Is Psychotherapy Really the Safest and Best Approach for Gender Dysphoria?

Contextualizing and Challenging the Psychotherapy Sections of the HHS Report on the Treatment for Pediatric Gender Dysphoria

I’m a psychologist who has specialized in understanding and improving trans community members’ mental health. I’m a trans man and my own experiences benefitting from affirmation and my belief that my male identity is valid alongside my (presumed) XX chromosomes add to my perspective. Some might call this added insight and anecdotal evidence; others will call this bias. I’ve also worked with dozens, maybe hundreds, of trans people and others exploring their relationships with gender. And as a PhD level counseling psychologist, I’m thoroughly trained in conducting rigorous research and understanding others’ research.

It is this background that equips me to really examine and translate what the heck is happening in this new HHS report on approaches to promoting wellbeing in trans youth and others with gender dysphoria.

Notably, this report, which calls itself a review of the existing literature, seems to start from the framework that transness is not real and that gender identity is not a truthful experience. They emphasize gender dysphoria rather than identity and transness. The executive summary only uses the word transgender twice: “children and adolescents who question their sex and identify as transgender or nonbinary” and “transgender-identified children and adolescents.” The full report explicitly states that the term “transgender child” will be avoided and further states that the (unnamed) authors will avoid the terms “sex assigned at birth,” “gender,” and “gender identity.” In so doing, the report sidelines transness as a meaningful experience and pathologizes the distress without naming the identity behind it.

The report has multiple sections looking into and ultimately promoting psychotherapy for “children and adolescents with gender dysphoria,” aka trans and nonbinary youth and youth exploring their gender or uneasy with their gendered or sexed experiences. I’m going to get into the weeds on the HHS report’s claims in these sections and whether they represent the existing literature and align with my experiences and perspectives.

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Summary

This substack piece will take about 20 minutes to read. I wanted to be thorough. The HHS report hides behind its lack of thoroughness and nuance. Here’s a quick summary if you’d rather just read the highlights:

This report claims to review existing literature but is framed by an underlying denial of the legitimacy of trans identities. It repeatedly promotes psychotherapy as a “noninvasive alternative” to medical interventions, creating a false binary between therapy and affirmation. In reality, advocates and affirming providers are not opposed to psychotherapy for youth struggling with gender dysphoria — in fact, many (including me) are deeply invested in expanding therapeutic approaches to help trans youth navigate distress, identity, and development. But effective therapy must be open to transness as a real and valid outcome — rather than frame it solely or primarily as a pathology to root out, as the HHS report advocates without empirical support.

The report also misleadingly suggests that psychotherapy carries no risk, ignoring decades of evidence showing that therapy can cause harm — especially when therapists dismiss, pathologize, or attempt to alter a client’s identity. Numerous studies have documented the psychological damage caused by gender identity change efforts (GICE), including heightened distress, shame, and suicidality. The systematic reviews the HHS report references actually show that affirming psychotherapy can support mental health in trans youth. But therapy imposed instead of social or medical affirmation is associated with negative outcomes. The HHS authors either misunderstand the data or are deliberately misrepresenting it. Psychotherapy can be transformative for trans and questioning youth — but only when it respects gender diversity, does not unnecessarily delay access to affirmation, and supports the client’s autonomy.

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Psychotherapy vs. Medical Intervention: A False Binary

The HHS report executive summary states that “psychotherapy is a noninvasive alternative to endocrine and surgical interventions for the treatment of pediatric gender dysphoria” and the report repeatedly positions psychotherapy as an alternative approach to gender-affirming medical care (termed “pediatric gender transition” by the mystery report authors), like puberty blockers and hormone therapy.

