ArticlePDF Available

Towards a Gender Exploratory Model: slowing things down, opening things up and exploring identity development

Authors:
Towards a Gender Exploratory Model: slowing things
down, opening things up and exploring identity
development
Anastassis Spiliadis1
Throughout the western world, the care of children and adolescents whose
sexed corporeality is at odds with their gender-related feelings raises medical,
psychological, and ethical dilemmas. There are currently differing views
around what constitutes responsive and timely support for these young people
and how professionals can operate within a rapidly shifting and contested field,
in which evidence-base is scarce. In this article I aim to reposition the
theoretical framework away from ‘affirmative’ or ‘reparative’ polarities, arguing
that both can be problematic, and to invite the reader into a Gender
Exploratory Model (GEM) grounded in a systemic-developmental framework;
such a model acknowledges and often embraces the notion of uncertainty with
regards to young people’s developmental trajectories and clinician’s ‘unknown
unknowns’ and exploratory responsibilities. A short introduction to the service
(GIDS), as well as a presentation of the current theoretical and clinical
debates, will offer a contextual base for clinicians supporting young people
experiencing gender dysphoria. This is not an attempt to explore the
multifactorial aetiology of gender dysphoria but rather one to add on the
theoretical underpinning of therapeutic approaches in supporting these young
people.
One is perpetually telling one’s story to oneself and others, trying to shape
things so that the next step fits with what has gone before, ceaselessly claiming
significance for one’s experience and actions and the question always is, in
what language can or must one do these things?
Boyd White (1984:277)
I write this article in my capacity as a systemic and family psychotherapist in
the highly specialist Gender Identity Development Service (GIDS) at the
Tavistock Centre, in London. In GIDS, I occupy simultaneously multiple
positions; I am a clinician and therefore, a supervisee but also a supervisor
and a trainer. I am aware of my responsibility to provide ethical care to young
people and families who experience distress with their developing bodies,
whilst holding in mind the multiplicity of the potential outcomes in young
people’s physiological and psychological development, as well as the potential
affordances and constraints that medical / hormonal interventions offer to
people who decide to change their bodies. Holding on to my systemic training,
1 Anastassis Spiliadis is a Senior Systemic & Family Psychotherapist and a qualified Systemic
Supervisor & Trainer. He works in the Gender Identity Development Service (GIDS) at the Tavistock
and Portman NHS Foundation Trust, in the Maudsley Centre for Child & Adolescent Eating Disorders
(MCCAED) and in independent practice, both in London and Athens.
Email: anastassis@icf-consultations.com
Issue 35 metalogos-systemic-therapy-journal.gr 1
I connect with the conceptualisation of gender identity as socially constructed
but equally acknowledge the sexed reality of our bodies and their boundaries
and limitations, irrespective of whether these are chromosomal or relating to
external genitalia or internal reproductive organs.
Therefore, practicing systemically, I am not focusing on linear aetiologies with
regards to someone’s experience of gender dysphoria. I am rather interested
in practicing from an idiosyncratic approach and position that would allow for
an open dialogue among health care professionals and service users to
develop, so as the meaning-making of embodied and gender(ed) experiences
can be explored. At the same time, I am interested in further developing my
capacity to be self-reflective. This is supported through on-going individual and
group-based systemic supervision and through reflecting on my own
experiences of gender identity development. My ultimate aim is to support the
families I work with to be curious about the diverse narratives, lived
experiences and developmental outcomes of those who have experienced
gender dysphoria and therefore often highlight ‘the danger of a single story’
(Adichie, 2009) in this specialist, often highly contested, field.
In my clinical practice, I often reflect on the ‘blind spots’ and the ‘unknown
unknowns’ that both clinicians and families can be faced with when supporting
gender questioning or gender non-conforming children and adolescents. As we
operate within a field where evidence is scarce, we often rely on evolving
practice-based evidence and clinical experience, as well as international
standards of care (Coleman et al., 2012). In the current article, I will present
the clinical context in which I operate as a systemically trained clinician; I will
then present the current theoretical polarities with regards to supporting young
people whose gender identity feelings are at odds with their sexed
corporeality. I will aim to present a modified theoretical and therapeutic
approach working with gender questioning young people with reference to a
specific case study and clinical reflections, connecting to my own clinical
experience as a systemically trained psychotherapist. That theoretical
underpinning aligns tightly with how I tend to practice in GIDS, whilst holding in
mind that other clinicians might approach exploration through a different lens. I
am also not claiming the application of such an approach as fitting with all
young people who present to the service; rather I am interested in enriching
the narratives available to young people who experience an incongruence
between their gender identity and their bodily reality (and to their families) and
make an addition to the wider debate in the field of gender identity
development.
The clinical context
The Gender Identity Development Service (GIDS) at the Tavistock Centre in
England is a highly specialist child and adolescent service, part of the wider
National Health Service (NHS). It supports young people up to the age of 18
years old, who experience difficulties with their gender identity. The service
was founded in 1989 by Domenico Di Ceglie, child and adolescent psychiatrist,
with the aim, among others, to encourage exploration of the mind-body
relationship and challenges for gender non-conforming young people through
a holistic multidisciplinary approach.
Issue 35 metalogos-systemic-therapy-journal.gr 2
Some of the young people presenting to GIDS identity as trans. Other young
people do not connect with this ‘umbrella’ term or other labels, which they
might often describe as ‘limiting’.
The team at the Tavistock Centre consists of systemic and family
psychotherapists, clinical psychologists, child and adolescent
psychotherapists, social workers, and a child and adolescent psychiatrist.
Paediatric endocrinologists and clinical nurse specialists are part of the team
and usually tend to meet, if relevant, with young people and families following
a psychosocial assessment. The current service protocol suggests 3-6
assessment sessions over 3-6 months, although the length of the assessment
can be flexible and is often longer depending on the complexity of a young
person’s gender identity development or the associated difficulties. Whilst the
service’s initial exploratory approach was aligned with a psychodynamic
understanding although parents and carers were involved at different phases),
current therapeutic exploration has a stronger systemic focus, as most young
people are encouraged to be seen together with their significant system; in
most cases with their parents or carers, siblings or even extended family
members and any significant others. Family days and parents groups are an
integral part of the psychosocial pathway. Family therapy is not currently part
of the routine GIDS pathways or assessment; however a small number of
families have been seen in the Family Therapy & Consultation Service in
London that was established in 2017.
