Elia Cugini investigates the ways in which the Cass Review recommendations diverge significantly from widespread professional recommendations around trans healthcare, as well as discussing the ways this aligns much more closely with a movement for psychological "resolution" of gender dysphoria that so far shows no evidence of success and raises significant concerns about harm.
In the wake of the publication of the Cass Review, the role that ‘therapy’ plays in trans healthcare – both the practical administration of therapeutic paradigms for trans youth, and the fraught invocation of ‘therapy’ as a way to resolve gendered distress – requires fuller treatment. Courses under the banner of ‘therapy’ may aid trans youth, stall them from transitioning for months or years,1 or actively attempt to detransition them (conversion therapy). Meanwhile, those hostile to transness often approach transness as a ‘mental illness’ which requires curative (conversion) therapy, and their perception of trans care assumes those terms. As such, unpicking the Cass Review’s model and guidelines around the therapeutic treatment of trans youth to identify potential sites of harm is essential.
It is widely accepted that gender transition, both social and medical, is an effective treatment for gender dysphoria2,3,4,5, and WPATH recognises hormone therapy and gender-affirming surgery as ‘medically necessary gender-affirming interventions’ for many patients in the latest edition of its care standards (2022, p.18). Various kinds of therapy can also be useful to, and sought by, trans individuals; WPATH advocates psychotherapy as potentially beneficial for trans patients, particularly for anxiety symptoms, but recommends that it should not be mandatory to access gender-affirming care, saying that this can act as a ‘harmful barrier’ (2022, p.176).
However, almost all trans youth in the UK are currently blocked from accessing medical interventions; the NHS UK page on dysphoria states that ‘psychological rather than medical’ treatments for children are advocated ‘because in many cases gender variant behaviour or feelings disappear as children reach puberty’, while treatment with hormone therapy must be prefigured by ‘lasting signs’ of gender dysphoria.6 Given the removal of access to puberty blockers for minors outside of a research protocol,7 therapy is part of a protocol here – alongside the standardised enforcement of natal puberty – that seeks primarily to test dysphoria, to see if it will or can resolve into “ease with your biological sex”.8
The Cass Review9 names the lack of pubertal resolution of dysphoria as a potential ‘harm’ of early social transition, saying that early social transition may result in an ‘altered trajectory’ that culminates in ‘life-long medical intervention’, losing the opportunity for dysphoria to ‘resolve at puberty’ (Cass 74, p31). The desirability of ‘resolution’ of dysphoria reveals the conflict at the heart of the term: ‘resolving dysphoria’ can both mean transition and the disappearance of ‘gender variant behaviour or feelings’, and the negative mention of ‘life-long medical intervention’ positions option 2 as superior to option 1.
Accordingly, the explicit desirability of dysphoria ‘resolution’ heavily impacts the possibility of a neutral therapy paradigm. This is a key issue noted in discussions of gender-exploratory therapy, a paradigm that opposes the gender-affirmative model in ‘discourag[ing] gender affirmation in favor of exploring through talk therapy the potential pathological roots of youths’ trans identities’10 – a paradigm clearly relevant to Cass both in its recommendations to heavily restrict puberty blockers and hormones (Cass 84, Cass Recommendation 8) and discourage full social transition (Cass 12.37), and its interest in potential ‘pathological roots’ of dysphoria, such as its comment that ‘at the end of a treatment package for BDD [body dysmorphic disorder] some young people say they no longer feel ill at ease with their birth-registered gender’ (Cass 5.38), or its comments on the high incidence of autism in trans youth and its suspicions regarding their ability to discern generalised feelings of difference from gender dysphoria (Cass 2.9, 5.41, 5.43, 8.29, 14.23).
Gender-exploratory therapy as a paradigm mandates gender exploration rather than offering it, occurs before rather than alongside medical options (and potentially vets suitability for said medical options), and is “predicated on suspicion toward trans identities and gender dysphoria”10. Cass does not specifically mandate psychotherapy for patients, though autism and mental health screenings may be mandated at point of entry (Cass Recommendation 2), but ‘[e]xploration’ of ‘psychosocial challenges and/or mental health problems’ is stated by the review as ‘essential to provide diagnosis, clinical support and appropriate intervention’ (Cass 11.5) – meaning that NHS transition care is locked behind some level of ‘exploration’ – and ‘suspicion’ of youth dysphoria is covered by the aforementioned prioritisation of ‘resolution’. Patients are likely to engage inauthentically with therapy that is, in practice, assessing their performance, as the Review itself acknowledges (Cass 11.11). As such, gender-exploratory therapy cannot effectively provide authentic exploration to trans patients, is likely compromised in its ability to provide relief, and may be amicable to explicit attempts at encouraging desistence. The connections between gender-exploratory organisations and hostility to transness are well-evidenced: Therapy First – formerly the Gender Exploration Therapy Association – links entirely trans-hostile resources in its guide for parents and families,11 and explicitly endorses the trans-hostile concept of ‘Rapid Onset Gender Dysphoria’,12 despite CAAPS and 61 other associations recommending the concept be ‘eliminated’ from clinical and diagnostic application.13
The Cass Review criticises psychological interventions in trans youth care being likened to conversion therapy, and the potential of this critique to ‘prevent young people from getting the emotional support they deserve’ (Cass 11.6). But the onus is on clinicians and policymakers, not critics, to evidence that their therapeutic paradigms are providing ‘emotional support’ to trans youth, that such a thing is meaningfully possible within a mandated exploratory model that bars most trans youth from medical care, and that conversion practice is being directly advised against and prevented, rather than passively assumed to not be present. ‘No formal science-based training in psychotherapy, psychology or psychiatry teaches or advocates conversion therapy’ (Cass 11.7) is a woefully insufficient response to the obvious threat posed by therapy paradigms that are amicable to transphobic hostility.