It is critical to understand that it is very untrue that medical intervention is being pushed by trans advocates as an alternative to psychotherapy — to the exclusion of support for effective therapy. These are only seen as mutually exclusive by people who are against affirmation or openness to non-cisgender identities. The rest of us are working hard to increase access to informed psychotherapists and peer-based psychosocial support interventions that can help young people understand their feelings and thoughts about their bodies and identities, and to help them best figure out what their needs are around this. Anecdotally, the number one thing affirming parents are looking for when they reach out to supportive organizations or providers are referrals for competent therapists for their kids. I am one of many psychologists working on specific psychotherapeutic approaches that alleviate distress from gender dysphoria. (Watch a 15 minute review of some of these approaches on YouTube.) Researcher and psychologist-in-training Lou Lindley has developed and tested an entire protocol on coping strategies for gender dysphoria. (That study will hopefully be published this year and he has plans for disseminating the intervention, which includes a video library. I’m currently working with Lindley and Dr. Em Matsuno to create a series on social media teaching viewers these coping strategies.)

I’m a psychotherapist. I voluntarily spent two years in a psychodynamic post-doc in the Program for Psychotherapy because I believe so thoroughly in the power of psychotherapy to foster change and provide relief. I want more psychotherapy for trans people — including trans young people. And I want young people who aren’t sure if they’re trans and/or who are feeling distress about their gender or their bodies to have spaces to fully explore and get support around that. As I assert in the video linked to above, openness to affirmation (both social and medical) is a critical part of being an effective psychotherapist to young people working to make sense of dysphoria and gender. Ideally, psychotherapy (or at least counseling) and affirmation go together. The only people advocating for them being separated are the people who want to deny people access to affirmation.

That is all to say, advocates for trans youth aren’t anti-psychotherapy, damnit!

Is Psychotherapy for Gender Dysphoria Harm-Free?

Potential & Documented Harms of Psychotherapy

Again, the executive summary describes psychotherapy as “noninvasive” and also states that “systematic reviews of evidence have found no evidence of adverse effects of psychotherapy in [the context of treatment for pediatric gender dysphoria].”

Is psychotherapy noninvasive? The HHS report doesn’t define the term, but in medical contexts it is typically used to describe a procedure that doesn’t require inserting an instrument through the skin or into a body opening. It’s a silly word to use to describe psychotherapy. Clearly it is being used this way to emphasize it in contrast to the surgical procedures anti-trans advocates want us to associate with affirmation of trans youth (but are ultimately a minimal component of gender-affirming care for young people). Social gender affirmation, oral hormonal medications, and transdermal hormone patches are also noninvasive approaches to gender dysphoria, but the report only uses the term when discussing psychotherapy.

And as a therapist, my initial reaction to reading that line was to think “that psychotherapy is incredibly invasive” — not physically, but emotionally, psychologically, relationally. Effective psychotherapy involves intensive vulnerability and can lead to huge disruptions in a person’s life. I once had an analytically-trained supervisor tell me that if we did true informed consent to psychotherapy where we list all the possible impacts of it, few would ever ultimately seek it. Warning: may totally shift your understanding of self, alter perspectives on and needs from relationships, diminish ability to ignore dissatisfying conditions in your life, increase honest experience of difficult emotions, lead to development of complex feelings for provider, etc. And that’s in good and ethical therapy.

Bad therapy can be incredibly harmful. In recent decades, there has been a growing research focus on documenting adverse effects from therapy and understanding contributing factors. In a fascinating 2019 meta-synthesis in Frontiers in Psychology, researchers found that adverse effects include symptom exacerbation, development of new negative feelings, ceasing therapy in ways that impair future treatment and/or life, self-blame, self-hatred, doubt, and shame. Some of the contributing processes they found for these adverse effects were therapists pathologizing the client, therapists asserting power or control over client, therapist inflexibility, lack of trust between therapist and client, client deference to or fear of therapist, client goals not being met, and client identity not being attended to. (You may want to refer back to this list when I discuss so-called “exploratory therapy” later.) This review was focused on adult experiences, but we can imagine that the experience of youth in therapy echoes and even amplifies these findings given their particular vulnerability and reduced autonomy in the process.

And of course we have the well documented harms of gender identity change efforts.

