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Embracing an Exploratory Approach to Gender Distress

by F. R. Garinson

The first time a patient told me he was questioning his gender, I was caught like a deer in the headlights. I’d seen this patient, an adolescent, for a few sessions at that point, and he was what is known as a “tooth puller;” we hadn’t been able to develop much rapport when he dropped this bombshell. My typical response to such a surprising disclosure would be to ask about his reasons for feeling a certain way, but since this particular disclosure was about gender, I was terrified that if I went in that direction, my patient would feel as though I was questioning his gender identity. Would I be causing harm by doing what I had been trained to do and practiced for a decade?

 At the same time, automatically rushing to agree and affirm didn’t feel right either. With a sense of unease, I asked how long he had felt this way and tried to get a developmental history.  He said that it started in childhood, but he was not able to describe how it affected him or go into any detail about how he experienced and expressed his discomfort with his gender. He also disclosed that his parents had not been aware that he was questioning his gender, which surprised me. At the time, I understood that gender dysphoria was strong and persistent starting in childhood. Moreover, I had been taught that children who expressed a trans identity usually declared that they were born in the wrong body when they were very young, so I was surprised that his parents did not know.

I wanted to ask more questions because I wasn’t getting much information, and what I was getting did not fit the pattern I had been trained to look for. But because I did not feel comfortable doing what I had practiced for years, I backed off and explored what medical interventions he wanted.  Thankfully, though, I did not write any recommendations for hormones or surgery. Still, it ranks as one of the worst sessions I have ever done.

A few years passed, and during those years, my sense that all was not well with our current paradigm around gender dysphoria led me to question it and eventually find and practice an exploratory approach to gender. Recently a friend who is also a counselor asked to confer with me about a case with one of her patients who was experiencing gender-related distress. Like me, my friend was scared to do what she had been trained in and practiced for a decade. After exploring the case with her and walking her through some strategies that she was already well-trained and practiced in, she exclaimed in relief that she would basically be doing what she would for any other patient.

And to me, this is the insidious nature of the discourse around gender identity and the gender-affirming model. It causes therapists to question and doubt their years of training and experience, rendering us ineffective at best and forcing us to collude with our patients at worst. Embracing an exploratory model is more in line with what I believe and what my training tells me is right. I just had to give myself permission to treat people with gender dysphoria the same way I would treat any other patient.

One thing that helped me to feel confident in embracing my style was listening to detransitioners who felt betrayed by the mental health profession and understanding that they felt their therapists let them down. And yes, I also have spent time listening to people who continue to identify as trans to learn about how they felt let down by mental health professionals. After going through this process, I am firmly on the side of wanting to ensure that I thoroughly explore where the gender distress is coming from as well as the pros and cons of transitioning, rather than send someone on the path of irreversible changes and have them come to the realization too late that they had made a mistake.

In some respects, I find working with people who are gender questioning similar to those who are in an abusive relationship and in denial about the abuse. My job is not to tell my patient that they are in an abusive relationship or a healthy one, and it is not to tell my patient whether to leave or stay with their partner; I do not have to live their life, and I could be wrong. My job as their therapist is to meet them where they are at and help them explore whether this is a healthy relationship for them, whether they are okay with tolerating certain behaviors, what are the reasons they may feel as though they have to tolerate certain behaviors that most people would find unacceptable.  I do this in part by exploring their family history and what patterns of behavior were acceptable there and by providing education about the nature of domestic violence, manipulation, and emotional abuse.

Sometimes a patient will make a decision that I feel is misguided. I can explore their reasons for making that decision, and I have an obligation to do so, but ultimately I have to accept that this is their decision to make.  My ultimate goal is for them to feel as though they can still trust me if and when they realize it was a mistake. If I turn this into a power struggle, I am going to have to be aware that I will likely destroy the therapeutic relationship in the process.

Much of this carries over into exploratory therapy with gender-distressed patients, except the pressure to not turn it into a power struggle is much more poignant. I have to keep in mind that my goal is to help my patient to the best of my abilities and not to impress the larger culture or prove a point. I explore the reasons they feel a certain way when the feelings started, what their family dynamics were like, what sort of traumatic experiences they have had, and what changes they want to see by transitioning.  I help them to evaluate whether these changes are realistic, as well as the risks and benefits of going down a medical pathway. I have found it often helps to have a few sessions in which we talk about issues unrelated to gender so they can see my style and realize that I am not treating gender differently from how I treat any other issue.  Accomplishing this with the “tooth pullers” and those who only want to discuss gender, however, can be much harder. And sometimes, a patient will make a decision that I disagree with, but the focus needs to be on being able to walk the journey with them, regardless of whether or not it works for them.

Remembering my training, my theoretical approach, and trusting myself has helped me to become a more effective therapist in treating this population.

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