At a broader-systems level, GIDS has adopted the network model approach
(Davidson & Eracleous, 2009), which can be conceptualised as an adaptation
of Seikkula & Olson’s (2003) open dialogue framework. Developed on
dialogical and Batesonian (Bateson, 1963) ethos and tradition, the approach
advocates for the ‘tolerance of uncertainty,’ ‘dialogism’ and ‘polyphony’ as
guiding principles in multiagency work in the community and with relevant
stakeholders. Specifically, even though the GIDS operates as a highly
specialist service with a strong focus on assessment of young people’s gender
identity development, any decision-making in relation to children’s and
adolescents’ gender identity, their embodied identities (Spiliadis, in press) and
their on-going psychological support, requires multiagency coordination,
cooperation and communication. This is in line with the complexity of the
clinical presentation of some of the young people attending GIDS (Holt,
Skagerberg & Dunsford, 2016) and gender identity services in other countries,
such as in Finland (Kaltiala-Heino et al., 2015), in Canada (Bechard,
VandeLaan, Wood, Wasserman & Zucker, 2017) and in the Netherlands (de
Vries, Doreleijers, Steensma & Cohen-Kettenis, 2011). Such observations
perhaps signify the need to move away from linear and simplistic explanations
around the aetiology of gender dysphoria but also the ‘thin narratives’2 with
2 Editors’ Comment: Michael White defines as “thin narratives,” “thin descriptions” and “thin
outcomes” concerning someone’s identity, those that are not based on a dialectic process leading to
some interpretation but simplified processes. Alternatively, he proposes the dialogue and the interaction
between the person (IP), the Mental Health professional, and the community leading to more secure / or
complex narratives, descriptions (thick descriptions) and outcomes (White, M. (1997). Narratives of
therapists' lives. Dulwich Centre Publications).
Issue 35 metalogos-systemic-therapy-journal.gr 3
regards to possible developmental trajectories for young people experiencing
embodied distress, and the relevance and value of clinicians’ interventions.
Clinicians working in the field of child and adolescent gender identity
development have to navigate through differing and competing narratives and
beliefs that professionals, families, third sector organisations or even the
media might have, in terms of persistence and desistance of gender dysphoria
across the lifespan and the relevance of any clinical intervention. There is on-
going debate about whether professionals supporting gender questioning
young people (and their families) can predict with confidence which young
people will ‘persist’ in their gender identification and/or their wish for
medical/hormonal interventions and which will ‘desist’; in the case of
‘desistence’ it could either mean that young people come to understand their
gender identity (and possible associated distress) in different ways or cease
wishing to pursue hormonal interventions (Churcher Clarke & Spiliadis, 2019).
There is some evidence that medical interventions can, for some young
people, alleviate gender dysphoria (Kreukels & Cohen-Kettenis, 2011).
However, there is anecdotal agreement among some clinicians working in this
field that different outcomes are possible and that gender-related distress (or
gender dysphoria) is not always alleviated through medical, hormonal or
surgical, interventions (Dhejne, Oberg, Arver & Landen, 2014; Levine, 2018).
In some cases, presentations of broader identity confusion indicate a need for
exploration beyond the gender identity narrative (Marcus, Marcus, Yaxte &
Marcus, 2015). These questions extend easily to wider moral and clinical
debates; in any case, they signify the need to ask ourselves ‘do symptoms of
gender dysphoria always predict a transgender identity”? And also ‘what type
of interventions should we offer to young people experiencing symptoms
consistent with a GD diagnosis’?
Current theoretical polarities
Clinicians working in GIDS are constantly faced with clinical and ethical
dilemmas. Equally training clinicians wanting to gain experience in the field of
gender identity are often puzzled by the rarity of a theoretical base that would
inform clinical practice and would allow trainees and newly appointed clinicians
to follow a well-defined theoretical framework. In the last five years, gender
identity services throughout the western world have experienced an
unprecedented increase in referrals; contrary to historical figures and referral
profiles, there has been a significant rise in the numbers of younger (often
prepubertal) children, as well as female-bodied adolescents being referred (de
Graaf & Carmichael, 2019), as well as the development of strong online
communities. These phaenomena raise important questions around the need
to possibly revisit current clinical approaches within a fast-evolving field and
highlight the importance of a carefully developed clinical formulation when
Perhaps it should be added that the terms «thin» and «thick description» were first introduced by the
20th-century philosopher Gilbert Ryle. Later on, Clifford Geertz, the cultural anthropologist, who
influenced the practice of symbolic anthropology, in The Interpretations of Cultures (1973), described
the practice of “thick description” as a way of providing cultural context and meaning that people place
on actions, words, things, etc. Thick descriptions provide enough context so that a person outside the
culture can make meaning of the behaviour. “Thin description,” by contrast, is stating facts without such
meaning or significance. https://cognitive-edge.com/blog/the-thick-and-thin-of-it/
Issue 35 metalogos-systemic-therapy-journal.gr 4
working with complexity and with uncertainty around possible developmental
trajectories (Hutchinson, Midgen & Spiliadis, in press).
There have been some attempts to review the differing clinical/therapeutic
approaches when working with young people with GD. Interestingly more
detailed accounts of these have focused on younger / prepubertal children and
the dilemma of early social transition (Zucker, 2019), or adults rather than
adolescents. Broadly speaking, we can conceptualise competing theoretical
approaches in working with young people with GD, as loosely connecting to
two different polarities: one that would affirm (often perhaps confirm) a young
person’s subjective gender(ed) experience and related hopes (for instance, for
medical interventions) in the context of ‘authentic self-knowledge’ (Lopez,
Marinkovic, Eimicke, Rosenthal, & Olshan, 2017) or on the basis of their
‘privileged access’ (Wren, 2014); and, on the other hand, one that would posit
that offering active therapeutic intervention will effect a change / desistance in
the young person’s identification and therefore lead to congruence with their
natal sex. The first position can be understood as the gender affirmative model
of care (Hidalgo et al., 2013), which initially developed in the USA and was
later adopted by different teams and clinicians throughout the western world
(Keo-Meier, & Ehrensaft, 2018; Lopez, Marinkovic, Eimicke, Rosenthal, &
Olshan, 2017) and is often criticised for its hypothesised underpinning in
neurobiology. An affirmative approach to therapy with people of diverse
sexualities has been well established. However, an affirmative approach to
working with gender questioning young people raises controversy. Clinicians
practicing from such an approach often affirm, perhaps actively confirm, young
people’s wishes for early hormonal (irreversible) and in some cases surgical
interventions in otherwise healthy bodies.
