Old-fashioned patriotism seems to be back in vogue again, after taking a short and well-earned break. One clue is in the resurfacing of classic war films, with a refreshingly straightforward take on allies and enemies. This stands in marked contrast to today’s muddy and complex international conflicts. One example provides a surprisingly topical take on current conflicted debates on transgender rights. Cue the ‘Yangtse Incident’, with square-jawed British naval heroes on the bridge of a warship, stuck upstream, caught in the closing stages of the 1949 Chinese Revolution. Safe exit to open water is prevented by Chinese Communist artillery on the shore, which responds to the frigate as a hostile foreign presence invading their territory. The solution? The captain hits on the tactic of waiting for a passing civilian merchant ship to pass by. The warship can escape by travelling closely in the wake of the now targeted, hapless freighter in front, safe from being shelled by the menacing enemy artillery, making good its own final escape to open water (Earl, 1952).

So what has this got to do with transgender rights and healthcare? One of the real puzzles of the current debate about transgender issues is the lack of any proper discussion. Any criticism of transgender healthcare runs the risk of either being ignored, misrepresented, or just dismissed as entrenched bigotry. The origins of this Teflon standard protection against media or academic investigation are perhaps easier to understand in the light of this obscure incident drawn from British naval history: you can avoid the risk of harmful objections to your controversial political cause by hitching your project closely to a bigger, safer, more socially acceptable, protective moral enterprise…Job done?

Not quite. Public and professional concerns about the consequences of transgender rights, policies and healthcare are beginning to break through, despite the current extensive media blackout (Economist, 2023). In the UK, the Cass Review (2022) into gender identity services has signalled a pause to previous medical policy in this contested field. This parallels similar pauses in Finland, Norway, Sweden, France and Florida, following systematic reviews revealing little evidence of benefit to patients. There are now early signs of disagreement and debate emerging within the medical profession in the UK on this issue (Block, 2023; RCPsych, 2023).

Affirmative therapy

However, these seismic changes have so far failed to register with mainstream counselling and psychotherapy professions in the UK. All major professional therapy bodies are signed up to the Memorandum of Understanding on Conversion Therapy (BACP, 2022). This is widely understood as mandating an affirmative approach towards clients who identify as trans, or otherwise being labelled as transphobic. So, what is trans-affirmative therapy, and why is it so problematic for clients and therapists alike?

The World Health Organisation (2023) offers its usual bland and reassuring attempt at defining the undefinable: “Gender-affirmative health care can include any single or combination of a number of social, psychological, behavioural or medical (including hormonal treatment or surgery) interventions designed to support and affirm an individual’s gender identity.” Ashley, a trans activist and non-therapist, defines trans-affirmative therapy as “Gender-affirmative approaches follow clients’ lead when it comes to gender, emphasizing the importance of respecting clients’ desires regarding social gender affirmation, which includes gender identity, gender expression, name, and pronouns; supporting clients’ free, self-directed gender exploration; and scaffolding their decision-making surrounding transition-related medical interventions” (2023: 472).

These definitions suggest a number of problems for therapists wanting to understand what affirmative therapy consists of, and what they may be required to do to meet its requirements. Firstly, affirmative therapy as a therapeutic response seems closely embedded within the wider context of healthcare, particularly medical interventions. This is particularly the case within the US context, where counsellors and psychotherapists can provide letters to clients recommending medication and surgery. Within the UK, outside of private or NHS gender clinics, therapists are much less likely to be directly involved in recommending medical interventions.

Secondly, there is the usual shape-shifting when it comes to identifying what exactly is the therapist supposed to be affirming here? The therapist’s responsibility is surely to affirm the client’s value as a human being in any form of therapy, regardless of therapeutic modality. Yet the therapist, in working with a client who identifies as trans, is presumably not there to affirm the client’s gender, as this may not be apparent, or even be disclosed by the client. Affirmative therapy requires something much more specific, namely that the therapist affirms the client’s espoused and declared gender identity. Gender identity has been defined as “the private experience of gender role, and gender role is the public manifestation of gender identity” (Money, 1994: 164-5).

