by Sasha Ayad, M.Ed., LPC
Sasha Ayad is a Licensed Professional Counselor who works with teens and young adults who began questioning their gender identity around puberty. Sasha uses an exploration-based approach which aims to discover underlying issues and help her clients work towards self-awareness, resilience, and long-term well-being. She also conducts occasional consultations for parents of teens with gender concerns.
Jungian analyst, James Hollis has called American popular culture an “adolescent culture”. He claims that growing up is about far more than inhabiting a big body and big roles in society. He explains further on the podcast, Speaking of Jung:
What does growing up mean? I think growing up means I really have to not only become conscious of, but accept responsibility for the fact that I am accountable for my life, for my sense of satisfaction, for my purpose, for my choices. Becoming an adult means you have to deal with what is difficult for you and you have to exercise as much freedom of choice as you can manage in the face of circumstances of the outer and inner world. Now, when you look at popular culture and you realize the typical rights of passage for men and for women have really disappeared, what we have is an extended adolescence. An adolescence fueled often by drugs and alcohol, by video games … and nothing that really helps sharply define a person and allow him or her to begin to draw upon inner resources. So often in the therapeutic world, adolescence, which used to be roughly the teenage years, today, we talk about it between 10-28, its extended in both directions. And when you think about adolescent behavior, what do you think of? You think about it as being impulsive, lacking patience, easily excitable, easily distractible, moving from one sensation to another sensation, incapable of really thoughtful rational evaluation of issues, but responding often out of complexes and out of emotional conditioning, and often interested in superficial things.
These words feel familiar to me, as I’ve worked with adolescents for almost a decade now. The teenager tends to look outside him or herself for solutions, having not yet developed those precious inner resources. In therapeutic work with adolescents, fostering this type of inner resource is a foundational guiding principle. The clinician helps the client look inward to unearth and nurture these resources, no matter how deeply buried or camouflaged they might be. This is true for all the cases one might encounter in the therapy room: and the same is true for clients who struggle with gender.
The APA has asserted, in their newest guidelines on working with gender-questioning youth, that the clinician’s role relegated to “affirmative care,” with the sobering reminder that the word affirm means “to say something is true in a confident way.” When a 12-year-old with a history of depression, social anxiety, and self-harm suddenly announces that she is really a boy, the clinician must emphatically and confidently agree with her assertion, and deeper introspective work is made impossible. This approach seems antithetical to the important work of the therapist. I would like to start by reflecting on the current state of mental health and its pervasive neglect of the known truths of adolescent development.
Back to Basics:
When it comes to treating gender dysphoria, decades of knowledge about child and adolescent development and long-standing best practices in the field of psychotherapy have been abandoned. Emotional experiences have been defined and fragmented into more specific diagnostic categories. Curiously, we are also told to believe that a perceived incongruence between mind and body, a seemingly terrifying experience, is actually neither pathological nor a transient state. Instead, we are told by affirmation-only advocates that gender dysphoria is fixed and immutable. The transgender “identity” actually empowers the client, if only we can fully embrace and affirm it. We are introduced to new language and incoherent jargon which can bewilder anyone trying to keep pace with the evolving cultural landscape. Reluctance to work with trans-identified teens is understandable given the alarming statistics we hear about suicidality in this population (statistics which are used inaccurately to scare parents and clinicians). Even therapists who have built decade-long working relationships with a young person are quick to terminate and refer out upon the very first utterance of gender-questioning from the teen (I’ve heard this from several parents).
I fear this type of abandonment does a terrible disservice to teens and may ultimately pathologize gender exploration. When clinicians feel the “trans teen” is too alien and complex to treat, these referrals-out are usually to specialized gender clinics. It seems these facilities operate as ideologically motivated medical informed consent clinics. They claim to conduct therapy but if therapy remains nothing more than a few superficial consent-based sessions, clearly some deep therapeutic work is being circumvented. Young adults facing major existential life questions need psychological support which is far more ambitious than what most gender clinics seem to offer.
