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The Unfolding Crisis in Therapy with Transgender Clients

A commentary on a recent research paper

A recent research paper (Puckett et al, 2023) illustrates the profound depths of the currently unfolding crisis in therapy with transgender clients. A group of 13 researchers have produced a paper looking at clients’ helpful and unhelpful experiences of therapy, and in particular the linkage by therapists of external political events, such as the election of Donald Trump as President, to their client’s worldview and emotional experiencing within the process of therapy. A limited sample (n: 107) of transgender clients (or, more accurately: clients identifying as transgender) was obtained via purposive sampling, in order to explore their perception of helpful and unhelpful aspects of therapy.

The paper seems designed to further refine existing guidelines for providing therapy to transgender clients, but with a much sharper political edge. The paper concludes that “therapists must invest their time and energy in learning about the unique life experiences of TGD people, such as common identity development experiences or current events. Otherwise, their clients may feel disconnected, feel less understood, or be burdened with educating their providers” (Puckett et al, 2023: 272: emphasis added). This is a theme which we will return to shortly.

The sample of adults aged 19-66, from selected mid-Western states, provides only basic demographic data, including sex, race, sexual orientation, education, and, of course, gender identity. No other baseline data was obtained, so there is no information about mental health conditions, or suicide risk. This is a (dis)satisfaction survey of sorts, given that participants are asked about helpful and unhelpful aspects of therapy received over a period of a year during the Covid crisis. No data on therapists was sought, so all experiences of therapy, helpful or unhelpful, might relate to one consistent therapist, or to a number of different therapists working with that client over the year, somewhat weakening the paper’s overall conclusions.

Helpful and unhelpful aspects of therapy seem to fall into two groups, namely those which are generic to any type of therapy, and those which are specific to the needs of transgender clients. Thus, generic helpful aspects include the practical availability of the therapist, validating responses, therapist attunement, and effective use of specific therapy models. Generic unhelpful aspects included lack of therapist availability, problems with video or telehealth, feeling disconnected from the therapist, and excessive therapist self-disclosure. So far, so banal…

The paper’s real focus is on helpful and unhelpful aspects of therapy which relate specifically to the client’s transgender status. Here, therapists were perceived as unhelpful if they “minimized their gender identity or gender-related experiences” (271), as in “She doesn’t understand what it feels like to be trans”, and were otherwise tardy or unsympathetic in providing the all-important letter of referral authorising medical transition. Conversely, helpful therapists were already knowledgeable about transgender identity, used affirming language, such as preferred pronouns, and assisted clients to access further gender-affirming care.   

However, beyond this basic level of helpful responding, the paper identifies and encourages a much more proactive stance on the part of therapists, in linking to current events (eg state legislation on transgender medical transition) in order to invite the clients’ responses and to actively promote discussion of wider political events and their emotional resonance within the clinical setting. This signifies a clear breach of the established principle of therapeutic neutrality within the clinical process, and the adoption of an overtly politicised role for the therapist, as an avowed trans ally and advocate. In conclusion, “Providers must also explicitly engage in efforts to improve their knowledge about the lived experiences of TGD people and how systems of power shape life experiences and mental health” (273). So, not only is the therapist required to be perfectly attuned to the changing landscape of the client’s inner world, but should also now be attuned to the infinite nuances of their perception of rapidly changing external world, in all its transphobic awfulness.

The paper provides a worrying snapshot of a profession in steep decline, with the issue of Gender Affirming Care as a Damocles sword hanging over the therapeutic process. We have here a bifurcated, ie deeply split, version of therapy. Either the therapist is affirming and completely accepting of the client’s worldview without demur, or they run the risk of being perceived as unsupportive. There is a puzzling lack of discrepant data here – namely, were there really no examples at all, in the whole data set of therapists, who weren’t acting as trans allies, but who still somehow managed to provide effective therapy, as a subtle balance of holding and challenge?

The risk of research over-claim is always tempting with a sample as small as this. However, the paper does provide useful ammunition in the ongoing war of attrition against mainstream, exploratory therapy, and in favour of an impoverished form of trans advocacy. In this model, practitioners not only affirm transgender identity without question, but also proactively select likely political events, in order to endorse their client’s worldview in all its developing rigidity.

This might even result in the emergence of a new variant or model of practitioner response (surely the unspoken dream of every novice researcher?) namely that of Political Gender Affirming Care (PGAC), to meet the needs of this newly emerging market. This might be best described as a form of clinical hand-holding for a sharply defined group of clients. As for therapy, well, it ain’t. 


Puckett, J. et al (2023) Transgender and Gender Diverse Clients’ Experiences in Therapy: Responses to Sociopolitical Events and Helpful and Unhelpful Experiences. Professional Practice: Research and Practice. 54: 4, 265-274.

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).  

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

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