How is Gender Different? Let me Count the Ways

Work with gender discomfort often seems to lead to very different approaches to those used in any other area of distress. John Proctor considers just how strange this is.

It happened at the end. At an event to discuss whether mental health initiatives in schools might sometimes be unhelpful. Short answer: yes – but it was the discussion that was illuminating. For two hours we considered Mental Health First-Aid, self-diagnosis via TikTok, and how ordinary feelings can be pathologised. Above all we debated how to work with teenagers who adopt diagnostic labels as identities. Then, just as we finished, one young audience member made a final point: “As someone who works with LGBTQ+ youth, their problem is external oppression. It’s about not being accepted for who they are.” [My emphasis]. No chance to reply. While initially frustrated at the lack of space for a response, I’ve thought about that statement many times since. More recently, I appreciate such a clear pronouncement on how we should work with gender discomfort, and such an explicit signal as to what our responses, including those of psychological practitioners, should be. Apparently these need to be different to those provided for any other kind of distress. And this is indeed what we have done over the last few years. Here I’d like to think about the ways we have treated gender as exceptional, and some of the resulting problems.

The first area of difference is the conflation of one issue with another: in this case of sexual orientation with gender. We frequently hear the letter combination LGBT, and the old rainbow flag has been replaced by the ‘Progress’ version. I do often wonder though if these labels actually belong together. It’s worth remembering that this teaming is a recent thing. Adopted for campaigning purposes, it steps adroitly over the fact that the issues raised by same sex attraction may be very different from those raised by gender identification in a way different to your sexed body. For example, being gay does not lead to either arguments about competing rights or to a proposed medical pathway. Indeed, far from a happy coexistence, some ideas about trans rights may be antithetical to the LGB part of the rainbow, as same-sex attraction may be replaced with the idea of same-gender (thus mixed-sex). This was a significant issue in the recent Supreme Court case brought by For Women Scotland in the United Kingdom.

While the commenter in my session only made a single remark, I think the reason it has stayed with me is that ideas of acceptance as primary have become very familiar in my professional circles as a psychologist. In particular, I often hear an emphasis on the validation of gender identity placed ahead of any attempt at investigation and of developing a detailed picture of why someone may feel the way they do. It’s been well documented how, in the UK’s primary specialist service for children with gender issues (the Gender Identity Development Service at the Tavistock Clinic), many clinicians turned away from a more exploratory approach to gender discomfort. Instead a more affirmative stance became favoured. Though some staff clearly held to a more traditional model of working (understanding and formulating), others wouldn’t, or couldn’t, do so. More worryingly this also led, for many, to referral for endocrinology treatment. The evidence for the effectiveness and safety of those treatments has been seriously questioned. 

Professional bodies have also taken steps towards encouraging more affirmative, identity-based, working with adults. For example, The British Psychological Society’s Guidelines for Psychologists Working with Gender, Sexuality and Relationship Diversity, as well as conflating sexual orientation with gender self-identification, place an emphasis on rights and on de-pathologising any aspect of sexuality or gender. There are cautions not to engage in “conversion therapy” and to make sure you make no judgement on someone’s choices. This makes sense to a point. Of course psychological practitioners wish to respect the people they see. But there is, perhaps, some balance needed.  The primary message is that the experience of being uncomfortable with your sexed body in particular is, in these guidelines, not something we aim to understand, but rather an identity that needs to be validated. Any idea that a therapist might think about the function of trans identification in managing painful emotions, or identification away from your bodily reality as a response to experience, is nowhere to be found.

At organisational levels too this idea of validation takes us along a different path from the one we might take for other issues. We fly flags in our departments, display posters, and put pronouns in our email signatures. All in the name of inclusion and allyship. Some colleagues even offer the idea that clients will know they are “safe” if they display these concrete signs. Presumably not offering such signs is therefore unsafe? And, uniquely, we decide that this issue, out of the many available, is the one we’ll announce a position on. However, for psychological therapists, neutrality is quite central to our ordinary stance. People come through the door and we think with them about their experience. It is not normally our job to pre-empt our conclusions or to take sides in painful and divisive areas. And yet our organisations decide for us that the task is to affirm the identity beliefs of clients. Good outcomes are already being framed according to our ability to agree with someone rather than to explore.

So why this need for validation: individual, organisational, and even societal? Again, I think the speaker at my meeting caught the essence of why this should be so. It’s because of “external oppression”. Over the last few years we’ve heard a narrative of marginalisation and powerlessness in answer to any questioning of how we respond to gender-related matters. Whether the conversation has been about women’s rights and protections, or about questions over puberty blockers, the response is so often that a marginal group is being attacked. The protection of a group we judge vulnerable is an imperative so strong it seems to stop thought about whether there is a different way to approach things. Additionally, we have tools to codify where privilege and powerlessness reside, and certain groups are always deemed to be at the margins. The listening and thinking, which are the work of therapy, are apparently no longer necessary. I sometimes wonder if such a prescriptive approach is to ordinary therapy as colour-by-numbers is to actual painting.

Such responses always raise my curiosity. Are we really talking about the most marginal and powerless group here? Some dispute it, and the prevalence of “trans rights” promotion (from road crossings to HR policies, to arguments made at public expense) in UK public life leaves the powerless narrative looking rather less than convincing. I see nothing comparable for marginal groups such as people with disabilities, or dementia, or who are homeless. In the area of sex and gender the powerlessness seems to me to be far more plausibly located in the people who have had to fight, through the courts, to express beliefs which go against our most recent orthodoxies. For some organisations taking a strong position has not been enough. Legitimate alternative views have also not been tolerated in the face of an axiomatic presumption that there is only one right perspective. This has not only been a divergence from our way of looking at other areas, but also more than a little alarming. 