The second approach can be understood as Dreger’s (2009) ‘therapeutic
approach’ involving quite radical interventions that can lead to it being
described as ‘conversion or reparative therapy.’ Such therapeutic
interventions, which in the past have been used as an active attempt to alter
people’s sexual orientation, have been officially described as unethical and
harmful, in the Memorandum of Understanding (MoU) against conversion
therapy, which was signed by many leading UK organisations, such as NHS
England and the UK Council for Psychotherapy (UKCP) among others (Keogh
et al, 2016). It can thus be hypothesised that the description of any
psychological or indeed psychotherapeutic intervention as ‘therapeutic’ for
young people with GD can easily raise concerns with regards to possibly
practicing conversion therapy. The launch of the Memorandum triggered much
debate and some anxiety among clinicians working in the field around what
would be the remit of ethical clinical practice, psychosocial assessment, and
therapeutic exploration. However, the MoU (Keogh et al., 2016) clearly states:
For people who are unhappy about their sexual orientation or their
transgender status, there may be grounds for exploring therapeutic options to
help them live more comfortably with it, reduce their distress and reach a
greater degree of self-acceptance. Some people may benefit from the challenge
of psychotherapy and counselling to help them manage dysphoria and to
clarify their sense of themselves. Clients make healthy choices when they
understand themselves better (p.2).
Issue 35 metalogos-systemic-therapy-journal.gr 5
Therefore, it can be inferred that a psychotherapeutic intervention for gender
questioning young people does not necessarily align with a conversion
approach, as long as the therapist practices from a curious stance, aiming to
support people explore the meaning they make of their symptoms of gender
dysphoria rather than actively ‘guide’ them to a different identification. The
question of ‘what would such a psychotherapeutic intervention entail’ is a valid
one.
Contrary to the discussed theoretical polarities, a third framework or approach
to supporting young people’s gender identity development operates within the
domain of exploration; in that domain, the therapist(s) could actively
acknowledge and respect the young person’s gender identity and subjective
experiences (without attempting to alter these) and at the same time invite
them into an exploratory therapeutic or ‘assessment’ process, in order to better
understand the meaning-making of their gender(ed) and broader selves. This
aligns closely with Di Ceglie’s (2009) psychodynamic - developmental
approach; the founder of GIDS proposed a developmental approach to
working with young people experiencing gender-related distress, where
acceptance, curiosity, unconscious meaning, and projective identification
would be at the core of the therapeutic journey.
While acknowledging Di Ceglie’s psychodynamic approach, I tend to privilege
a relational and systemic framework when working in GIDS; I view people and
therefore their challenges as developing between relationships, contexts, and
multi-layered narratives. I also attend to young people’s developmental needs
and processes; this means I work differently with the family of a 5-year-old,
where I might take up a rather structural systemic approach, as opposed to
working systemically with the family of a 17-year-old service user. I do not view
gender variance as a mental illness; however, I am mindful of the diverse
presentations (and also co-occurring difficulties alongside gender dysphoria)
that some young people present with at GIDS. Through my clinical experience
with gender questioning children, adolescents and adults in the NHS, I have
come to appreciate how therapeutic exploration should be taking place before
as well as through (Wren, 2019) and potentially after any relevant medical
decision-making, and that this could happen within a developmentally informed
systemic framework. What I often call the ‘Gender Exploratory Model (GEM)’ is
an integration of systemic practice with a dynamic developmental lens (Fausto-
Sterling, 2012) -the one that a clinician can develop experience in through
years of practicing within a developmental child an adolescent service like
GIDS. Such an approach can offer a framework through which the young
person’s identity status at a particular moment in time could be acknowledged;
and yet through a process of exploration, the young person could be invited
into a collaborative exploration of their stories lived and told (Pearce, 2007),
through reflective conversations around their embedded and embodied context
(Hardham, 1995) and intergenerational narratives, as well as future hopes
around intimacy which often intersect with both gender identity and sexuality. It
is also important to hold in mind that there is currently no consensus among
thoughtful and committed professionals working in the field of gender identity
development with children and adolescents on whether the administration of
the GnRH analogue (the ‘hormone blocker’) potentially offers all young people
the opportunity to ‘buy time’ and explore or, conversely, serves as a radical
Issue 35 metalogos-systemic-therapy-journal.gr 6
intervention that could arrest wide-ranging physical and emotional
development (Giovanardi, 2017).
The below diagram is an attempt for a brief presentation of different theoretical
approaches:
The above diagram is an attempt to position a systemically informed Gender
Exploratory Model (GEM) away from ‘affirmative’ or ‘reparative’ extremes into a
ground where young people and their significant systems will be invited to
explore broader, as well as gender(ed) identity development within a
collaborative framework. I argue that such an exploration can take place
through different domains of action: production, explanation/exploration, and
aesthetics. Such a distinction can be useful to clinicians wanting to gain
experience in this specialist area, as well as trainees being part of the team,
aiming to link theory to practice.
Domains of action in gender identity work
The Domain of Action theory, as developed by Lang, Little & Cronen (1990)
and based on Maturana’s (1988) theory of human act and existence, serves as
a helpful framework in supporting clinicians and mental health professionals
interested in systemic practice with gender questioning young people and
families to reflect on their clinical responsibilities, acts, moral postures and
their relationship with the notions of neutrality and curiosity (Cecchin, 1987). It
might be helpful to reflect on how this could apply to ‘action’ within a Gender
Identity Service.
