By Jesse Singal

With the number of referrals to the UK’s only gender identity development service (GIDS, at the Tavistock and Portman NHS Trust) increasing sharply in recent years – a pattern seemingly mirrored in other European countries and the US (anecdotally, at least — many countries don’t keep comprehensive data the way the UK does) – debate has inevitably intensified over how best to help transgender and gender nonconforming (TGNC) youth. As some expert clinicians have pointed out, there has been a tendency for commentators, campaigners and the general public to adopt an oversimplified view in which therapists are seen as fitting one of two categories: those who don’t believe their clients when they say they are trans (and who are therefore condemned by trans advocacy groups for practicing conversion therapy), and others who simply accept their clients’ statements about their gender, and who are therefore affirming or affirmative.

The clinical reality is more complicated: these days, there is a welcome consensus against actual conversion therapy — forcing a young person to “go back” to being cisgender — but at the same time responsible clinicians do not simply nod along to what a young person with gender dysphoria says. There are complexities inherent to childhood and adolescent development, and many experts warn it’s important not to accidentally medicalise perfectly normal qualms about growing up, hitting puberty, and being exposed to powerful and often frustratingly restrictive gender roles. Young people present at gender clinics with a wide variety of issues ranging from comorbid mental-health issues to unexamined trauma, and the process of helping them determine the best path forward, particularly with regard to medical interventions like puberty blockers or cross-sex hormones, is a lot more complicated than making a rapid decision to deny or approve such interventions.

Indeed, in an open-access practice review published in the BMJ last year, clinicians at UCL, GIDS and Great Ormond Street Hospital explained that the thorough psychosexual assessment period for such clients “usually takes 6 months or more over a minimum of four to six sessions” and involves a range of psychometric measures and interviews, covering the client’s expectations and understanding of social and physical transition, their mood and emotional functioning. The review adds that, “With the adolescents, there is an in-depth consideration of their sexuality and fertility, and possible preservation approaches are discussed. The attitude of important people in the child’s life towards gender dysphoria needs to be explored and understood.”

Now a study published in Psychology & Sexuality by a pair of Norwegian researchers, Reidar Schei Jessen and Katrina Roen, has explored these complexities from clinical psychologists’ perspective, including what it means to help a young person work through the issues they are facing and to make important decisions about medical treatment.

For the study, “Five clinical psychologists working with gender non-conforming youth in an interdisciplinary team at a specialized gender identity clinic in Europe participated in interviews.” In reading their work, I was struck repeatedly by how similar their experiences were to what I heard when I spoke with American clinicians for an in-depth article about transgender youth for The Atlantic. For example, Jessen and Roen write that “Sometimes the clients themselves want to transition, but sometimes the possibility seems driven by the family or others in the young person’s life, such as school staff.” The pair include a poignant example of this:

One young person I worked with […] was referred by school. Biological male, who presented in very… like stereotypically… call it female clothes, like pink and yellow, long hair. Often was read as female, and the school didn’t know what to do with the young person. But when I met the young person, the young person didn’t have any issues with the body or […] developing in a masculine way. So all, so I was kind of again looking at where the stress lies, and it was really in the separation or gender division at school […] and they would ask him to cut his hair short, because he is a boy […] and I think in my report I wrote that… you know, I would really advise you not to address… the pupils as girls and boys, but just call them pupils, students. (Participant C)

I didn’t come across any examples quite so dramatic in my own reporting, but this was a common general storyline: I noted that “Several of the clinicians I spoke with, including Nate Sharon, Laura Edwards-Leeper, and Scott Leibowitz, recounted new patients’ arriving at their clinics, their parents having already developed detailed plans for them to transition. ‘I’ve actually had patients with parents pressuring me to recommend their kids start hormones,’ Sharon said.”

Kids who are gender nonconforming often make adults uncomfortable, and in some cases one way adults attempt to dispel this discomfort is to push for transition. “The [clinical psychologist] participants have the impression that sometimes the school or family expect these young boys to transition to girls,” write Jessen and Roen, “because they do not want them to be feminine boys. This illustrates how difficult it can sometimes be to understand which expectations belong to whom, and how gender non-conforming youth can be referred to the clinic by adults who hold the opinion that gender non-conformity is a problem to be addressed clinically.”

Similarly, as I wrote in my Atlantic article, clinicians told me about instances in which “the child might be capably navigating a liminal period of gender exploration; it’s the parents who are having trouble not knowing whether their kid is a boy or a girl.” Sure enough, this theme of pressure to choose a gender ‘side,’ too, popped up among the Norwegian clinicians:

Participants were concerned about the possibility that binary gender norms force gender non-conforming youth to become “the opposite gender,” instead of allowing them space to explore their unique gender expression. According to the clinical psychologists interviewed, many clients and families believe that gender is binary, and that there are only two gender identities. This belief does seem to influence clients’ expectations of outcomes, and may encourage them to seek physical treatment at the expense of exploratory work. According to the participants, many clients and their families experience societal and community pressure to conform to gender norms.

Exploration and nuance and liminality are key concepts that come up over and over again in interviews with experienced youth TGNC clinicians. But it can be challenging to tell a child who is in distress, or his or her parents, that it’s worth taking a bit more time to explore before proceeding to physical interventions or making other major decisions about transition — perhaps doubly so given the belief in some quarters that “exploration” or “therapy” are near-synonyms for “transphobia” and “conversion therapy.”

As “Participant B” told the researchers, “Not surprisingly, exploratory strategies can be aggravating to clients and families. We are always very subject to this discourse of the bigot […] this idea of you know transphobia […] so people that are bigoted are very narrow-minded […] this is where then you know the power that we then have starts to really create lots of tension and problems.” That is, at the end of the day, clinicians stand between young people (and their parents) and medical treatments they feel they need, so it’s an understandable reaction for delays caused by responsible, thorough clinical work to be misread as transphobia. This tension was partly what motivated last year’s practice review in the BMJ: “Faced with very distressed young people, they [clinicians] may feel under pressure to initiate physical intervention without consultation with psychosocial colleagues,” the review states.

If gender clinics in three very different countries with three very different healthcare systems are experiencing the same sorts of scenarios over and over, that’s a signal that everyone should try to better understand what’s going on. Many of the young people mentioned in this study likely will, in the long run, benefit from puberty blockers and hormones. But some won’t — their gender exploration will lead them elsewhere, whether or not they come to identify with their biological sex. It’s important to understand what separates these two groups, and scientists have only barely begun to do so.

—Balancing in the margins of gender: exploring psychologists’ meaning-making in their work with gender non-conforming youth seeking puberty suppression

Post written by Jesse Singal (@JesseSingal) for the BPS Research Digest. Jesse is a contributing writer at BPS Research Digest and New York Magazine, and he publishes his own newsletter featuring behavioral-science-talk. He is also working on a book about why shoddy behavioral-science claims sometimes go viral for Farrar, Straus and Giroux.