The affirmation-only trend also prevents us from viewing our clients as whole beings in a particular temporal context. I worry that it blinds us to the errors and biases of our generation, time, and place. I suggest, instead, that we take a long-view, remembering the basics of therapeutic philosophy and ethics of clinical practice. If we can read between the lines, we often discover there’s nothing new under the sun.
In this light, when an adolescent client states that she’s is transgender, we don’t defenestrate everything we know about the inner lives of teenagers. Instead, we can slow down and look at the big picture, as we should with any other client. It’s crucial to use a well-founded and broad therapeutic perspective about what teenagehood is, how identity exploration can serve (or hurt) a client, and how to work with adolescents in a meaningful way. In this manner, clinicians don’t necessarily need to be the ultimate experts on every psychological manifestation we might face in the counseling room. Gender questioning can be treated like any other mental health issue – with compassion, curiosity, and gentle companioning.
Here I share some of the guiding questions and themes that I use in my work with adolescent-onset transgender identification. I’ll start by explaining my general approach, share details about the intake process, and offer some meaningful areas for deeper exploration in later phases of therapy. I have also included ways to navigate some of the complex ideological material that can often weave itself into this therapeutic work. My perspectives are informed by a pragmatic, back-to-basics theory of mind and adolescent development. While some of the ideas here deal directly with gender identity, I believe my approach should feel quite familiar to all therapists and clinicians who work with adolescents.
Basic assumptions about gender identity:
Gender identity is complex and dynamic. It is influenced by biological, environmental, and personal factors; these include familial, social, sexual, emotional, psychological, and subconscious factors.
The clinician’s job is to gently help clients move beyond simplistic gender cliches to a place of deeper self-discovery, regardless of where that leads.
Understanding Transgender Theory & Terminology:
It has been important to familiarize myself with gender identity theory so I can decipher what clients mean when they bring different concepts into therapy. For example, when I was growing up, a “stereotype” was understood as a behavior or trait we falsely ascribed to someone based on our own prejudices. Gender stereotypes would include ideas like “girls are too emotional” or “guys always like sports”. However today it seems trans-identified kids have a completely different conception of gender stereotypes. They often believe that when we look at a male person and refer to him as a guy or man, we are “stereotyping” him – i.e. that we’ve made the faulty assumption that this person “identifies as a guy.” It’s a remarkable distinction that took me some time to recognize. There are many more examples of ways in which trans-identified teens use language differently from people outside the transgender advocacy circles. Learning the language helps me spot these injected concepts; I’m careful not to assume these ideas have organically developed in the client’s psyche.
Don’t approach therapy from a political angle
I understand transgender theory and how it operates politically, but I’ve learned that approaching the therapeutic work from a political angle misses the point. Approaching topics from either an activist or critical lens pulls the work away from a more profound, psychological place. The political and critical approaches also recycle stale arguments the teen has likely heard in friend groups, at home, or online. Instead, I’ve learned to model a completely different, third way to hold this experience with them so we can probe much more rich and interesting questions.
Manage your expectations:
Depending on your involvement with the gender critical community online, you may need to manage your own assumptions. Reading a variety of material from both gender-critical and gender-affirmative approaches is important, but remain mindful of how these perspectives may influence your perspective. Stay open to the depth and complexity of your client’s individual gendered experience.
I try to use neutral language which neither concretizes nor dismisses the client’s identity. Phrases like “your identity” or “identifying as trans” are used instead of “as a trans person” or “you are trans.” In early phases of therapy, to lessen defensiveness, I will attempt to detach both old and new identities from the client in conversation. For example, if I’m working with a female client who has taken on a boy identity as “Jaden,” here is how I may speak with her: So, “tell me more about “Jaden.” What is “Jaden” like. How is Jaden different from Stephanie? In later stages, I may directly invite clients to embody either identity momentarily so they can access the experiences, thoughts, and feelings unique to each persona.
I’m cautious with the term “coming out” because it implies finality which may not serve the client’s dynamism and flexibility. Instead I might say “when you told mom about your identity.”
With clients who seek out counseling for the first time as adults, I use their chosen name but incorporate similar neutral approaches to our gender conversations. The need to refer to the client in third-person pronouns is rare.