Issue 35 metalogos-systemic-therapy-journal.gr 7
Production. The domain of production relates to rules, processes, and ‘realities’
that emerge contextually at any particular time. In GIDS, clinicians are
expected to work in line with the service protocol and to focus on providing
ethical care for young people experiencing gender-related distress. Quite
often, families expect an assessment period between 3-6 sessions and at the
end of this, a report, which includes an agreed care plan. Operating in a
domain of production, clinicians often find questions within a landscape of
action helpful (Bruner, 1986; White, 2007) in order to elicit information and
connect with the young people’s gender narratives. It’s important that clinicians
maintain a curious stance in relation to when the young person started
questioning their gender, how they managed this, whom they shared their
thoughts and feelings with, how their significant others found out and what they
have done (or not done) ahead of their first appointment. The landscape of
action questions can provide information about preferred names and pronouns
and parents’ or carers’ reactions. Within a domain of production, we can often
situate young people’s wishes in relation to medical transitioning. It is often felt
that some service users in GIDS view this specific domain of action as a
stepping-stone to hormonal interventions. Any clinician working in such a
context should acknowledge the importance of that domain for gender
questioning young people and its relevance to good standards of care, in that it
supports young people’s narrative and personal journey.
Explanation. The domain of explanation relates to the exploration of meaning
making in lived experiences, rather than with the search for absolute truths or
aetiologies. In this domain, Cecchin’s (1987) ‘curiosity’ is privileged, as well as
ideas around alternative narratives and the possibility for these. In GIDS, it can
be hypothesised that such a domain offers the opportunity to explore ideas
around diverse gender identity pathways and developmental outcomes
(Churcher Clarke & Spiliadis, 2019), which are not uncommon within a child
and adolescent gender identity service. Within a wider social constructionist
approach, clinicians should continuously reflect on their own relationship to
medical interventions and perhaps challenge dominant narratives around their
necessity.
Questions within a landscape of consciousness (Bruner, 1986; White, 2007)
can help explore young people’s subjective gender identity and experiences.
Inviting the young people to reflect on how they understand their experienced
gender dysphoria, what is the meaning they give to their lived and told
experiences and how these influence others (and are influenced by others) are
of primary importance.
Exploration of key developmental processes, such as intimacy/closeness,
masturbation, meaning making of developing sexuality, is crucial as they offer
the platform through which identity development in broader terms can be
explored. Exploration of cultural influences, religious beliefs, and societal
pressures around gender expression and norms are paramount. As a clinician
who was born and raised in Greece but having lived as an adult in the United
Kingdom, I often locate myself as a person (and as a clinician) within often-
contradictive social realities, where ideas around femininity and masculinity
had their own culturally embedded fixity. Such interventions, within this domain
of action, are not intended to challenge the young person’s gender identity.
Issue 35 metalogos-systemic-therapy-journal.gr 8
However, as aligned with the MoU, they are rather intended to invite young
people (and families where relevant) into a collaborative exploration so they
can better understand their lived experiences and make informed choices.
Aesthetics. The domain of aesthetics relates to how clinicians do what they do –
how they attempt to explore. Attending to the systemic tradition, clinicians
often rely on social constructionist ideas around the co-creation of people’s
subjective experiences. At the same time, by paying close intention to
language, clinicians can embrace the tentativeness that relates to exploring
behaviours and identities in young and still developing children. For instance,
when talking to the parents of a five-year-old child that has been referred to
GIDS, clinicians might prefer to move away from ascribing the identity ‘trans’ to
a minor. They rather might privilege phrases such as ‘gender questioning’ or
‘gender non-conforming,’ which offer multiple developmental possibilities. In
any case, clinicians should practice in line with their professional standards,
attending to difference and diversity and use ongoing clinical supervision to
reflect on how they attempt theory and practice links ethically, while gracefully
attempting to invite ideas around safe uncertainty in systemic conversations
(Mason, 1993).
Beyond the single gender(ed) narrative
The following case, vignette serves as a representative example of exploratory
work in GIDS, grounded in the Gender Exploratory Model. The vignette has
been anonymised and identifying information changed to preserve
confidentiality. Oral and written consent was obtained from both the young
person and the family. The pronouns used to reflect the young person’s
preference at the end of the exploratory work.
Referral. Peter -known then as ‘Louise’-, a 15-year-old white male-bodied
young person, was referred to GIDS by the school counsellor. The referral
included information about Peter’s female identification and his wish to
medically transition so that ‘(s)he could be (her) his true self’. The referral
posited that Peter had done a lot of thinking while growing up in a very
supportive family, in which parents would support him in ‘any decision (s)he
might take.’ The counsellor referred Peter to GIDS formulated that Peter had
always felt different while growing up and that his certainty around his
subjective gender identity had intensified in the last year.
Peter (then Louise) presented as a tall, strong-built young person. He would
usually choose to dress in what he described as ‘stereotypically female
clothes’ and wore his hair long. Peter would talk in length about his
experimentation with make-up, in an attempt to be ‘perceived as more female’.
Exploratory intervention. The work consisted of eleven assessment sessions
(eight family-based; three individual) over a period of twelve months. At the
end of this period, an assessment report was shared with the family and
further exploratory work in GIDS was recommended. This consisted of seven
individual face-to-face sessions over a period of eight months. Peter’s certainty
around his female gender identity was communicated openly at the start and
throughout the assessment. Peter had already pursued a social role transition
Issue 35 metalogos-systemic-therapy-journal.gr 9
and was known as ‘Louise’ in school, at home, and in GIDS. Parents had
consented to an official / legal name change, which the young person had
achieved through a deed poll.
Early on in work, Peter shared with confidence that he wanted to transition
medically through oestrogen and hoped to pursue surgery to alter his
secondary sex characteristics as an adult. He was initially upset about the
lengthy assessment process and struggled to understand the need for a
holistic psychosocial assessment in the context of getting to know him better
and therefore developing a relevant care plan. Most appointments were
attended by Peter and his mother, Maria, who could be described as having
occupied a one-down position (Minuchin, 1974), thus suggesting that she
would support Peter in any decision he took and that she did not feel able to
express her own view.
Peter lived at home with his biological parents and two older sisters. All were
supportive of Peter’s wishes and felt that he had finally ‘found his authentic
self’. Peter was initially focused on the domain of production with regards to his
transition into a female role. He spoke about his realisation at the age of 14
that he must be trans, which he connected to his lived experience of ‘always
feeling different’. Peter was well into puberty and had acknowledged that his
voice had already got deeper. However, he was clear that he was experiencing
significant distress due to body-hair growth, as he felt this did not align with his
female identification. Peter was complaining about his body image and his
dislike of his broad shoulders. I was struck by Peter’s account of his coming
out process. He initially shared his body-related distress online, initially with a
trans-affirmative community-based in the USA. He spoke about how the
community quickly affirmed with experienced distress as signifying that ‘he
must be trans.’ I expressed my surprise by reflecting on the fact that the
diagnosis of gender dysphoria was initially given by these other young people
that Peter had never met in his ‘offline’ life, rather than an experienced
professional. By doing so, I was aware I was communicating an ‘expert’
positioning for myself; expertise not in relation to Peter’s gender identity or
communicated distress but rather an expertise in relation to having worked
with similar presentations in the NHS.