Gender identity ideology

Gender identity has been critiqued elsewhere as a key part of a wider belief system and political ideology, but with no established empirical status (Jenkins, 2023). For therapists to affirm the client’s self-belief in terms of gender identity marks a major break within the therapeutic frame. Therapists would not usually seek to affirm and validate a client’s beliefs about their obesity, eating distress, depressive cognition, auditory hallucinations, or low self-esteem. The current pressure on therapists to adopt gender identity affirmative therapy may carry an undeniable persuasive force, but only because this pressure derives from the related and unchallenged concepts of trans fragility, and the consequent need for trans exceptionalism within therapy.

Gender identity affirmative therapy requires much more on the part of the therapist than the occasional use of the client’s preferred pronouns. Affirmative therapy (this term is used here simply for the sake of brevity) is an integral but subordinate part of a much wider and comprehensively defined political worldview. The key elements of this worldview are common to the main policy statements on trans healthcare provided by a wide range of captured professional associations in the US (AAP, 2018; ACA, 2010; APA, 2015; Coleman, 2022.) This worldview has been channelled by professional associations into the UK, notably by the British Psychological Society, and then formalised into national policy via the Memorandum on Conversion Therapy. The key aspects of affirmative therapy are:

• compliance with the core belief that innate gender identity has primacy over biological sex;
• commitment to a minority social stress causal model of adverse mental health;
• close cooperation with those selected medical, mental health, education and social services, which share and apply the above belief systems in their practice;
• commitment to facilitating client progression on the treatment pathway as indicated, i.e. via social transition, puberty blockers, cross sex hormone therapy, gender affirming surgeries and legal transition.

For good measure and completeness, the American Counseling Association also contributed a fifth element:

• affirmation of a politicised worldview recognising the systematic oppression of transgender and other social groups, and the need to articulate the resultant intersectional identities (ACA, 2010).

The first four elements outlined above are inter-connecting parts of a political worldview, which closely bind therapists into collaborating with client, agency and social pressures to expedite medical intervention. This process is geared, in the words of the World Professional Association for Transgender Health (WPATH), “to better align their body with their gender identity ” (Coleman, 2022: S31). It is made clear that therapy can play a usefully supportive role in this process, but at no point is therapy considered to be essential. The fifth element, suggested above by the ACA, does not reappear in later versions of gender affirming healthcare policies by other US professional associations, perhaps because it is already implicit within the first four aspects.

Ethical principles

In the US, this policy turn towards the adoption of gender identity affirmative therapy meets the needs of an assertive client-consumer base, a politically influential trans movement and the commercial interests of a medico-pharmaceutical industry, i.e. the ‘Lupron lobby’. If affirmative therapy is thought to need ethical justification, then recourse is made to the principles of autonomy and justice. Needless to say, client autonomy is presented as an overwhelming social good in its own right, with no need for age limits, safeguarding or gatekeeping processes: “…unbounded social transition and ready access to puberty blockers ought to be seen as the default” (Ashley, 2019: 233).

The research base for affirmative therapy is still somewhat lacking or ’emergent’, in other words meaning not quite ready, or yet fit for purpose. The American Psychological Association refers coyly to “empirically-supported practice guidelines that encourage clinicians to use gender-affirming practices when addressing gender identity issues” (2021: 2; emphasis added: PJ). This is a phrase which urgently needs copyrighting, as it is clearly going to be over-used in the coming period. The research base for medical interventions, let alone for affirmative therapy, is weak and unconvincing. This is made clear by the latest run of systematic reviews of gender medicine, of which the one produced by Florida (2022) is probably the most detailed so far. The ‘best available research’ favouring affirmative healthcare typically relies on small samples, self-reported benefits, an absence of follow-up for those leaving the survey and short timescales for claimed positive outcomes. There does seem to be an endemic, strenuous avoidance of randomised controlled trials within the affirmative healthcare sector, perhaps for fear of what unwelcome truths this might well reveal.