Leave the door open to the WHOLE person: individualized care
I want the teen client to come out of their shell and embody the multitude of who they are in session. I try to engage clients in ways that feel congruent with their age, interests, sense of humor, and comfort level. Being flexible in my approach and using different aspects of myself helps to make room for the teen’s personality to emerge. I find myself using jokes and modified self-disclosure with certain clients. And at other times, I may use metaphor and stories from TV or pop culture. Still, in other sessions a more serious intellectual and analytical approach feels best. With clients who have a spectrum diagnosis or similar characteristics, I use straightforward ideas and concrete examples with less nuance or figurative language.
Accepting your own emotions:
My work with this population humbles me in many ways, but especially in my own eagerness to help clients feel whole. There is no special way to rush that process, and by checking my own sense of urgency, I can model an attitude of patient curiosity. When things feel like they are moving at a snail’s pace, or even feel completely stuck, I try to gently befriend my own discomfort. I try to use my own reaction carefully – at times I may need to hold the mirror for the client about what I see, and at other times, I need to remain a neutral companion, allowing the client to be responsible for plunging deeper. When the client’s panicked rush to “fix” their dysphoria is approached calmly, wonderfully surprising material emerges and deeper hurts are unearthed. This is where we find doubts about the utility of trans identity, fears about romance, pragmatic reality checking, etc. I take things slow, and model a calm openness to all feelings.
Read between the lines & stay present:
I’ve found that when I take the client’s words too literally, it can move us away from deeper exploration. I try not to get wrapped up with jargon, recycled narratives, and minute details in the client’s gender story. It is tempting to dig deep into complex rationalizations, trying to unpack confounding ideas. Instead, I listen for something deeper, look for patterns, and stay present with the emotions. By helping the client stay present in session, I might help her stay present in her own life and her own body.
Building Trust Before Therapy Starts
Gender questioning adolescents find their way to the counseling room in a variety of ways. Some have asked their parents for a counselor to work through their feelings, and others are specifically seeking a quick-and-easy path towards hormones or “top surgery.” More often, though, I meet kids who are reluctantly following through with parental requirements to go to counseling. Anyone who has worked with mandated therapy clients of any age knows this dynamic can present special challenges around trust-building and openness.
Giving teens some autonomy in the therapeutic process before it even begins can be hugely useful in building a trusting, productive relationship. When a spot opens on my caseload, inquiring parents are asked to first set up a free 20-min phone call between myself and their teen – I require that the teen has privacy and can speak to me freely. In this initial conversation, I start by explaining the purpose of the call: I tell the teen it’s their opportunity to hear my voice, feel me out, and see if they think working together would be a good fit. I then ask about friends, hobbies, school, etc. I keep the conversation casual but also ask about what types of things the teen may want to discuss if we end up working together.
I always ask the teen if they have any questions for me that would help them decide what they want to do. I answer honestly. I ask them to take a few days, let the conversation sink in, and reach out to their parents when they’ve made a decision.
Teens almost invariably say yes to starting therapy together.
Intake Gender Identity Questionnaire
Teen clients and parents are given two different sets of questions to fill out before therapy starts. These questions have been changed and tailored as I have learned more and more about my clients and the ‘trans teen’ population.
The teen intake covers a range of questions about gender identity, gender expression, “outness,” other psychological issues, parent relationships, personal strengths, hobbies, etc.
Parental intake includes standards like medical & mental health history, diagnosis and medication, but also contains specific items related to the emergence of the gender identity. These include teen sexuality, what responses parents have had to the identity, and their level of acceptance for gender non-conforming behavior or homosexuality in their child.
Answers to these intake questions help build an initial picture of the micro- and macro- forces impacting the family. As therapy proceeds, I have these written responses to refer to as my clinical impressions of the family and client get filled in by direct experience.
In my 75 min intake, I spend time alone with the teen client, alone with the parents, then a brief period of time with the whole family together at the end.