By focusing on questions within a landscape of action, I was able to elicit
information on the timing of his coming out, as well as the length of what was
described as gender dysphoria. It soon transpired that Peter had been given
this diagnosis a few years after his onset of puberty and that his realisation
that he should be trans connected with some linear hypotheses mainly around
his gender expression and relational challenges in school, mainly in the
context of being bullied or feeling excluded.
There were times when I felt that Peter might disengage from the exploratory
process, mainly due to him insisting on starting hormonal treatment as soon as
possible. I attended to his wishes by reflecting on how challenging it must be
for him perceiving me as wanting to support him to ‘think more,’ whilst for him
‘acting on his wishes to transition medically’ was of primary importance.
Locating myself openly as a white, male, cisgender, non-native speaker
clinician and attending to the power dynamics relating to myself as the
Issue 35 metalogos-systemic-therapy-journal.gr 10
gatekeeper of Peter’s medical intervention, opened up more space for
relational reflexivity and impacted positively on the therapeutic alliance.
I invited Peter to reflect on different aspects of his embodied distress. I noticed
that Peter focused on his fixation with body hair and we thought together how
there might be alternative ways for him to manage this while continuing with an
explorative assessment. These conversations led to Peter trying out laser
treatment, which eventually alleviated part of his experienced dysphoria and
opened up space for further exploration. It was felt that this allowed for Peter’s
urgency to medically transition slow down and gradually opened up space for
further exploration.
Within a domain of explanation, I expressed my curiosity around Peter’s
meaning making around his sexuality. These conversations took place over a
number of sessions, and it was through revisiting them often that Peter
gradually became more interested in these. His initial avoidance to explore
sexuality was understood in the context of his past experience of bullying.
Peter was able to share how, from a young age, he enjoyed trying out his older
sisters’ clothes and playing with make-up. While this was supported at home,
he reflected on regularly experiencing homophobic bullying and teasing in
school. It soon transpired that Peter had decided not to share this with his
family, as he connected it to a sense of shame and hopelessness. I wondered
about the impact of this on Peter’s psychosexual development and meaning
making of his embodied identity; through reflective conversations, I was struck
by the impact of societal pressures and stereotypes on his gender(ed) self.
Peter was reflective about how different levels and contexts of his daily reality
interacted in a dynamic and how he often experienced oppression with regards
to his freedom to live comfortably in his body. People in his neighbourhood
would openly disapprove of his gender fluidity as a developing adolescent,
while he would struggle to develop friendships with males in his local youth
centre, as he was never interested in rough and tumble activities. Peter soon
reflected on how contact with the trans-affirmative online community had given
him a sense of safety and felt supported by ‘other young people who felt
different from the norm’. Through deconstructing these narratives, it gradually
became apparent that Peter’s distress mainly connected to the
disempowerment he had felt as a young adolescent.
Issue 35 metalogos-systemic-therapy-journal.gr 11
I sought permission (Aggett, Swainson & Tapsell, 2015) to ask ‘landscape of
consciousness’ questions around Peter’s experience of puberty and
relationship to genitalia and masturbation. Peter reflected on how he found
pleasure in masturbation and ejaculation and gradually started talking more
openly about his sexual fantasies. Having not had any intimate experiences,
Peter felt that the only way for him to find relational / intimate pleasure in the
future would only be possible after a medical transition. He described how he
thought this would be the only way possible for him to take up a more feminine
role; this was understood to serve as a thin narrative in relation to his gender
identity development and how this was perhaps (at times) conflated with his
emerging sexuality (White, 2001). While acknowledging Peter’s subjective
gender(ed) status and attending to Peter’s wishes around preferred pronouns
and name, I aimed to enrich the narratives available to him and shared
experiences of male-bodied young people starting of GnRH analogue
treatment. I shared how this treatment often suppresses young people’s libido
and how there are still many ‘unknown unknowns’ on how this might affect
young people’s intimate experiences. During the later phase of the exploratory
work, therapeutic alliance improved significantly. Peter would come in with
ideas around which aspects of his identity development he would like to
explore and would often reflect on how his confidence had improved, and his
Issue 35 metalogos-systemic-therapy-journal.gr 12
experienced dysphoria had weakened. It was during this phase that I noticed
Peter not referring to medical intervention and his wish to transition.
Soon after his 17th birthday, Peter presented to GIDS having cut his hair short
and without wearing make-up. Peter shared that he had had his first intimate
experience with another male-bodied young person, in what he described as a
consensual sexual act. He reflected on how this had served as an important
developmental process for him in that he allowed him to connect with another
aspect of his identity, namely his sexuality, which he felt he had ignored
throughout the years. Peter spoke confidently about his wish to start
experimenting with a more fluid, rather than a stereotypically female, identity
and asked to put a pause to a referral for hormonal interventions.
When asked what enabled him to understand himself in a different way to how
he initially presented to GIDS, Peter spoke about the invitation from the GIDS
to explore the meaning of his multi-layered identities. He was able to share
how his initial frustration around the staged approach of our interventions was
gradually alleviated by him feeling understood and listened in the consulting
room. During the last session, Peter asked me to start using his birth name
and male (he/him) or gender neutral (they/them) pronouns. It was agreed that
a review session would take place after six months in order to revisit Peter’s
care plan and to potentially agree on his discharge from the service, as Peter
no longer wished to pursue hormonal interventions.
Conclusion
In this paper, I attempted to move away from current theoretical polarities
around psychosocial support for gender questioning young people and invite
the reader to a different approach, the Gender Exploratory Model. Drawing on
systemic and developmental theories, clinicians working with gender identity
can invite service users into a process of collaborative exploration, whilst being
mindful of the different domains of their action and the intersection with
different contexts of the embodied and narrated distress. Such a model offers
more possibilities with regards to assessment outcomes and young people’s
developmental trajectories. I do not claim the universal application of such an
approach, as it is well documented that different countries have different
regulations and protocols on the treatment of gender dysphoria in childhood
and adolescence.