Gender affirming healthcare and resultant harm

The APA go on to claim that “gender affirming psychotherapy is founded in clinical practice guidelines, and harm has not been identified for any of these gender-affirming treatment practices” (2021: 3, emphasis added: PJ). This is the nub of the issue. In ethical terms, principles such as autonomy and justice must be balanced against others, such as promoting welfare and, crucially, avoiding harm to clients and to other third parties (or, ‘primum, non nocere’ for Latinists). The potential harms associated with gender identity healthcare, with affirmative therapy as a willing and fully complicit partner in this process, can be listed as including the following:

• destruction of healthy tissue and body parts for cosmetic purposes;
• long-term adverse health consequences (risk of reduced bone density, infertility);
• failure to resolve gender identity distress, despite irreversible medication and surgery;
• unnecessary and unethical medicalisation of same-sex attraction;
• failure to address/resolve concurrent long-standing conditions (anxiety, autism, eating distress, sexual trauma
• medium-term risk of retraumatisation, via detransition or retransition;
• heightened longer-term risk of suicide.

This is a sobering list. Given the pervasive lack of research, not all of the potential harms can be fully documented. The destruction of healthy tissue is a self-evident cost of undergoing surgery, framed here as a potential harm. The raft of systematic reviews of gender medicine attest to the risks of reduced bone density and infertility from hormone therapy, and to the common failure of medical intervention to resolve gender identity distress (Florida Medicaid, 2022: 26). The high proportion of gay and lesbian young patients seeking medical intervention at the Tavistock GIDS is a striking and well-documented theme in Barnett (2023). Dhenje (2011) records that “sex-reassigned persons were at increased risk for suicide attempts” over the longer-term. Research into the effects of detransition and retransition is severely lacking and sorely needed.

Gender identity affirmative therapy thus serves as the handmaiden to medical intervention for gender distress, relying on weak research, political ideology and a truncated use of ethical principles. In the UK, there is a widespread assumption amongst therapists that the Memorandum of Understanding requires the use of (gender identity) affirmative therapy with clients identifying as trans. This was the working brief at the Tavistock Gender Identity Development Service (GIDS). The resultant chaos at the GIDS contributed to the service being deemed ‘inadequate’ by a government watchdog, the Care Quality Commission, in 2021. In reality, the Tavistock could serve as an instructive case study in the complete failure of gender identity affirmative therapy at an institutional level (Barnes, 2023). In reality, the MOU does not mention affirmative therapy as such, although this might reasonably be assumed to be implicit in its ideologically driven worldview. The MOU’s relentless focus on the dangers of conversion therapy now means that any critics or doubters within the counselling and psychotherapy professions are in danger of being driven underground, to avoid allegations of being labelled as transphobic, or of being subjected to professional disciplinary proceedings.

Legal protection for gender critical therapists

Professional counselling and psychotherapy associations continue their policy of whistling in the dark and denying the reality of the unfolding crisis in gender healthcare. There is little recognition of a growing unease about the imposition of affirmative therapy upon their members. One research paper notes that “There are a significant minority of therapists who do not work with trans people in an affirming way, [and: PJ] do not believe that there should be a ban on conversion therapy…” (Mollitt, 2022: 1024). Furthermore, “Responses suggest a real split along modality lines, namely that humanistic therapists are more comfortable with an affirmative stance, whereas some psychoanalytic therapists are concerned that the essence of their work—curious exploration—will be inhibited by the MoU” (2022: 1023-4). This perhaps gives some small hope that therapy associations will have to engage in an informed debate about these issues in the future, even if prospects appear somewhat limited at present.