Alone with the Teen Client
A task that is likely given little to no thought in gender-typical populations is how to address the client. For teens whose nascent transgender identity is only weeks old, it seems brash to immediately begin using the new name they’ve selected. However at this stage, the birth name often represents a power struggle which is antithetical to building trust and confidence with a new client. To circumvent this problem, I have opted to call my clients by their last name. I explain in our intake that this is a tradition of mine, and ask if that’s okay. Teens seem to enjoy having a special name for therapy. This naming process also begins building the special space in which gender takes on a different, third meaning. This is not their birth name (which parents likely still use), and it’s not their newly adopted name (used by their affirmative friends). Getting some distance from either name seems to open up different possibilities for how the client relates to gender.
Much of this conversation (and documentation) is relatively standard, however I have a few extra topics to cover in my teen intake (and write into the signed consent form):
I conduct one 30-minute call every 6 weeks with minor clients’ parents. I explain to the teen that in these calls, we can discuss general themes, but not specific details. For example, I may share with parents that we’ve been discussing social issues, or gender in the context of school. However I wouldn’t tell them if you name a friend you have a crush on or hide a bad grade from them. I also ask the client to give their parents privacy if they are on a call with me.
Limits to Confidentiality
I have built into my informed consent some additional limits that go beyond the standard safety or court-related exceptions. If clients put themselves at risk by ordering off-label hormones online, going behind parents’ backs to get a binder that’s too small, doubling up on binders, or other similar behaviors, those would be safety concerns. If this comes up, and we have to disclose to parents, I encourage the teen client to lead or be part of that process.
Establishing Realistic Expectations About the Purpose of Therapy
Sometimes I must confront the perception that therapy is a short series of sessions aimed at securing a gender dysphoria diagnosis for the subsequent goal of beginning hormone treatments or having surgery. I address some of this preemptively on the 20-minute call, but sometimes additional clarification is needed in the first several sessions. Additionally, when working with adolescents who are likely anxious, self-conscious, and have a host of preconceptions about therapy, taking things slow is very important. I like to explain a few basic things to teens when we start therapy, and I’ll do so in this type of language:
- I’m similar to gender therapists you might have heard about online in that I work almost exclusively with people who struggle with gender. I’m different from other gender therapists in that I am not going to just talk to you a few times and send you off for hormones. I really enjoy talking about gender, I think it’s very complex, and with my clients, I try to explore issues much more deeply and carefully.
- Therapy is like a journey and if you or I go into it with too many rigid goals, we may not be open to wherever the road might lead us. The best therapeutic work happens when both client and therapist remain curious to discover what’s there, even in some unexpected or scary places.
- Just because I’m a therapist, I don’t expect you to spill your guts immediately. LIke with any other relationship, it can take time for us to get to know each other and feel open.
- Unlike other relationships, my job is to help you explore deep parts of yourself, and that can be really hard at times. There may be moments when we nudge a little past your comfort zone, but like the waves of the ocean, we’ll push forward, then retreat into safety over and over again.
I’ve chosen not to rush through intake questions at the outset of work with a new client. Instead, we slowly weave them into the beginning stages of therapy in a more natural manner. There are a few reasons for this. Most importantly, I want the child to understand that I don’t see her as a walking identity. She is a whole person – a deeply interesting soul I really want to encounter and engage. It also alleviates the pressure a teen may feel if she perceive the intake as a sort of interrogation or assessment. The desire to “say the right thing” can be grating when you are trying to prove your gender dysphoria to the therapist. Ebbing and flowing to and from gender this way helps ease and open up clients to revealing other parts of themselves. Later in therapy there are better opportunities for deep dives into gender identity content.
Time Alone With Parents
By the time we are conducting the intake, I’ve talked extensively with parents about their child’s case. In the intake session, we review what they hope their child will get from therapy. I explain that parents should look at this process as a marathon and not a sprint. Developmentally, there’s nothing terribly unusual about body discomfort, trying on identities, and fantasizing about being someone else. We discuss how to create safe boundaries within which the teen has room to experiment, think critically, and mature. We also use this time to set up our first 6-week call.
