Are you a trans-hostile therapist?
Healthcare Counselling and Psychotherapy Journal, April 2024

At the Conservative party conference in October last year, Rishi Sunak, the Prime Minister, made clear his views on gender. He told the audience: ‘We shouldn’t get bullied into believing people can be any sex they want to. They can’t; a man is a man and a woman is a woman. That’s just common sense.’¹

The comments were greeted with loud applause and cheers by the audience. On social media, a familiar wave of fear and distress rippled through the trans community and its allies. 

It isn’t unusual for trans people to be used as a political football, but there was something particularly disturbing about this occasion. It’s one thing to hear these sorts of sentiments ‘shouted’ at you on social media; it’s something very different to have the most powerful politician in the country espouse such antagonistic views, to such a raucous response, on such a public platform.

The Prime Minister was not the only person to set out his opinions on transgender people at the conference. The Health Minister, Steve Barclay, announced plans to ban transgender people from being admitted to single-sex wards in hospitals.² Trans people would instead be moved into private rooms or forced to suffer the humiliation of being placed in the wrong ward, calling attention to their trans identity.

Over the past few years, we have also seen legal challenges to the use of internationally accepted trans-affirmative medical care for trans children and young people, which is now being positioned as experimental or controversial.³ 

Public attitudes 

It seems that those in power are determined to roll back the progress that has been made over the past decade. Worryingly, data from the National Centre for Social Research show that this shift is also reflected in public attitudes towards transgender people; not only is hate crime rising year on year (for trans people as well as for other marginalised folks) but general attitudes towards transgender people are also becoming less supportive and more hostile.⁴ 

As practitioners, I invite us to consider the impact of this increasingly hostile rhetoric on how we show up and engage with these topics with our clients. How does this relentless attack on the legitimacy of the trans experience filter down into the minutiae of practice? 

Trans experiences are not inherently more political than cis experiences (cisgender being the antonym of transgender). But what happens to us when wider culture continually suggests that trans people are a talking point, a subject of debate, rather than living, breathing, feeling, autonomous individuals? 

As a transgender man and psychotherapeutic counsellor in private practice, mainly working alongside transgender, non-binary and questioning people, I’ve seen first-hand the impact of the so-called culture war on the mental health, happiness and stability of trans communities. It also feels necessary to acknowledge the disproportionate level of hostility and derision directed specifically towards transgender women and transfeminine people. 

Many people in these/our communities experience a profound fear that the healthcare they rely on will not exist in the coming years. They also worry that services are being de-funded, to the point where they might be left with unfinished surgeries. They would then have no alternative but to pay for private care, something that is unaffordable for most people, especially in a cost-of-living crisis. 

It also seems to me that this hostility towards the legitimacy of trans people is seeping into the therapeutic community. I have been engaged with delivering inclusion training to both practitioners and organisations over the past six or seven years – and there has recently been a palpable shift in the tone of the conversations. 

What used to feel like an open-hearted curiosity and a fear of saying the ‘wrong’ thing, causing harm or upset, now seems to have morphed into something quite different. I have noticed an increase in the number of people who are openly hostile and critical of trans experiences.

If hostile attitudes are slowly being normalised, what does this say about our engagement with the core conditions or our ethical responsibility to, at the very least, do no harm to clients? Is institutional hostility seeping further into our practice? 

The change in attitude is evident in the debate about conversion practices (not conversion therapy, as it would be a mistake to call these practices therapeutic). 

The Conservative Government pledged to ban conversion practices in 2018. But the legislation has been beset by delays. There was also an announcement in 2022 that transgender people would be exempt from any ban, with the suggestion from some therapists that a ban would prevent therapists from exploring the ‘root cause’ of trans identity, such as trauma, internalised homophobia or social contagion.⁵ 

Minoritisation 

It is important to note the multiple intersecting forms of minoritisation here, as people of colour are disproportionately more likely to have been offered or have undergone conversion practices.⁶ 

The Government has since declared that the ban will cover all forms of conversion practices, including those aimed at transgender people. However, the bill has yet to be published. 