In addition to this, research into detransitioner communities can shed light on how cultural ideas around dysphoria therapy translate to self- and community-guided practice, and how inextricable therapeutic ‘alternatives’ to transition are from explicitly transphobic conversion rhetoric. ‘Detransitioner’ broadly describes people who stop or reverse gender transition, be that socially, medically, surgically, or legally,14 though the term is not synonymous with a return to cisness, with many detransitioners continuing to experience forms of dysphoria and gender dissonance15. Detransitioner communities are notably invested in dysphoria treatments outside of transition, as many describe continuing to experience dysphoria. However, detransitioners’ own community resources make clear how the idea of ‘therapeutic alternatives’ to transition relies heavily on rejecting the reality of transition.
A 2021 pamphlet, created by two detransitioners and based on interviews with 75 more, includes a section on ‘alternative ways to deal with gender dysphoria’, collating resilience strategies to ‘handle […] bodily discomfort’.16
The methods cited are:
a) various forms of therapy for other conditions that they believe could be ‘underlying issues’ behind dysphoria (p. 41).
b) generalised therapeutic activities like ‘mindfulness’, ‘working out’, ‘self-soothing talk’ and ‘journaling’ (p. 41).
c) finding community (p. 44).
d) ideological rejection that transition is possible, which they phrase as “full acceptance of one’s biological reality” and the belief that it is “rationally impossible to change [one’s] sex” (p. 42).
This rejection of transition is implicit in the pamphlet’s conception of self-acceptance and ‘feminist consciousness’, which are premised on “being a woman does not require anything else than being female” (p. 43): the rejection of gendered stereotypes is falsely implied to rely on transphobic sex essentialism. Formalised detransitioner organisations, such as TDAN, Detrans Canada, Detrans Voices and GCCAN (all now-defunct) near-universally express the belief that sex change is not possible, reject established science on transition effectiveness, and partner with openly trans-hostile organisations such as TransgenderTrend and 4thWaveNow. Meanwhile, former detransition activist Ky Schevers has described her experiences with detransition movements as ‘anti-trans conversion therapy’, where ‘gender dysphoria is separated from trans identity and treated like a symptom to be managed, much like ex-gays draw a distinction from experiencing same-sex attraction and identifying as gay’.17
In the absence of effective treatments for dysphoria outside of transition, ‘alternatives’ rely primarily on impossibilising transition. Meanwhile, Schevers’ account indicates the harms of attempting self-reconciliation work when only a cis outcome is acceptable, which led her to ‘reinterpret, disconnect from and/or suppress my feelings’. Accordingly, any therapeutic paradigm for trans and gender-variant young people must explicitly centre the reality and accessibility of transition and affirm all potential genders/embodiments, and should provide information on what pseudo-therapeutic manifestations of anti-trans rhetoric look like, both in clinical and community settings. Models that do not include this risk endorsing the influence of transphobic hostility on identity formation, for instance, or affirming rhetoric that assigned sex is ‘reality’ when this coheres with a given young person’s identity. ‘Therapy’ is vague, covering a wide array of potential interventions as well as describing a desired outcome. Some therapeutic interventions can help some trans youth with navigating transition and addressing co-occurring sources of distress. However, attention to the conversion possibilities of purportedly ‘neutral’ therapeutic paradigms (including the engendering of transphobic self-regulation) is crucial for caring for trans youth in this time, as is knowledge that using mandatory therapy to test, vet, and/or stall trans youth degrades the status of said therapy as therapy. In addition, as the detransitioner accounts show, the idea of coping and resilience-building mechanisms for dysphoria can easily disguise self-policing and self-harm, particularly when ideological rejection of transness is involved. The desired inculcation of ‘resilience’ (Cass 59, 101, 2.28, 10.40, 10.73, 16.39) and ‘flexibility’ (Cass 79, 12.36, 12.37) in young trans people denied healthcare, which are qualities that denote responsiveness to the impositions and desires of others, is symptomatic of a desire to police more than to ensure wellbeing; providing access to desired care and unequivocal affirmation is essential for the latter.
Correction: This article previously listed IATDD as a now defunct "detransitioner" organisation. However, IATDD though defunct, was a coalition of therapists promoting detransition support.
References
American Medical Association policy: Removing Financial Barriers to Care for Transgender Patients H-185.950, passed as resolution 122 A-08 in 2008, reaffirmed in 2022 with Resolution 012, A-22.
16 Post Trans: Our booklet about Detransition