so dangerously toxic in the public discourse, it would be risible. Despite the 'Gender Ideology' smear featuring regularly in the British government's increasingly demented rhetoric around all this, even in its written policy proposals, I don't wish to dignify it here further by writing about it. But I will discuss the other two questions, at least briefly.


Kids are, obviously, not mature adults. They are growing, physically, mentally, emotionally, and yes, in many ways, children's sense of self will change, perhaps significantly, as they do. But in my view none of this means that our job as a therapist is essentially any different. Our task is still to really listen, to park our assumptions, to explore our client’s life with them not for them, wherever that goes, and to not pathologically label a child’s instinctive desire to present to the world one way or another as sick, or wrong, or delusional. To not, automatically, as some strident voices suggest, pre-judge a child or teenager's distress around their gender presentation as a consequence of some other pathology which must be present because the authenticity of their being trans is for you impossible to ever accept. As for the question about social media, and the media-friendly assertion that the experience of being trans is somehow a learned response by young people in response to peer behaviour or to the fashionable opinions of an 'influencer', I'd repeat first that it is - of course - the therapist's responsibility to try and help their young client tell their story as authentically as they can. Again - don't prejudge anything.

But a few points about that are worth making, albeit briefly, here.

In the last two decades, social media has increased our exposure to and understanding of the possibilities of life. Trans people come to their experience of themselves in all sorts of ways and always have. For me, I can track it to the age of four and then a tortuous and, for years, winding road of fear-driven concealment. Until I was in my late teens I thought I was the only one in the world who felt what I felt, who had ever felt it. And I knew that - above all else - I needed to hide this part of myself. The shame was overwhelming. I tried every version of an answer I could possibly think of on myself. I was - if you like, using the description above - conducting so-called Exploratory Therapy on myself, looking for an answer, any answer, other than the one I feared most. It didn't work. None of this was to do with social media because social media didn't exist. I longed to know that others might be like me. I longed to know that my experience was valid. And had I known that, and been able to shed the shame, then maybe I would have been able to make changes in my life years earlier than I did and avoided a long time of inner turmoil and pain. The grotesque trolling apart, I wish Instagram or TikTok had existed for me then. It might have changed my life. I wonder what the generations of trans people who have lived in all cultures of the world for centuries, well before the arrival of Gates, Musk and all the rest, would say?


Junk, and debunked, theories like 'Rapid Onset Gender Dysphoria' have been created to support the 'social contagion' accusation. In my view, not only are such positions rubbish, but they feed directly into the prejudices from which ET has sprung; the 'anything but trans' position.

So, ultimately, what does it all amount to? For me, it's about walking alongside your trans or gender questioning client, helping them make their choices for themselves. Using your training, and your humanity, to help them to explore their own feelings plus the meaning and implications of those feelings. Earning their trust by demonstrating that you come to the encounter with an open mind and open heart. Help them be who they are and help them understand that whoever that is, is ok.



****** Footnote: Over the next few days, Britain will see the final report from the Cass Review - an enquiry set up to overhaul the care of trans kids within the UK's NHS. Thus far, this review has succeeded only in finally breaking an almost broken system as the British government rushed to implement its interim criticisms of London's Tavistock Gender Identity Service - the only centre supporting trans kids in the UK - by closing it down and then neglecting to set up the successor clinics that Cass suggested. Trans kids and their families have been left in despair. The UK trans community - and others - have expressed major misgivings about the direction that Cass has seemed to be taking, its inbuilt biases, and the stakeholders from whom it has chosen to take, and not take, evidence. It remains to be seen what it will conclude, but whatever that is, it seems sadly inevitable that its findings will be weaponised against the interests of young trans people in the UK by the British media and political establishment. I hope to write more about the report once it has been released.


*******


Jo Shaw is a practising psychotherapist in London and Kent. She transitioned many years ago. It was the best decision she ever made. * My focus here is on clients who specifically want help with respect to their gender identity; understanding it, reconciling with it, living it, whatever it is. Trans people do of course show up in therapy rooms (or GP surgeries) for all sorts of reasons, many of which may have nothing to do with this, and that's vital to remember. You'd be surprised perhaps how often it isn't.


[1] Forcing gay men to vomit at the site of pictures of naked men.



[3] Sadly not just threats as those who followed the tragic case of the murder of teenager Brianna Ghey in the UK in 2023 will know. Following her death, whilst receiving much support, her bereaved mother was also subject to widespread abuse online and was a called a "child abuser" by a prominent anti-trans activist.


Learn more about so-called 'Exploratory Therapy' at:


Edited April 9th to add some more links and small section of addition text


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