An alternative to gender transition
The recently published Cass Review in the United Kingdom highlights the tumultuous debate surrounding gender-related distress and how to best provide professional support, particularly with young people. A little more than a year ago, Utah prohibited pharmaceutical and surgical transition for minors, following the lead of several other states and countries that have banned or severely curtailed these treatments for minors. At the same time, other states and countries have moved in the opposite direction, expanding access to these treatments and disciplining those who publicly oppose them. What is to be done? And what about the vulnerable young people and their families caught in the middle?
We agree with Dr. Hilary Cass when she urges clinicians and others on all sides to stop vilifying each other and instead engage in open, respectful debate about how to best conceptualize and treat gender distress. She describes the difficulty clients and families face in finding timely therapeutic support, and the need for clinicians to provide sensitive and cautious care to developing youth.
Yet research in this area is controversial and often generates seemingly contradictory conclusions. Sincere and caring providers come down on different sides of this issue and disagree, sometimes bitterly. While we respect the skills and devotion of medical providers, we believe, based on our own values and our understanding of the scientific research, that psychological and family therapy — without the inclusion of medical and social transition options — is the best treatment approach, especially among young people.
It seems research supporting our position is growing, as is skepticism about the benefits of transition. Recently, England’s National Health Service gender clinic, known as the Gender Identity Development Service, published a study on the effects of puberty blockers they had been administering at the clinic for eight years. The study reported that there was no improvement in psychological function among the young people undergoing this treatment.
A deeper analysis by an independent researcher showed a more nuanced finding: roughly one-third of patients got worse, one-third stayed the same and one-third improved in their psychological function — accompanied by all the medical risks entailed in prolonged use of puberty blockers, including reduced bone density, height, infertility and stunted brain development. As a result, England has seriously curtailed these treatments for young people.
For years, the loudest voices have assured distraught parents that social transition, puberty blockers and cross-sex hormones are safe and easily reversible and provide such dramatic mental health benefits as to be “life-saving.” While some research suggests that these social and medical efforts sometimes improve client well-being, other research indicates that little to no benefit is derived from these interventions. Additionally, puberty blockers are often the first step in a more invasive and permanent transition process that includes cross-sex hormones and surgery.
Despite these side effects and questions over benefits, parents who do not believe medicalization is the best treatment route for their child sometimes feel pressured to travel down the medicalized pathway against their intuition. We believe psychological and family-centered treatments have much to offer gender-distressed clients and their families, and that we don’t need to reinvent the wheel — we just need to use it with this population. Regular, family-centered therapy can be used to promote strong relationships, body acceptance and authentic living.
As independent family therapists, we came together during the debate and passage of Utah’s HB40 law restricting medicalization and surgery for minors. We supported the law, but also understood that families would need more support than ever. The distress and anguish these young people and their families feel is real, and their need for support and effective treatment is great.
We recently founded the Gender Harmony Institute to implement best practices of regular, time-tested therapy in treating this population and pairing it with solid research that monitors the well-being of our clients even after they terminate treatment with us; follow-up is all too lacking in this area where there are still so many unknowns. We recognize that not all clients and families will want or will respond to treatment that is limited to psychological and family therapy. In these cases, we will flexibly adjust treatment interventions according to client responsiveness and well-being. If clients desire support for legal, social and/or medical transition, we will refer them to professionals to help them in these areas, while continuing to support their overall well-being.
Additionally, our nonprofit model allows us to receive grants and donations to provide subsidized care to a growing population that sometimes lacks economic means. For maximal impact, Gender Harmony Institute also plans to disseminate what we are learning through training and certification programs directed at other clinicians, parents and schools. We’re gathering caring providers in Utah and around the country to apply well-established and empirically validated psychological and family treatments for gender-related distress.
Our clinic’s treatments are based on time-tested theories and methods such as developmental psychology, attachment, cognitive behavioral therapy, family systems, social learning, minority stress, mindfulness and more. These methods help parents discover additional ways to provide warm and steady support while also setting boundaries and honoring their own and their child’s integrity. They assist families in being more open and becoming better at disagreeing. They also allow for gender nonconformity and authenticity in the ongoing process of reconciling sex and puberty with social expectations, individual temperament and life goals.
Three examples of clients we have treated demonstrate the power of this approach:
1. A teenage girl told her parents that she “really is a boy.” At first, she thought the only way to deal with her gender-related distress was to socially transition. She was highly anxious and vacillated between shutting down and becoming angry when talking to her parents about her experience.. We supported the family in strengthening their connection, accepting her experience of same-sex attraction, and navigating the challenges of female puberty. Now, she has far less anxiety about her relationship with her parents, her body and her sexuality, and happily identifies as a gender-nonconforming girl.
2. A young adult woman came in because her parents suggested that therapy would be helpful as she makes steps toward medicalization. Through therapy, she realized where some of her anxieties were coming from — difficulties fitting in with others in the past, neglect as a child, a strained relationship with her parents and difficulty maintaining employment. While she still feels unable to fully accept her body, she is more confident, has better relationships with her friends and parents, and is able to tolerate work she does not fully enjoy. She also has a better understanding of the risks and the reasons why she is choosing a medical pathway.
3. A teenage boy came to therapy at the insistence of his parents after he announced that he “is a girl.” He is autistic and had been struggling with his mental health and peer relationships. Through therapy, he noticed that he started thinking he was transgender when he was experiencing a depressive episode. We supported him in learning to better communicate with friends, regulate his emotions and engage in self-care — getting enough sleep, having a healthy relationship with tech, spending enough time outside and staying active. Now, he says he doesn’t think about gender very much, and focuses most of his energy on building healthy relationships and taking good care of himself.
These examples demonstrate the value of taking a comprehensive, family-focused approach to gender-related distress. There are a variety of professional options to support families facing this complex experience, and there is always opportunity for families to strengthen their relationships — even when strong disagreement persists. We invite clinicians, gender-related distress patients, families and community leaders to partner with us to support families and clients by helping them strengthen their relationships, accept their bodies and live authentically.
Chelsea Johnson, M.S., is a licensed marriage and family therapist and president of Gender Harmony Institute. David Haralson, Ph.D., is a licensed marriage and family therapist and approved supervisor and clinical director of Gender Harmony Institute. Jeff Bennion, M.S., is a licensed marriage and family therapist and vice president of Gender Harmony Institute.