The ‘exploratory’ approach is put forward by some as a neutral ground between conversion practices, which might be seen as unethical, and gender-affirming care, which is positioned as ‘radical’.⁷ However, in their paper on the subject, Florence Ashley⁵ comes to the conclusion that they can see no discernible difference between exploratory practice and conversion practice. 

The conclusion is important, because we know not only that conversion practices are unsuccessful in their attempts to change someone’s sexual or gender identity⁸ but also that they cause profound and long-lasting harm. Gender exploratory therapy seeks to find a pathological root of trans experience and, as Ashley notes,⁵ the coining of gender exploratory therapy coincides with broader attempts to criminalise gender-affirming care in America.

The philosopher EM Hernandez⁹ offers an antidote to the suspicious, paternalistic stance posited by the gender exploratory approach, explaining that we should attend to people on their own terms, with an approach of ‘loving attention’ to our clients. 

Interestingly, I’m noticing an increasing number of therapists who are no longer afraid of saying the ‘wrong’ thing, but are conversely afraid of saying the ‘right’ thing, in a way that might be too affirming. In other words, therapists are afraid that an eagerness to support a client who thinks they could be trans might lead the client into believing they are trans, when they aren’t. 

They fear that speaking about gender transgressions in a way that is not suitably critical or suspicious might be doing clients a disservice or even causing harm. I find this way of thinking fascinating. And while I can understand the need to acknowledge the inherent power dynamic in the therapeutic relationship, and the risk of unduly influencing a client who we might feel is vulnerable, this is a fear that deserves some unpacking. 

It's worth remembering that, by the time a client comes to see you about gender incongruence or dysphoria, they have more than likely been trying to manage and make sense of these feelings for many years, often (but not always) to the point of despair. It might feel like a new enquiry to you, but it will certainly not be a new enquiry for the client, even if it is a new experience to share these thoughts out loud. 

I’d also invite you to consider how often you think you have convinced your clients that something about them was true, even when you felt strongly about an interpretation or felt the pull to give them advice in some way. It is worth noticing here the danger of falling into a paternalistic way of thinking which, if we are committed to working anti-oppressively, we must engage with and resist. 

I wonder whether this fear arises from the therapist’s fantasy of being all-knowing and all-powerful. Again, I’d invite you to consider whether, even at your most vulnerable or distressed, someone could have convinced you to sign up to a five-year waiting list, undergo daily, weekly or monthly hormone therapy and endure invasive genital surgery. 

Perhaps the fear of convincing a client they are trans might be understood as projective identification. Trans people are acutely aware of the need to prove themselves and present a coherent narrative that will satisfy those around them that they are truly who they say they are. 

As therapists, we might feel under pressure to offer a succinct, clear formulation with proof of our ‘working out’, while feeling uncertain and indecisive – the same pressures the client might be holding, when trying to understand and explain their gender to you. As a psychodynamically trained practitioner, paying attention to – and working with – transference, projection and countertransference here are crucial.

The fear might be complicated by the fact that trans people are also influenced by narratives that are presented in popular culture, which can lead clients to reach for stock phrases, such as: ‘I was born in the wrong body’ or ‘I used to like playing with dolls rather than trucks when I was little’. It is not necessarily a full and accurate picture of their gender, but this is the language they have available to them to understand their gender – and it might also be the language that they know you will understand as their therapist. 

Limitations of language

It is necessary, therefore, to hold in mind the limitations of language when trans clients are attempting to explain something profoundly personal, something we might not even be able to find the words to describe. 

I also wonder whether this fear of convincing a person they are trans is connected to the wider narrative that transgender people are confused and vulnerable, that transitioning can be done on a ‘whim’ or that people are ‘becoming trans’ because they are susceptible to surrounding influences. 

I can understand how this fear might have crept into the minds of therapists engaged in this work. International discourse around trans lives, particularly around trans children and young people, has swirled with talk of social contagion and rapid onset gender dysphoria (ROGD). 