However, this theoretical underpinning seems pertinent to the current UK
clinical context, the ever-shifting landscape in the consulting room, as well as
systemic training and approaches. Clinicians ought to respect the young
person’s identity and gender expression, acknowledge the communicated
embodied distress, and simultaneously invite service users into a process of
exploration which can safely and respectfully shed light into the meaning-
making of the lived experiences.
Finally, the dynamic intersection of gender identity with other markers of
broader identity and psychosexual development is important, as is the
acknowledgement that the notion of uncertainty is central in exploratory work
with gender questioning or trans-identified young people. Systematic research
into the different theoretical approaches utilised in different gender services
Issue 35 metalogos-systemic-therapy-journal.gr 13
can offer important qualitative and quantitative data and can serve as a base
for future developments of clinical practice and service delivery.
Declaration of conflicting interests
The author declared no potential conflicts of interests concerning the
authorship and/or publication of this article.
The views, thoughts, and opinions expressed in this article belong solely to the
author and don’t necessarily express the views of the author’s employer,
organisation, committee, or other groups and individuals.
References
Adichie, C. N. (2009, July). The danger of a single story.
Retrieved from https://www.youtube.com/watch?v=D9Ihs241zeg
Aggett, P., Swainson, M., & Tapsell, D. (2015). ‘Seeking permission’: an interviewing stance
for finding connection with hard to reach families. Journal of Family Therapy, 37(2), 190-209.
Bateson, G. (1963). Exchange of information about patterns of human behavior. Information
storage and neural control, 173-86.
Bechard, M., VanderLaan, D. P., Wood, H., Wasserman, L., & Zucker, K. J. (2017).
Psychosocial and psychological vulnerability in adolescents with gender dysphoria: A “proof
of principle” study. Journal of Sex & Marital Therapy, 43(7), 678-688.
Boyd White, J. (1984). When words lose their meaning: Constitutions and Reconstitutions of
Language, Character, and Community. Chicago: University of Chicago.
Bruner, J. S. (1986). Actual minds, possible worlds. Cambridge: Harvard University Press.
Ceccin, G. (1987). Hypothesizing, Circularity, and Neutrality Revisited. Family Process,
26(4), 405-413.
Churcher Clarke, A., & Spiliadis, A. (2019). ‘Taking the lid off the box’: The value of
extended clinical assessment for adolescents presenting with gender identity difficulties.
Clinical child psychology and psychiatry, 1359104518825288.
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., &
Monstrey, S. (2012). Standards of care for the health of transsexual, transgender, and gender-
nonconforming people, version 7. International journal of transgenderism, 13(4), 165-232.
Davidson, S., & Eracleous, H. (2009). The gender identity development service: Examples of
multiagency working. In Clinical Psychology Forum (No. 201, pp. 46-50). BPS.
de Graaf, N. M., & Carmichael, P. (2019). Reflections on emerging trends in clinical work
with gender diverse children and adolescents. Clinical child psychology and psychiatry, 24(2),
353-364.
de Vries, A. L., Doreleijers, T. A., Steensma, T. D., & Cohen‐Kettenis, P. T. (2011).
Psychiatric comorbidity in gender dysphoric adolescents. Journal of Child Psychology and
Psychiatry, 52(11), 1195-1202.
Dhejne, C., Öberg, K., Arver, S., & Landén, M. (2014). An analysis of all applications for sex
reassignment surgery in Sweden, 1960–2010: prevalence, incidence, and regrets. Archives of
sexual behavior, 43(8), 1535-1545.
Issue 35 metalogos-systemic-therapy-journal.gr 14
Dreger, A. (2009). Gender identity disorder in childhood: Inconclusive advice to parents. The
Hastings Center Report, 39(1), 26-29.
Fausto-Sterling, A. (2012). The dynamic development of gender variability. Journal of
Homosexuality, 59(3), 398-421.
Giovanardi, G. (2017). Buying time or arresting development? The dilemma of administering
hormone blockers in trans children and adolescents. Porto Biomedical Journal, 2(5), 153-156.
Hardham, V. (1996). Embedded and embodied in the therapeutic relationship: understanding
the therapist’s use of self systemically. In C. Flaskas, A. Perlesz (Eds). The Therapeutic
Relationship in Systemic Therapy, pp. 71-89. Karnac, London.
Hardham, V. (1996). Embedded and embodied in the therapeutic relationship: understanding
the therapist’s use of self systemically. The therapeutic relationship in systemic therapy, 71-
89.
Hidalgo, M. A., Ehrensaft, D., Tishelman, A. C., Clark, L. F., Garofalo, R., Rosenthal, S.
M., ... & Olson, J. (2013). The gender affirmative model: What we know and what we aim to
learn. Human Development, 56(5), 285-290.
Holt, V., Skagerberg, E., & Dunsford, M. (2016). Young people with features of gender
dysphoria: Demographics and associated difficulties. Clinical child psychology and psychiatry,
21(1), 108-118.
Hutchinson, A., Midgen, M., & Spiliadis, A. (in press). In Support of Research Into Rapid-
Onset Gender Dysphoria. Archives of Sexual Behaviour.
Kaltiala-Heino, R., Sumia, M., Työläjärvi, M., & Lindberg, N. (2015). Two years of gender
identity service for minors: overrepresentation of natal girls with severe problems in
adolescent development. Child and Adolescent Psychiatry and Mental Health, 9(1), 9.
Keo-Meier, C., & Ehrensaft, D. (Eds.). (2018). The gender affirmative model: An
interdisciplinary approach to supporting transgender and gender expansive children.
American Psychological Association.
Keogh, B., Calderwood, C., Ruddle, A., Newell, R., Hawkins, A., Lousada, J., & Weisz, J.
(2016). Memorandum of understanding on conversion therapy in the UK.
Kreukels, B. P., & Cohen-Kettenis, P. T. (2011). Puberty suppression in gender identity
disorder: the Amsterdam experience. Nature Reviews Endocrinology, 7(8), 466.
Lang, P., Little, M., & Cronen, V. (1990). The systemic professional: domains of action and
the question of neutrality. Human Systems, 1(1), 34-49.
Levine, S. B. (2018). Transitioning back to maleness. Archives of sexual behavior, 47(4),
1295-1300.