Research on the Impacts of Gender Identity Change Efforts

We know that gender identity change efforts (GICE) are harmful. In their 2022 chapter on GICE, Drs. David Rivera and Seth Pardo state:

It is most important to point out that (a) the invalidation or rejection by others (e.g., families, therapists) of transgender identity and/or diverse gender expressions are forms of discrimination, stigma, and victimization; and (b) stigma, discrimination, and rejection are, in and of themselves, forms of external social harm that may become internalized and result in psycho-emotional harm. GICE causes harm by reinforcing anti-transgender stigma and discrimination and by creating social pressure on an individual to conform to an identity and/or presentation that may not be consistent with that person’s sense of self.

Every study I found that examined the relationship between gender identity change therapies and wellbeing found a negative relationship. Know that these are imperfect studies: for example, they rely on retrospective reports of the GICE and cannot alone establish causality. Still, the consistency is damning and suggests long-lasting negative impacts. For example, Mammadli and colleagues’ (2024) study using the U.S. TransPop survey data from 271 trans adults found that people who had experienced GICE had meaningfully higher distress levels on average and significantly more days with poor mental health in the past month than people who had not been exposed to GICE. They also found that trans people who had experienced GICE were more likely to have fears of experiencing stigma and negative outcomes in healthcare. Turban and colleagues’ 2020 study of nearly 28,000 adults found that adults who had experienced GICE were more likely to have experienced severe distress in the past month and to have attempted suicide in their lifetime, compared to trans adults who had talked to a mental health professional about their identity but had not been exposed to conversion efforts. Adults whose GICE exposure occurred before they were 10 did not show increased risk of current distress but did have higher rates of lifetime suicide attempts. Dr. Heiden-Rootes and colleagues’ (2021) study examined whether religiosity affected these relationships, and found that both religious and nonreligious GICE were associated with lifetime suicide attempts but only nonreligious GICE was associated with current severe psychological distress. That study also found that Black trans survey respondents were at increased risk of binge alcohol consumption if they’d been exposed to GICE. None of these studies seem to appear in the Psychotherapy section of the HHS report.

There are also many memoirs and qualitative studies in which people describe the damage of being in therapy or a program that tried to facilitate the dissolving of their gender identity. Common themes are the persistent sense that a person is inherently wrong, broken, and failing — both for their gender feelings and for the fact that the programs weren’t “working”: As one participant said in a study published in 2023, “[I had] that concern within me, that what I’m feeling is wrong, I’m broken, and this needs to be healed. […] But, [I was] never really getting any resolution [in SOGIECE]. It just created more turmoil within me.” Survivors of this kind of psychological violence also report long-term impacts of relational distrust, healthcare avoidance, diffuse shame, self-invalidation, persistent internalized transphobia, worsened gender dysphoria, and lost time. In that same study, a trans woman in her 30s whose GICE in youth was mandated instead of accessing the puberty blockers she had been seeking said, “I think of my body as a prison, because it was the conversion therapist’s deliberate inaction that forced me into a body that doesn’t fit me and that I’m going to be stuck in for the rest of my life.”

Interestingly, a recent Rand Corp-solicited peer-reviewed comprehensive review of the literature on pediatric gender dysphoria interventions cited in the HHS report found that all studies examining GICE outcomes found negative impacts on mental health, including suicidality. More on that report soon. It’s important.

Scrutinizing the HHS Conclusions and Data

So what gives?! How can the mystery authors of the HHS report state that there is “no evidence of adverse effects of psychotherapy in [the context of treatment for pediatric gender dysphoria]”?? Where are they getting their data?