But Ashley¹⁰ describes ROGD as a ‘... politicised pseudo-diagnostic category’, which ‘... reflects a deliberate attempt to weaponise scientific-sounding language to dismiss mounting empirical evidence of the benefits of transition for youth’. In spite of this, ROGD was, for a time, widely embraced by the scientific community as evidence against the legitimacy of the experiences of young trans people. 

Given the popularity of these pseudo-scientific theories, I’d like to suggest here that, instead of trans people being too suggestible, it might, in fact, be trans-hostile therapists who are being disproportionately influenced by wider antagonistic discourses about the legitimacy of trans experiences. 

To help us make sense of this, we might look to Rachel Hare-Mustin’s, Discourses in the Mirrored Room.¹¹ Hare-Mustin describes the permeable boundary between the outside world and the therapy room, stating that therapists are not immune to the cultural and political influences that shape the lives and internal worlds of our clients, as well as therapeutic approaches. 

There were three and a half times as many articles on transgender people in the national media in 2018-2019 as there were in 2012 – and the vast majority were anti-trans.¹² As a trainer, I can see the influence of the hostile landscape on the approach of therapists to working with trans clients. It inevitably impacts the questions and curiosities we bring to the therapy room. 

Conversely, it seems fair to mention that it might indeed be possible to be too affirming, in a way that shuts down exploration of more difficult or disowned parts of the client’s internal world. It is necessary to integrate conflicting parts of the client, as they will almost certainly hold many different feelings about their gender, and even about medical transition. 

I would like us, as practitioners, to move away from an expectation that someone has to be 100% sure about their gender before they take steps to transition, or even that they must identify wholly with the term transgender. 

We must be careful about imposing unrealistic expectations on our clients to always experience gender euphoria after or during transition, to be wary of the ‘happy ever after’ story. They should also be wary of the promotion in the media of people who have ‘failed’ in transition, and who detransition (or retransition) to live as the gender they were assigned at birth, as some kind of warning about the risks of transitioning ‘too quickly’ and ‘getting it wrong’.

In my experience, although there is an increase in hostility towards trans clients, the vast majority of practitioners I have met are overwhelmingly supportive of the trans community, and demonstrate a curiosity that is not ‘othering’, paternalistic or fetishising. Instead, it seems to come from a genuine desire to demonstrate a profound level of care towards a consistently marginalised population. 

I think we can get around many of the fears about working with trans people by first acknowledging that being transgender is not a worst-case scenario, that transgender people are and can be happy, experience joy and euphoria in their bodies and genders, and that transgender people will exist whether we believe them to or not.

They will exist whether they are forced to be treated in a single-sex ward that doesn’t align with their gender or sex characteristics, post transition. They will exist whether our approach is affirmative, exploratory or actively harmful. Expelling transgender people from single-sex spaces, or subjecting them to prolonged therapy in an attempt to find a pathological root of their gender incongruence, does not disappear the trans community; it only makes their lives harder. Either way, they will continue to exist. 

What we can do instead is be alongside our clients while they make small, but simultaneously life-changing, steps towards living in a way that is more truthful, peaceful or perhaps simply less painful than before. 

In my own practice, I care deeply about creating not just affirmative therapeutic experiences but also a gender-expansive practice that breaks apart our colonially enforced, binary notions of what gender is and how it should feel and look. 

We can track our current understandings of gender and sexuality back to the era of empire and colonial expansion. Colonialism attempted to wipe out diverse expressions of gender and sexuality, and violently replace them with white, Western ideology, backed up by newly-formed, pseudo-scientific principles, such as phrenology or, indeed, the idea of separate races. 

Instead, I’m excited by moving towards a more decolonial framework that is critical of the ways we expect gender and sexuality to show up in our clients, in ourselves and in society and culture at large. 

Of course, gender wasn’t invented by the colonists. But I believe that understanding the origins of the violent enforcement of the gender binary – and working to actively challenge and undo those restraints – are vital next steps in moving towards a society that celebrates all types of gender-expansive experience, for both cis and trans people alike.