Lopez, X., Marinkovic, M., Eimicke, T., Rosenthal, S. M., & Olshan, J. S. (2017). Statement
on gender-affirmative approach to care from the pediatric endocrine society special interest
group on transgender health. Current opinion in pediatrics, 29(4), 475-480.
Marcus, L., Marcus, K., Yaxte, S. M., & Marcus, K. (2015). Genderqueer: One family’s
experience with gender variance. Psychoanalytic Inquiry, 35(8), 795-808.
Mason, B. (1993). Towards positions of safe uncertainty. Human Systems: The Journal of
Systemic Consultation and Management, 4, 189–200.
Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press.
Pearce, W. B. (2007). Making social worlds: A communication perspective. Malden, MA:
Blackwell Publishing.
Seikkula, J., & Olson, M. E. (2003). The open dialogue approach to acute psychosis: Its
poetics and micropolitics. Family process, 42(3), 403-418.
Issue 35 metalogos-systemic-therapy-journal.gr 15
White, M. (2001). Narrative practice and the unpacking of identity conclusions. Gecko: A
journal of deconstruction and narrative ideas in therapeutic practice, 1, 28-55.
White, M. K. (2007). Maps of narrative practice. WW Norton & Company.
Wren, B. (2014). Thinking postmodern and practicing in the enlightenment: Managing
uncertainty in the treatment of children and adolescents. Feminism & Psychology, 24(2), 271-
291.
Wren, B. (2019). Reflections on ‘Thinking an Ethics of Gender Exploration: Against Delaying
Transition for Transgender and Gender Variant Youth’. Clinical child psychology and
psychiatry, 24(2), 237-240.
Zucker, K. J. (2019). Debate: Different strokes for different folks. Child and Adolescent
Mental Health.
Issue 35 metalogos-systemic-therapy-journal.gr 16
... The gender affirmative model of care may leave some or all of these psychological factors unaddressed because one of its basic tenets is that the role of the therapist is to affirmor confirmwhat the patient 'knows' (Spiliadis 2019). I believe that this principle is in direct opposition to usual and best psychotherapeutic practice: the role of the therapist is to open space for exploration, for nuanced thinking and expanded and deepened self-understanding. ...
Article
Full-text available
Within the last decade, there has been a sharp global rise in the number of young people identifying as transgender. More recently, there appears to be an increase in the numbers of young people detransitioning or returning to identifying with their natal sex after pursuing medical transition. A case is presented of a young woman who pursued a gender transition and returned to identifying as female after almost two years on testosterone. The author considers and critiques the affirmative model of care for gender dysphoric youth in light of this case.
... But given the complexities of the gender dysphoria described in the current study, one might consider a low bar of "adequate" to be the exploration of factors that could be misinterpreted as non-temporary gender dysphoria as well as factors that could be underlying causes for gender dysphoria. The most recently emerging approach to gender dysphoria is called the "exploratory approach" which is a neutral psychotherapeutic approach to help individuals gain a deeper understanding of their gender distress and the factors contributing to their dysphoria (Churcher Clarke & Spiliadis, 2019;Spiliadis, 2019). The study's findings suggest that an exploratory type of approach may have been beneficial to some of the respondents. ...
Article
Full-text available
The study’s purpose was to describe a population of individuals who experienced gender dysphoria, chose to undergo medical and/or surgical transition and then detransitioned by discontinuing medications, having surgery to reverse the effects of transition, or both. Recruitment information with a link to an anonymous survey was shared on social media, professional listservs, and via snowball sampling. Sixty-nine percent of the 100 participants were natal female and 31.0% were natal male. Reasons for detransitioning were varied and included: experiencing discrimination (23.0%); becoming more comfortable identifying as their natal sex (60.0%); having concerns about potential medical complications from transitioning (49.0%); and coming to the view that their gender dysphoria was caused by something specific such as trauma, abuse, or a mental health condition (38.0%). Homophobia or difficulty accepting themselves as lesbian, gay, or bisexual was expressed by 23.0% as a reason for transition and subsequent detransition. The majority (55.0%) felt that they did not receive an adequate evaluation from a doctor or mental health professional before starting transition and only 24.0% of respondents informed their clinicians that they had detransitioned. There are many different reasons and experiences leading to detransition. More research is needed to understand this population, determine the prevalence of detransition as an outcome of transition, meet the medical and psychological needs of this population, and better inform the process of evaluation and counseling prior to transition.
... These individuals, searching for ways to understand and remedy their distress, can incorrectly attribute their discomfort to being transgender. Several case reports (Churcher Clarke & Spiliadis, 2019;Lemma, 2018;Spiliadis, 2019) indicate that the distress of young people with GD can lessen or resolve with appropriate psychotherapeutic interventions that address the central issues. ...
... If what has preliminarily been referred to as rapid onset gender dysphoria (ROGD) represents a new developmental pathway to gender dysphoria and transgender identification, one where psychosocial factors including social influence, trauma, homophobia, maladaptive coping mechanisms, and psychiatric disorders are contributing factors or even causal to identifying as transgender, it would disprove the premise that psychological issues can only be responses to negative experiences, not intrinsic to the process. If it is confirmed that one population of gender dysphoric individuals is harmed by approaches that affirm gender identity without questioning and benefits from extended clinical assessment (Clarke & Spiliadis, 2019) and a gender exploratory model (GEM) approach (Spiliadis, 2019), the evaluation process for gender dysphoric Gender dysphoria refers to the persistent discomfort from the incongruence between a person's experienced gender identity and their natal sex. The term gender incongruence refers to the difference between experienced gender identity and natal sex but discomfort or distress is not required. ...
Article
Full-text available
We conducted a systematic review of research into transgender and gender non-conforming people's experiences of psychological therapy. Ten studies were subjected to a thematic meta-synthesis, resulting in two analytic themes and five subthemes. One theme was concerned with participants' experiences of how gender was approached in therapy, including experiences of it being overemphasized, ignored, or pathologized. The second theme related to participants' views on their therapists' identities, and their approaches to therapeutic work and social action. We argue that therapists should be mindful of issues of power in the co-creation of therapeutic relationships and that therapists should discuss with clients about whether and how gender is discussed within therapy.