So part of the disconnect here is that the HHS report is trying to say it is not promoting GICE or conversion therapies. In discussing that Rand systematic review and the systematic review led by York University researchers for the Cass Report, the HHS report states “For mental health outcomes, the certainty of evidence [of psychotherapy interventions] was very low. However, no harms were reported.” They strategically ignored the findings on GICE. But there’s a serious problem in their interpretation of the data — in their assertion that non-affirming psychotherapy can benefit youth with dysphoria. See if you can pick up where they’ve erred:

Here are the psychotherapy studies included in the Rand Corp review and the Cass Report review that the HHS report uses — systematic reviews which I should refer to by their lead authors, so: Dopp et al., (2024) and Heathcote et al., (2024), respectively. Here are the psychotherapy or psychotherapy-alike interventions included in the Dopp et al. (2024) review:

• Austin, Craig, & D’Souza (2018): Intervention was AFFIRM, an affirming CBT skills group. No harmful effects reported according to Dopp review.

• Becker-Heblet et al., (2021); Nider et al., (2021): Intervention was psychosocial and mental health support during diagnostic phase at a clinic while seeking medical intervention. Harmful effects reported by Dopp review: Multiple participants suspended treatment during the mental health support phase due to mental health concerns or distance from the clinic.

• Brandsma et al. (2022): Intervention was support group for co-occurring autism spectrum disorder and gender dysphoria (plus parent support meetings). Harmful effects reported by Dopp review: self-rated dysphoria increased.

• Costa et al. (2015): Intervention was psychosocial support and therapy while waiting for puberty suppression. No harmful effects reported by Dopp review, but the review noted these participants did not improve in psychosocial functioning as much as comparison group who received puberty suppression immediately without psychotherapy.

• Weinhardt et al. (2021): Intervention was “Pride Camp,” a 6-day group psychosocial intervention for sexual and gender minority high school students. No harmful effects reported by Dopp review.

• Kirchner et al., (2022): Intervention was viewing “It Gets Better” videos. No harmful effects reported by Dopp review.

The Heathcote et al. (2024) review is less robust and did not report outcomes for each study, but stated that none of the psychosocial interventions they evaluated had adverse effects. (This is actually a dubious claim. As S. Rudd pointed out in a comment on this post, the Lucassen et al. study actually found that many gender minority teens had very low completion rates and their change from baseline mental health varied considerably with some showing significant decreases in symptom scores.) Here are the psychotherapy or psychotherapy-alike interventions included in the Heathcote et al. review that weren’t included in Dopp:

• Bluth et al., (2023): Intervention was an online Mindful Self-Compassion for Teens group, using modified protocol with adaptations to accommodate transgender teens.

• Davidson et al., 2019: Therapeutic peer-support group at a gender clinic for youth. “Aims to explore young people’s difficulties in the context of their social systems and to provide concrete strategies to help them in their interpersonal relationships, prepare them for gender transitions, sustain hope and manage challenging emotions.”

• Hollinsaid et al., (2020): Intervention was the Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems.

• Lucassen et al., (2020): Intervention was an online CBT-based e-therapy program.

• Russon et al., (2022): Intervention was Attachment-Based Family Therapy with adaptations to be affirming and relevant to LGBTQ+ youth.

• Silveri et al., (2021): Intervention was Acute Residential Treatment (ART) including CBT, DBT, motivational interviewing, and additional therapies at the individual, family, and group level.

You should note two critical things about these studies:

1. The psychotherapy and psychosocial interventions were affirming.

2. Most of the studies did not include psychotherapy being offered as an alternative to medical intervention.

   1. Many studies explicitly stated that participants were also receiving gender-affirming medical interventions.

   2. The only two that did require psychotherapy or mental health support instead of medical intervention were conducted in gender youth clinics and designed as delay studies, meaning that the youth being studied were not denied medical intervention but had to have psychotherapy or mental health support first. Notably, contrary to the assertions in the HHS report, those two studies did have negative outcomes for the groups that had to wait for therapy. In one, researchers noted a number of dropouts during the mental health support phase because youth mental health wasn’t improving and in the other the group of youth who had to delay their medical care did not have the same amount of mental health improvement as the group that started medical care immediately without psychotherapy.