Therapy associations do need to start making some allowance for the presence of this sizeable minority in its ranks, even if only to avoid costly litigation in the near future. There has been a string of successful challenges to gender ideology, albeit so far at the lower levels of the English legal system, but with necessarily far-reaching consequences. Sonia Appleby brought a successful case against the Tavistock GIDS over its safeguarding failures; Harry Miller challenged the routine recording by police of non-crime hate incidents over his views expressed via social media; crucially, Maya Forstater won her case defending her right to free expression of gender critical views. The Forstater Appeal in 2020 clarified that holding and expressing gender critical beliefs constituted a protected belief under the Equality Act 2010. The Forstater Appeal thus clarified that the expression of gender critical beliefs is therefore protected in law under s.10 Equality Act 2010 and Article 9 (freedom of thought, conscience and religion) of the Human Rights Act 1998. Hence in Forstater:

“The Claimant holds gender-critical beliefs, which include the belief that sex is immutable and not
to be conflated with gender identity. She engaged in debates on social media about gender identity
issues, and in doing so made some remarks which some trans gender people found offensive and
“transphobic”. “

“The Claimant’s gender-critical beliefs, which were widely shared, and which did not seek to destroy the rights of trans persons, clearly did not fall into that category. The Claimant’s belief, whilst offensive to some, and notwithstanding its potential to result in the harassment of trans persons in some circumstances, fell within the protection under Article 9(1), ECHR and therefore within s.10, EqA” (Forstater v. CGD, 2020).

Like it or not, professional therapy associations will be bound by such case law and by the revised  provisions of the Equality Act 2010 to permit the free expression of gender critical views within their ranks. This discussion will, no doubt, include informed criticism of their continuing support for the MOU and of their reckless promotion of gender identity affirmative therapy, despite the growing evidence of its associated harms.

Conclusion

And so, to return to the earlier metaphor of a British warship adrift in the Chinese Revolution…this will maybe strike some readers as far-fetched and unconvincing. And yet, the clear policy advice given to transgender lobby groups in advancing their unpopular case for sweeping legal and healthcare reform is uncannily similar in all its essentials. The legal firm, Dentons, offered the following pro bono advice to transgender reformers:

“Tie your campaign to more popular reform. In Ireland, Denmark and Norway, changes to the law on legal gender recognition were put through at the same time as other more popular reforms such as marriage equality legislation. This provided a veil of protection…” (ILGYO et al, 2019: 20: emphasis added: PJ).

This is a telling phrase, ‘a veil of protection’. The implication seems to be that if the people aren’t told the full story about unpopular gender policy reforms, then they probably won’t make any objections. The public currently seems to be experiencing an unwelcome moral queasiness about radical reform of transgender healthcare. Tying such a campaign to the coat-tails of ‘more popular reform’, such as same sex marriage, may not be as dramatic as a naval frigate putting a civilian ship at risk, by closely shadowing it downstream. However, this covert political strategy for promoting gender healthcare reform is still, apparently, infinitely preferable to openly debating the evidence about the harms of medical transition. In terms of ethics, particularly the injunction to ‘First, do no harm’, both approaches i.e. ‘shadowing’ and relying on ‘a veil of protection’, seem to share a calculated reliance on subterfuge to achieve their aims. Both tactics also reveal a casual disregard for the collateral casualties thus engendered.

References

American Academy of Pediatrics (AAP) (2018) Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. 142(4): https://pubmed.ncbi.nlm.nih.gov/30224363/

American Psychological Association (APA) (2015) Guidelines for Psychological Practice With Transgender and Gender Nonconforming People.  American Psychologist, 70 (9), 832-864. doi: 10.1037/a0039906, transgender.pdf (apa.org)

American Psychological Association (2021) Resolution on Gender Identity Change Efforts. APA Resolution on Gender Identity Change Efforts

American Counseling Association (ACA). (2010) “Competencies for counseling with transgender clients”, Journal of LGBT Issues in Counseling, 4:3-4, 135-159. Full article: American Counseling Association Competencies for Counseling with Transgender Clients (tandfonline.com)

Ashley, F. (2019). Thinking an ethics of gender exploration: Against delaying transition for transgender and gender creative youth. Clinical Child Psychology and Psychiatry, 24(2), 223–236. https://journals.sagepub.com/doi/abs/10.1177/1359104519836462

Ashley, F. (2023) “Interrogating gender-exploratory therapy”, Perspectives on Psychological Science. 18:2, 472-481. Interrogating Gender-Exploratory Therapy – Florence Ashley, 2023 (sagepub.com)

Barnes, H. (2023) Time to think: The inside story of the collapse of the Tavistock’s Gender Service for Children. London: Swift.