With Teen and Parents
All together, we review frequency of therapy, schedule, logistics, cancellation policy, confidentiality, etc. I also reiterate expectations about the client and parents having privacy for sessions and parent calls, respectively.
Third Person Speech
When in conversation with both client and parents, I always refer to the client by their last name to avoid using pronouns. I often address the teen client directly and refer to parents in third person as “Mom” and “Dad”.
Working with Parents: 6-week calls
These conversations also give me insight into what parents are seeing at home, often shedding a new light on what teens report in session. Inversely, client confessions also help me contextualize the energy and requests coming from parents. In these calls, I recommend ways that parents can support their child in manners congruent with the therapeutic work.
Areas for deeper exploration in session with teen client
The following suggested themes are by no means a comprehensive list of possible therapy topics for trans-identified teens. Depending on the clinician’s therapeutic perspective, paths for deeper work can be nearly unlimited. In my experience, the following areas provide fruitful avenues for meaningful case planning and work in session. I have also included the types of things I look for as we weave in questions from the gender identity intake.
Whether to directly broach gender conversations
When getting to know a new client, I ask questions to test the waters regarding how they discuss gender. Is their understanding very superficial and simplistic, or are they thinking in deep nuanced ways about their identity?
Some clients come into therapy explicitly wanting to talk about gender. Clients might say that conversations they have with peers about gender are too simplistic. Perhaps they don’t see their story reflected in the cookie cutter activist narrative, and are looking for a deeper, more nuanced discussion. I try to ask what parts of gender identity don’t seem to work for them or explore the ideology from a philosophical point of view. Again, this is an opportunity to create a completely different, third way of exploring gender identity.
On the other hand, many kids get completely stuck in gender conversations. They lean on catch phrases and recycled narratives, and if I ask any deeper question, they can get defensive and tearful. This usually happens with the posturing over-confident client types. They may be revealing the shaky ground on which they’ve built their identity. It’s important to be careful in these moments. Ask about what’s going on beneath the dialogue. What is the client afraid of? What is happening in the counseling room right now?
Sometimes pulling away from gender altogether is necessary, especially if deeper trust is still being built. In these cases, I might focus instead on other needs the client has, usually related to accepting other parts of the self, social anxiety, dating & sexuality, etc.
Nuanced understanding of the self
How sophisticated is the teen client’s understanding of herself? Anxious clients may display what seems like introspection, often perseverating over every thought and feeling. But clients like these often lack the internal resources to mitigate their over-thinking and struggle to act with bravery in their outer world.
Other clients may present with a hyper-confidence about anything gender-related. They may be insisting they’ve already done all the deep introspective work necessary. They claim to have zero doubts or questions about their identity or about complex medical procedures and treatments. They might only look to the clinician as the signatory to their gender dysphoria. When you encounter this apparent self-assuredness, keep an eye out for indicators of maturity and psychological sophistication in other areas of their life. If you fail to discover an age-appropriate level of deep maturity, the client is likely overcompensating. Perhaps she/he is splitting feelings of ambivalence that demand more attention.
Gender, Masculinity, Femininity, Sexuality
Does her conception of gender identity seem mature? Has it evolved organically from her own mind, or does it seem more like a copy/paste manufactured persona? Listen closely to establish which came first, body discomfort or the new gender identity. Furthermore, does experimenting with masculinity (for females) or femininity (for males) lead to more anxiety, self-criticism, etc? Does it make the client feel powerful, sexy, invisible, etc. What changes for the client when they put on the costume of the opposite gender?
What is the sexuality of the client? Many trans-identified teens are unable to identify who they are sexually attracted to. I suspect some of this has to do with their high levels of social anxiety and body discomfort. Some, on the other hand, are clearly inclined towards same-sex attractions. Some families or peer groups have consistently deride gender non-conforming behavior and homosexuality. What messages has the client internalized about homosexuality and lesbianism? Internalized shame about same-sex attractions may lead to thinking the only acceptable explanation for their feelings is being transgender. On the other hand, some clients have told me they believe as a “trans guy” that they should foster more of an attraction to girls, though they previously only crushed on boys.