This all means that when the HHS report says that the evidence suggests offering psychotherapy as an intervention has no adverse effects they are referring to studies of psychotherapy approaches that directly violate what they are proposing. While they propose psychotherapy alone and psychotherapy that resists affirmation, the only studied psychotherapy interventions without adverse effects are affirming and did not preclude medical intervention. Psychotherapy approaches that delayed medical interventions and those that were classified as non-affirming gender identity change efforts all had documented adverse effects.

The unnamed authors of the HHS report are either incompetent at assessing the data or are deliberately misrepresenting it.

Is Psychotherapy for Gender Dysphoria Helpful?

Psychotherapy FOR Gender Dysphoria

Something we need to get clear here is whether we are talking about psychotherapy for youth who are experiencing gender dysphoria — a broad category of potential approaches, or psychotherapy for gender dysphoria — where the target is reducing or fully “resolving” the incongruence. The HHS report conflates these categories. None of the studies cited in the systematic reviews (that again, the HHS says they’re drawing from) seems to measure effects of the therapy on gender dysphoria or on gender identity consistency/change. When these reviews suggest there is some evidence for positive outcomes from psychotherapy interventions for youth with gender dysphoria, the outcomes they measured are psychosocial functioning, suicidality, anxiety and depression symptoms, etc. HHS misleadingly presents “positive outcomes” as though psychotherapy would address gender dysphoria directly — helping young people to “come to terms with their bodies.” The report and the systematic reviews the report cites include no study that has provided evidence psychotherapy can do this.

And again, we come to the issue of GICE and conversion therapy, which has been documented time and time again to be harmful and ineffective in its stated goals. The report’s mystery authors try to pooh-pooh away the notion that they are promoting conversion therapy. They state that “gender identity” doesn’t exist and so the issue of whether or not a therapy is trying to get a young person to change their gender identity is obsolete. As they write, “if gender identity is obscure, the goal of changing the patient’s gender identity is equally obscure.” Convenient.

So just to be clear. There is nothing in this report nor in the literature suggesting that there is a psychotherapeutic approach that can make a person’s gender dysphoria or sense of incongruence between their gender and their assigned sex go away.

Another risk of conflation: psychotherapy aimed at resolving gender dysphoria vs. psychotherapy aimed at reducing the distress and impacts of gender dysphoria. As I mentioned earlier, I am interested in psychotherapeutic interventions that reduce the extent to which people (including youth) are affected by their dysphoria. Contrary to the authors of the HHS report who do not believe in gender identity and want people to “come to terms with their bodies,” many of us affirming therapists want to help people better cope with the incongruences they experience between their genders and their bodies and/or between their genders’ and others’ impressions of their genders. We do want to improve therapists’ capacities to help with the distress related gender dysphoria — particularly in this context where the most effective interventions (medical and social affirmation) are becoming harder to access. Soon there will be studies showing that therapists can help with this, and many of us already do that in our practice. Do not allow these studies to be twisted to seem to prove efficacy of the very different kind of psychotherapy that HHS seems to want to mandate.

But Isn’t Exploration Good?

The HHS report mentions “exploratory therapy” as a way of describing psychotherapeutic alternatives to medical intervention for youth with gender dysphoria. I’ve been frustrated by this terminology for a long time. It reminds me of anti-abortion or forced-birthers calling themselves pro-life. If they’re pro-life, then the people who are against them must be anti-life. [Wrong, obviously.] If exploratory therapists are pro-exploring, then affirming therapists must be anti-exploring. [Also wrong.] It’s another false binary. Poke around conservative therapist facebook groups and forums and you will see this horribly misinformed accusation lobbed at affirming therapists repeatedly.

My clients, trans and cis and everything in between, might tell you they’re sick of how much exploring we do! I’m joking, but to emphasize that exploration — of deeper levels of affect, of avoided conflicts, of shame-filled ways of thinking, of traumatic pasts and their sequelae — is fundamental to how I practice psychotherapy. My work with trans youth is both affirming and exploratory.

