Here is a post I made on the WPATH listserv. 🧵 We are increasingly seeing references to exploratory therapy as a prerequisite to transition-related medical interventions. Oftentimes although not always, this is coupled with concerns that youths are transitioning due to trauma.
Or due to social pressure, or internalized misogyny and homophobia. Beyond the idea that potential ’causes’ of the trans identity should be explored, I have rarely seen extensive discussions of the parameters of exploratory therapy.
For those who practice it, I had a few questions. I acknowledge that they are leading questions, but hope you will nevertheless make a good faith attempt to answer them as fully as possible:
1. What do you do if the patient refuses to explore with you? Do you refuse them gender-affirming care, even if it may be necessary? 2. How long does the exploratory therapy last? How do you know if it has gone on long enough? Do you go until you find a ’root cause’?
3. How do you distinguish between, e.g., trauma that caused someone to be trans and trauma that a trans person happens to have? Do you trust the patient’s beliefs? Would you equally trust a patient’s view that it is not grounded in trauma?
4. If you find that self-identification is rooted in, e.g., trauma, how do you assess whether this response is adaptive or maladaptive, and whether the person can safely be encouraged or helped to reidentify with the gender assigned at birth?
If this proves unsuccessful, would you ever consider recommending access to gender-affirming care? Under what conditions?
5. If a patient re-identifies as cisgender, do you wind-down the therapy or do you continue at the same pace to ensure their re-identification is genuine and not a coping or adaptive 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 exploratory therapy?
7. Is there any evidence that exploratory therapy leads to better outcomes, however you define them, or that it can successfully identify youths who aren’t ‘truly trans’, youths whose identification is maladaptive, and/or youths who would be harmed by medically transitioning?
8. 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 present gender dysphoria or as a way of helping the individual explore their gender […]
...and whether gender-affirming care is right for them? Do you think transition being temporary is an inherently undesirable outcome? Why or why not? Is this related to an intuition that bodies that have undergone medical transition are less desirable and should be avoided?
9. What do you make of the distress of the numerous youths who are ‘truly’ trans, who we have reasons to believe are a strong majority and will experience ongoing distress during ?
Based on the recent Littman study, the high end of non-disclosure of detransition to clinician is around 75% and the high end of detransition estimates is around 3%. Even assuming the correctness of these higher bound estimates, we would still have 88% not detransitioning.
9. Given your concern about precipitated and premature affirmation as a foreclosure of gender identity and exploration, what are your thoughts on encouraging puberty blockers more broadly to all questioning or even perhaps all cisgender kids?
Would your answer change if we were 100% certain that puberty blockers had no long-term side effects?
10. Do you believe that such exploratory therapy can create psychological and emotionally pressures to re-identify with the gender they were assigned at birth?
11. Do you believe that such exploratory therapy can psychological and emotionally pressures to lie, misrepresent, or otherwise engage in the therapy in bad faith so as to ensure access to sought interventions?
Do you believe this could lead patients to suppress doubts and worries and, as a result, make less-than-informed decisions on accessing gender-affirming care? Thank you ahead of time for your answers.
In the interest of transparency, here are my views on the matter:
journals.sagepub.com/doi/full/10.11…
And:
jme.bmj.com/content/45/7/4…