For those who do feel comfortable with sexual attractions (to either sex), have they experienced any kind of sexual contact – with self or others? Do they understand intimacy and pleasure: both receiving and giving? Do they understand how transition may impact their prospects for romantic connection in the future? For example, if a female client is only attracted to boys, does she understand that transitioning will not likely make her attractive to gay males? If a boy at school is dating her now, aware of her trans identity, is this a good representation of what adult males will be comfortable with later in life? Is she interested in intimacy with other trans guys?
Clients with same sex attractions should absolutely be regarded as a potentially gay person in the earliest stages of sexual identity development, which is undoubtedly fraught with complicated feelings, confusion, shame, and gender issues.
Has the client come to believe that certain emotional experiences are incompatible with their natal sex? For example, one client told me that she grew up believing that women are supposed to be strong and fearless. When she felt vulnerable and scared, she wondered if something was wrong with her. Conversely, many female clients say that women are weak and transitioning will help them feel strong and confident. Normalizing the entire range of human emotions for either sex can be important to help the clients sort out false beliefs about what’s possible one’s own body – another example that calls for a completely apolitical approach to the discussion of gender.
What about aesthetics?
Regarding aesthetics, I’ve found two general categories of trans-identified female adolescents. One group has a long history of preference for masculine aesthetic. A girl may describe her younger self as a tomboy who didn’t “know anything was wrong.” Around middle school, when all kids naturally start to segregate themselves by sex, these girls start becoming aware of their own divergence from other girls in appearance, mannerisms, sexuality, etc. Feeling terribly alone and different, they wonder if their aesthetic preferences indicate something is wrong. They search the internet for an explanation or begin identifying with other gender nonconforming peers or “trans” kids. The client may start taking online quizzes and “piecing things together.” Once they’ve adopted the trans explanation for their aesthetics and preferences, they push for an even more masculine presentation, and begin developing “gender dysphoria” that was previously absent.
In the other category, however, girls have always been admittedly very feminine. They report having dressed that way to “overcompensate” for their hidden internal wish to be a boy. Social pressure to be feminine made them uneasy, and they may describe parental acceptance as having been conditionally based on her expression of femininity (or masculine for boys) – this may be perceived or real. I often hear stories about how exhausting it felt to chase the ideal of hyper-femininity. But to abandon femininity as a girl seemed way too great a chore, requiring a huge amount of bravery and confidence. Instead, it felt easier to justify masculinity by coming out as trans. One female client told me that it would have been too hard to explain to people that she, a girl, could want to look more masculine, so telling people she is trans felt more palatable (I completely agree with the trans activist mantra, “listen to kids”).
“Coming out” and what happens next
I avoid making assumptions about how has the identity impacted relationships in the client’s life. If there are people he hasn’t told, why not? Has the trans declaration lead to closer peer relationships, or has the client been ostracized by friend groups? Do teachers and staff now take a protective stance towards the client, or make him the center of attention – is this a good or bad thing to the client? In relationship to the parent, does the child feel like he’s finally out from under mom and dad’s thumb? Or maybe he’s too scared to talk to them about sexuality? Stay curious about relational outcomes of the identity declaration.
How others see the client
I often like to ask: does it matter to you if others really see you as a guy, or if they are just using he/him pronouns so they don’t offend you? Some kids have never even thought about this question before and may ask for an example of what I mean. I often get either completely blank stares, and a space for deeper processing, or canned responses about pronouns indicating respect. The answer to this question can tell me a lot about the way this dysphoria evolved, how it manifests, and where it may be rooted. The implications for later in life are inescapable, and clients may not understand the difference between actually being a natal boy and simply modifying your looks to appear like one.
Transformation – the seduction of a new life
What might the child be attempting to escape by taking on a new persona? If a socially awkward male transforms into beautiful, sexy woman, might this mean easy access to admiring romantic partners? Does he long for a sassy and confident personality, or a life with less burdensome dating responsibilities? If a young woman has been picked on and hurt by others, does transition represent an escape from vulnerability? These feelings of vulnerability or social awkwardness are ubiquitous in adolescence, and though teens are constantly connected by internet and social media, there’s still a pervasive belief that no one else feels the same way. Kids conclude that they are so radically different from their peers, that puberty alone is an impossibly simplistic explanation for their overwhelming emotions. Being a different “kind” of person seems like a better explanation.