I would argue that so-called exploratory therapy allows for far less true exploration and reflection than therapies that are rooted in affirmation and are fundamentally open to transness. If the unnamed authors of the HHS report want therapists to believe their assertion that gender identity isn’t real and think therapists should not accept that a young person can really have a gender identity that differs from their assigned sex, there’s a whole giant world of outcomes and reflections a young person could land on through exploration that these therapists would reject. Can you have true exploration if the person facilitating that exploration refuses to enter certain terrains or accept certain discoveries? I say no, you cannot. Florence Ashley (they/them) wrote an excellent paper critically examining the positioning and vaguely-defined approaches of exploratory therapy, highlighting practitioners’ use of conversion therapy components and lack of sound theoretical or practical foundation. One of the questions Ashley asks (in a list that everyone should read and I will paste at the end of this article) is “Do you consider self-identification as transgender more suspect or deserving of exploration than self-identification as cisgender? Why or why not? How is this reflected in gender exploratory therapy?”

The HHS report’s Psychotherapy chapter includes excerpts from two rather prominent critics of affirming psychotherapy — psychiatrists Stephen Levine and Robert D’Angelo — describing the approach to exploratory therapy they promote. Both excerpts highlight these men’s fundamental belief that gender dysphoria and trans people’s gender identities develop out of traumatic stress or other psychopathologies, a view echoed by the unnamed authors throughout this chapter. They argue that psychotherapy should unearth the pathology underlying a young person’s gender dysphoria and work to resolve that. If this sounds familiar, that’s because this is exactly the premise of many conversion therapies targeting queerness and same-sex attraction, too. The idea that you can change your sexuality by identifying a root trauma or mental health issue and addressing that has been debunked and abandoned by mainstream psychotherapy. There’s similarly no support for this premise as it relates to trans people and psychotherapy.

Yes, Psychotherapy for People with Gender Dysphoria Can Be Helpful

The mystery authors of the HHS report and I agree on at least one thing: “Psychotherapy for adolescents with gender dysphoria is a well-suited intervention, as it is intended to help patients develop self-understanding, engage with emotional vulnerability, and build practical strategies for managing distress.” Yes! I want more psychotherapy that helps young people with gender dysphoria (whether they are trans or exploring or feeling otherwise constricted by gender roles) develop self-understanding, engage with emotional vulnerability, and build practical strategies for managing distress. [I’m actually teaching a 5-day CE course on this on Cape Cod (and virtually) this summer.]

We do have empirical evidence that psychotherapy is helpful for young people struggling with gender dysphoria. The systematic reviews mentioned above did find some positive effects in the psychotherapy studies they evaluated. But again, those studies all examined affirming psychotherapy interventions and didn’t deny young people medical affirmation. Psychotherapists can help these young people cope with dysphoria and cope with oppression and related stressors. We can help them develop meaning and power and self-esteem, to grow more comfortable in all the corners of their consciousness, to express themselves in ways that feel authentic and values-aligned. We can help them identify their needs and support them in advocating for those. We can facilitate connection to community and history that helps them feel less alone. We can create spaces for them to engage with internal conflict and make sense of interpersonal relationships and all they stir up.

Trans youth and youth who think they might be trans are carrying so much right now. This world needs knowledgeable and compassionate psychotherapists who prioritize empowerment and can help these youth assert their developmentally appropriate autonomy, engage in explorations of their dynamic self-understanding, and build tools to make residual distress manageable. More psychotherapy for trans youth! More psychotherapy for youth with gender dysphoria! But none of the bunk being promoted by the HHS’ selective reading of the literature.

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Appendix: Florence Ashley’s Questions from “Interrogating Gender Exploratory Therapy”

Again, this is from Ashley’s excellent 2022 article in Perspectives on Psychological Science. You can read the whole article for free or listen to audio of Ashley reading it.

Their “Questions for Clinicians”:

1. What do you do if a client refuses to engage in gender exploration with you? Do you refuse them gender-affirming care, even if it may be necessary to their well-being?

2. How long does gender-exploratory therapy last? How do you know if it has gone on long enough? Do you go until you find a “root cause” of the client’s trans identity or gender dysphoria?