It’s perhaps only when we consider how different all this is from the way we approach other forms of distress that it becomes apparent just how strange it all is. Let’s think for a moment how it would look to treat eating issues in a similar fashion. The similarities between eating disorders and gender discomfort are evident. Both may be characterised by unease with one’s body, by steps to respond to that distress with quite extreme physical changes, and an underlying context of trauma. After the initial similarities however, gender issues and eating issues part ways. Generally the response to eating disorders is grounded, very firmly, in attempts to understand and work with the experiences and the feelings we encounter. Psychotherapeutic approaches are to the fore and, in cases where greater physical harm is a risk, compulsory hospitalisation and even force feeding come into play. While I, and many, have reservations about the compulsory aspects of treatment, it’s understandable how we get there. Sufferers are at risk of permanent physical harm, or even death. We struggle to let that go unaddressed and tend to use any means we have available to stop it. No surprise therefore that, societally, our response to “pro-ana” advocacy (the idea that starving yourself and extreme thinness is a human right or lifestyle choice) has largely been one of horror. The contrast with gender is striking. At no stage do health professionals working with eating disorders wear “pro-thinness” lanyards, promote bariatric surgery as a human right, and include celebrations of our true body shape in our messages to colleagues and service users.

You could make a similar case related to self-harm, body dysmorphia or a belief one is Jesus. In each case therapists balance empathy with careful exploration of underlying causes. They don’t typically affirm harmful behaviours, quickly move to physical interventions, or suggest that the primary source of distress is others’ failure to understand that someone really is the Son of God. Yet, in gender therapy, chest-binding and surgical alteration can become marks of autonomy, and those who are cautious about someone else’s metaphysical beliefs may be branded bigots.

It is clear that at least some things are changing. The fate of the child GIDS service is, by this point, well known. The Cass Review strongly criticised existing practices in gender healthcare, particularly highlighting weak evidence for puberty blockers, and GIDS closed its doors in 2024. Cass made recommendations for a more holistic, and psychological, approach to gender distress. In the UK children’s access to puberty blocker medication and cross sex hormones has either been restricted or is under review. Adult gender services in the UK are also under scrutiny. Similar developments can be seen elsewhere. Not only have several European countries executed a volte-face in policy, but significant segments of the USA seem to be waking up to widespread public concern about “gender-affirming” medical interventions for children in particular.

Despite these increasing doubts about where we’ve been, this picture of change is, at best, partial. Though many organisations have welcomed the Cass Review, a number of others have either publicly opposed its recommendations or have experienced significant internal conflict about how to respond. There are private providers who, while they may offer assessment, still seem rooted in a belief that they can somehow divine who will benefit from irreversible medications during puberty. To use such drugs we’d surely have to be pretty certain about the predictability of a settled trans identification, something which, as Cass made very clear, we aren’t. This issue of predictability is also a serious concern given that, The UK is, at time of writing, set to press ahead with a clinical trial of puberty blockers for children. Such a step carries risks related to the effects of such drugs on brain development and bone health, as well as the established limiting of male genital development. This seems a very obvious case where a proper follow up of the cohorts who have already been given this medication is the logical initial step in developing the evidence base. Though, as some readers may know, follow up data from adult gender clinics was more  difficult to obtain than one might imagine.

Also significant is the proposed “trans inclusive” ban on conversion therapies in the UK. It looks likely that forthcoming legislation will restrict any steps to challenge someone’s sexual orientation or gender identity. A number of prominent bodies representing psychological therapy practitioners in the UK (including the British Association for Counselling & Psychotherapy and the British Psychological Society) have signed something called the Memorandum of Understanding on Conversion Therapy promoting this aim. Other organisations, such as the UK Council for Psychotherapy, have signed and then, following the concerns raised by Cass, withdrawn support. In forthcoming legislation there will apparently be protections for legitimate therapeutic exploration. However, it’s unclear just how the experience of feeling misaligned with your body will be distinguished from what is deemed the existence of a gender identity. If understanding the former is legitimate ground for therapy but thinking about the latter is not, this is not a matter of trivial concern. Therapists could face prosecution if exploring underlying psychological distress around gender identity is misconstrued as conversion therapy. Similar legislation proposed in Scotland in 2024 (and ultimately withdrawn) did not succeed in making such a distinction related to legitimate therapeutic exploration, and it remains to be seen if the UK Government can do any better. Indeed Hillary Cass herself has said that such a law is likely to put pressure on therapists to inhibit exploration.

It seems the commenter in my meeting managed to summarise, in 15 seconds, several of the principles currently in operation in gender healthcare and in psychological therapies. However, such principles (conflation with other issues, an emphasis on validation of identity labels, a very fixed interpretation of powerlessness, and either disregard of or hostility to alternatives) seem to take us away from a path we are committed to in all other domains. The unique approach to gender discomfort also contrasts sharply with evidence-based practices used in other psychological treatments. Though there was no chance to answer, the questioner did, I now think, do me a favour by saying the quiet part out loud. By saying that this area is different and special. Being clear about that offers us an opportunity to think about how we have, in so many areas, embraced that difference. More than that though it offers us a chance to think about whether we want to change our approach in future. Those we are there to help deserve care that genuinely addresses their distress, not care only shaped by ideology. Young people, actually all people, of course deserve to be accepted for “who they are”. Let’s also help them try and understand what’s painful rather than jumping to tell them they’re something they are not.

The author is a clinical psychologist specialising in severe and enduring mental health problems.