None the less, exploring the teen’s fantasy about this new identity can be instructive. How might this very confident new person deal with this or that situation? How can you become more like that confident person right now? There is also a profound soul-searching going on here. The client is attempting to look inwards for a deeper understanding of herself, and this must be acknowledged in therapy. But maybe there is a different kind of transformation awaiting the client – based on befriending struggle, developing new skills, maturation, and wisdom. Might this be an even better transformation than discarding the old self and replacing it with a new one?
Understanding the body
Kids often seem to have a rigid timeline for medical treatment and a list of boxes to check. They want to “transition” before high school, or before college. They want to start the next chapter of their life as a new person, and transition is the way to achieve this biologically supernatural fantasy.
But what does the client actually know about reproductive anatomy, natural cycles of the body, and what life-long medical intervention really means? Some kids are quite sheltered and have a limited or superficial understanding of how the body works. Some believe that undergoing treatments will essentially turn their body into an exact functional equivalent of the opposite sexed body. Some clients have major chronic health issues and have not considered how their own medical history could make them ineligible for treatments or put them at a much higher risk of complications.
Gender transition is a commitment someone must make for life. To sustain the appearance of the desired gender, life-long treatment will be required. Therefore, it’s not something that one should rush into just to beat the clock on a major life milestone. Therapists should help clients understand the level of commitment and bodily risk involved. Some side effects are both prominent and permanent. For neurotypical teens, the urgency to “fix” things seems to color all the medical interventions with a light of triviality, so I try to engage them more deeply here and we settle into longer conversations. For teens on the autism spectrum, learning the details medical transition procedures often leads them to quickly changing their minds about hormones and surgery.
Being IN the body
Kids with deeply rooted body discomfort or dissociative tendencies are often afraid of their own sensory experiences. Traumas can manifest as aversion to noises, textures, smells, tastes, etc. Working with clients on gently accepting their bodily sensations can be useful, and I draw from somatic and yogic therapies for this type of work. If a client can stay calmly present with intense bodily sensation, she changes her relationship with discomfort. She may be able to integrate difficult feelings and estranged parts of herself. This type of work is also incredibly useful as young clients start exploring intimacy with self and others.
Later Stages & Desistance
The maturity to change one’s mind & desistance
Many clients report suspicions that their identity was either hastily adopted or no longer feels congruent with their understanding of self. However, these new revelations can be difficult to integrate into their social world, since they are known by others as a “transgender” person. Perhaps there is a desire to shed the label, but the client doesn’t want to seem immature, wishy-washy, or like a “poser.”
Here it’s important, again, to emphasize a more holistic concept of the self. I work on reframing the new perspective as a sign of growth and evolution, rather than evidence that she “made a mistake”. At this stage, I often joke with clients and exclaim, “congratulations, you are a human being! With lots of contradictions, discoveries, and room to change your mind!” Helping to normalize this shifting experience is important so that the client can celebrate and face their social world with bravery. It is the client’s own life and identity to experiment with, after all.
For the desisted client, it’s useful for them to reflect back on what’s changed since letting go of the gender struggle. Clients often point out how much of their mental and emotional energy was consumed by gender and how much lighter and happier they feel since letting go. They may feel remorse for having wasted time or fallen behind their peers in dating, friendship, sports, hobbies, etc. This remorse can be used as a gentle reminder that helps client stay committed to their own growth. This intense gender detour can instill a stronger intuition, a warning sign, when the client faces other identity issues or miscalculations in the future.
Therapy clients are our greatest teachers. When youth are given permission to plunge deep within themselves, much is revealed to the clinician, and we can ultimately help them tap into their inner resources. Only when the client can speak for herself can the real therapeutic work be done. In this respect, I believe affirmation advocates may be onto something when they say, “listen to children.”