3. How do you distinguish, for example, trauma that caused someone to be trans from trauma that a trans person happens to have? Do you trust the client’s views? Would you equally trust clients’ view that their gender identity or gender dysphoria is and is not grounded in trauma? Why or why not?

4. If you conclude that trans identity or gender dysphoria is rooted in, for example, trauma, how do you assess whether this response is adaptive or maladaptive? How do you determine whether the person can safely and effectively be encouraged or helped to reidentify with the gender they were assigned at birth? Is there any evidence that gender-exploratory therapy is safe or effective?

5. If clients eventually come to identify as cisgender, do you wind down gender-exploratory therapy, or do you continue at a similar pace to ensure that their reidentification is genuine and not itself a coping or adaptive/maladaptive response? Why or why not?

6. Relatedly, do you consider self-identification as transgender more suspect or deserving of exploration than self-identification as cisgender? Why or why not? How is this reflected in gender-exploratory therapy?

7. Is it possible that the, for example, trauma permanently altered the person’s sense of self?

8. If the psychotherapeutic attempt to treat gender identity and/or gender dysphoria proves unsuccessful, would you consider recommending gender-affirming care? Under what conditions?

9. Do you see refusing to affirm someone’s expressed sense of self and experiences of gender as an appropriate response to individuals who may be experiencing trauma? Does nonaffirmation conflict with trauma-informed care’s emphasis on fostering clients’ sense of choice, empowerment, and acceptance (Levenson et al., 2021)? Do you think nonaffirmation poses risks of retraumatization?

10. Is there any evidence that gender-exploratory therapy leads to better outcomes, however you define them, than gender-affirming approaches? Is there any evidence that it can successfully identify youths who are not “truly” trans, whose identification is maladaptive, or who would be harmed by gender-affirming interventions?

11. Do you believe that gender-exploratory therapy can create psychological, social, and emotional pressures to reidentify with one’s gender assigned at birth? Do you believe that it can create pressures to misreport reidentification or alleviation of gender dysphoria? Do you believe that it can create pressures to identify specific factors, for example, trauma as a cause of trans identity or gender dysphoria?

12. Do you believe that gender-exploratory therapy can create pressures to lie, misrepresent, or otherwise engage in gender-exploratory therapy in bad faith to obtain gender-affirming care? Do you believe it can lead clients to suppress their doubts and worries and, as a result, make decisions regarding gender-affirming care that are less informed and thoughtful?

13. What do you make of the distress of the numerous youths who are “truly” trans, who will experience ongoing distress during gender-exploratory therapy, and who form a strong majority of individuals seeking gender-affirmative care? High-end estimates of detransition are around 3% (Brik et al., 2020; Narayan et al., 2021). There are some suggestions that up to 76% of people who detransition do not tell their clinicians that they have done so (Littman, 2021). Even if one assumes, for the sake of argument, that these upper-bound estimates are accurate, one is left with a large 88% of individuals who do not detransition. Detransition seems rare.

14. What pronouns and gendered terms do you use during gender-exploratory therapy? Do you use terms desired by clients or terms that reflect their gender assigned at birth, or do you avoid pronouns and gendered terms altogether? Do you see using terms reflecting the client’s gender assigned at birth as a neutral option? Why or why not?

15. Do you believe that transition-related medical interventions, such as hormones, can be offered in parallel to exploratory therapy either as a means of reducing current gender dysphoria and/or as a way of helping clients explore their gender identity and ascertain whether gender-affirming care is right for them? Do you think social and medical transition being temporary is an inherently undesirable outcome? Why or why not? Is this related to a belief that bodies that have undergone medical transition are less desirable and should be avoided if possible?

16. Given concerns that premature affirmation may foreclose gender identity and exploration and considering that puberty blockers arguably have far less of a foreclosing impact on gender than endogenous puberty, do you think that clinicians should offer and encourage puberty blockers for all questioning and even perhaps all cisgender kids? Would your answer change if you were absolutely certain that puberty blockers had no negative long-term side effects?