British Association for Counselling and Psychotherapy (BACP) (2022) Memorandum of Understanding on Conversion Therapy. Memorandum of understanding on conversion therapy in the UK (bacp.co.uk)

Cass, H. (2022) The Cass Review: Independent Review of Gender Identity Development Services for Children and Young People: Interim Report. Cass Review – Independent Review of Gender Identity Services for Children and Young People

Coleman, E. et al. (2022) Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health. 23:sup1, S1-S259. DOI: 10.1080/26895269.2022.2100644. Standards of Care – WPATH World Professional Association for Transgender Health

Dhenje, C. et al, (2011) “Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study in Sweden.” Plos One. 22^nd February. Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden | PLOS ONE

Earl, L. (1952) Yangtse Incident. Non-fiction Book Club: London.

Florida Medicaid (2022) Generally Accepted Professional Medical Standards Determination on the Treatment of Gender Dysphoria. FLORIDA-MEDICAL-STANDARDS-Medicaid-treatment-GENDER-DYSPHORIA-6.2022.pdf (personandidentity.com)

IGLYO, Dentons, NextLaw and Thomsons Reuters (2019) Only Adults? Good practices in legal gender recognition for youth: A report on the current state of laws and NGO advocacy in eight countries in Europe, with a focus on the rights of young people. IGLYO_v3-1.pdf

Jenkins, P. (2023) “Unpacking the concept of gender identity: Not fit for purpose?” Critical Therapy Antidote. Unpacking the Concept of ‘Gender Identity’: Not Fit for Purpose? – Critical Therapy Antidote

Mollitt, P.C. (2022) “Exploring cisgender therapists’ attitudes towards, and experience of, working with trans people in the United Kingdom.” Counselling and Psychotherapy Research. 1013–1029.
DOI: 10.1002/capr.12559 Exploring cisgender therapists’ attitudes towards, and experience of, working with trans people in the United Kingdom – Mollitt – 2022 – Counselling and Psychotherapy Research – Wiley Online Library

Money, J. (1994) “The concept of gender identity disorder in childhood and adolescence after 39 years”, Journal of Sex and Marital Therapy, 20(3), 164-5. The Concept of gender identity disorder in childhood and adolescence after 39 years: Journal of Sex & Marital Therapy: Vol 20, No 3 (tandfonline.com)

World Health Organisation (WHO) (2023) Gender incongruence and transgender health in the ICD (International Classification of Diseases). Gender incongruence and transgender health in the ICD (who.int)

Legal references

Mrs S Appleby v The Tavistock and Portman NHS Foundation Trust: 2204772/2021 – Final Judgment. EMPLOYMENT TRIBUNALS (publishing.service.gov.uk)

Forstater v. CGD UKEAT/0105/20/JOJ. Maya_Forstater_v_CGD_Europe_and_others_UKEAT0105_20_JOJ.pdf (publishing.service.gov.uk)

R (Harry Miller) v The College of Policing [2021] EWCA Civ 1926 Miller, R (On the Application Of) v The College of Policing [2021] EWCA Civ 1926 (20 December 2021) (bailii.org)

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By Peter Jenkins, counsellor, supervisor, trainer and researcher in the UK. He has been a member of both the BACP Professional Conduct Committee and the UKCP Ethics Committee. He has published a number of books on legal aspects of therapy, including Professional Practice in Counselling and Psychotherapy: Ethics and the Law (Sage, 2017).  https://us.sagepub.com/en-us/nam/author/peter-jenkins

Peter Jenkins is also a member of Thoughtful Therapists, whose scoping survey for the  government consultation on conversion therapy can be found here