Article
In less than a decade, the western world has witnessed an unprecedented rise in the numbers of children and adolescents seeking gender transition. Despite the precedent of years of gender-affirmative care, the social, medical and surgical interventions are still based on very low-quality evidence. The many risks of these interventions, including medicalizing a temporary adolescent identity, have come into a clearer focus through an awareness of detransitioners. The risks of gender-affirmative care are ethically managed through a properly conducted informed consent process. Its elements-deliberate sharing of the hoped-for benefits, known risks and long-term outcomes, and alternative treatments-must be delivered in a manner that promotes comprehension. The process is limited by: erroneous professional assumptions; poor quality of the initial evaluations; and inaccurate and incomplete information shared with patients and their parents. We discuss data on suicide and present the limitations of the Dutch studies that have been the basis for interventions. Beliefs about gender-affirmative care need to be separated from the established facts. A proper informed consent processes can both prepare parents and patients for the difficult choices that they must make and can ease professionals' ethical tensions. Even when properly accomplished, however, some clinical circumstances exist that remain quite uncertain.
Article
Full-text available
As the number of young people referred to specialist gender identity clinics in the western world increases, there is a need to examine ways of making sense of the range and diversity of their developmental pathways and outcomes. This article presents a joint case review of the authors caseloads over an 18-month period, to identify and describe those young people who presented to the Gender Identity Development Service (GIDS) with gender dysphoria (GD) emerging in adolescence, and who, during the course of assessment, ceased wishing to pursue medical (hormonal) interventions and/or who arrived at a different understanding of their embodied distress. From the 12 cases identified, 2 case vignettes are presented. Implications for the development of clinical practice, service delivery and research are considered.
Article
Full-text available
Thirty-one years after living full time as a woman, a 53-year-old skilled machinist returned to have therapy with me, a psychiatrist, because of a decision to return to living as a man. As our work together continued, I suggested to this would-be published novelist that others might benefit from his experience. This led to his posting an extensive account of his life in September 2016 on Gender Trender. Now living in good mental and physical health as a male, he has given me permission to discuss his initial presentation, my understanding of his motivations, and to reflect on the broader questions that his life rises for the field of transgenderism. This report describes regret, defenses against regret, and a dramatic 3-day catharsis followed by the patient’s first loving relationship. He now ironically reflects that he escaped from the sensed inauthenticity of his youthful maleness only to create a felt inauthentic feminine social psychological state. The professional literature about the long-term outcome of the transgendered who do not have surgery is largely nonexistent in English. Anecdotal accounts, however, are readily accessible on the Internet.
Article
Full-text available
In recent years, the use of gonadotropin-releasing hormone (GnRH) analogues in adolescents with gender dysphoria (GD) to suppress puberty has been adopted by an increasing number of gender clinics, generating controversial debate. This short essay provides an overview of the difficulties associated with this heterogeneous group of adolescents and discusses arguments for and against the suspension of puberty. Further, it reviews the main follow-up studies conducted in some of the world's largest clinical centres for gender-variant children and adolescents.
Article
Full-text available
Increasing numbers of adolescents present in adolescent gender identity services, desiring sex reassignment (SR). The aim of this study is to describe the adolescent applicants for legal and medical sex reassignment during the first two years of adolescent gender identity team in Finland, in terms of sociodemographic, psychiatric and gender identity related factors and adolescent development. Structured quantitative retrospective chart review and qualitative analysis of case files of all adolescent SR applicants who entered the assessment by the end of 2013. The number of referrals exceeded expectations in light of epidemiological knowledge. Natal girls were markedly overrepresented among applicants. Severe psychopathology preceding onset of gender dysphoria was common. Autism spectrum problems were very common. The findings do not fit the commonly accepted image of a gender dysphoric minor. Treatment guidelines need to consider gender dysphoria in minors in the context of severe psychopathology and developmental difficulties.
Article
In this short article are offered some brief reflections on the commissioned response to my article on ethical issues arising in the provision of medical interventions for gender diverse children. Ashley argues for the importance of ‘an ethics of exploration’ which prioritises making opportunities for fluid, open-ended reflection by gender diverse children and young people, operating through and alongside, rather than prior to, social and medical transition. While noting significant areas of shared outlook between Ashley and myself, I correct some assumptions that Ashley may be making about the range of young people seen at the UK Gender Identity Development Service (GIDS) and the way we work clinically within a developmental framework. I highlight my reasons for thinking that there are particular concerns arising in the care of the very young. Finally, I reiterate my view that professionals cannot so easily abandon altogether an ‘ethic of prediction’ and surrender their responsibilities and accountabilities in this area of clinical practice.
Article
Gender is a fast-evolving and topical field which is often the centre of attention in the media and in public policy debates. The current cultural and social climate provides possibilities for young people to express themselves. Gender diverse young people are not only developing new ways of describing gender, but they are also shaping what is required of clinical interventions. Emerging cultural, social and clinical trends, such as increases in referrals, shifts in sex ratio and diversification in gender identification, illustrate that gender diverse individuals are not a homogeneous group. How do evolving concepts of gender impact the clinical care of gender diverse young people presenting to specialist gender clinics today?
Article
Purpose of review: The purpose of this Position Statement is to emphasize the importance of an affirmative approach to the health care of transgender individuals, as well as to improve the understanding of the rights of transgender youth. Recent findings: Transgender youth have optimal outcomes when affirmed in their gender identity, through support by their families and their environment, as well as appropriate mental health and medical care. Summary: The Pediatric Endocrine Society Special Interest Group on Transgender Health joins other academic societies involved in the care of children and adolescents in supporting policies that promote a safe and accepting environment for gender nonconforming/transgender youth, as well as adequate mental health and medical care. This document provides a summary of relevant definitions, information and current literature on which the medical management and affirmative approach to care of transgender youth are based.
Article
Accounts of the experiences of gender variant individuals that have recently received attention in the popular and psychoanalytic literature have led to an increased appreciation for the complex nature of identity; gender development; and the interaction of mind, body, and the social environment. Although there is still a great deal to be learned about the developmental trajectories of transgender identities that fall within what is a more familiar, male/female binary-based landscape, even less is known about developmental pathways for individuals whose gender identities remain neither comfortably male nor female. In this article, we present selected episodes reflecting our experiences as a family, drawn from over a 25-year period in which a gender variant individual, along with the rest of us, grew up. We tell this storyour family's storyto better understand what we have been through and learned, to help other families going through similar experiences, and as a thought-piece to clinicians and students of gender. The result is both a narrative and a meditation on the nature of gender identity and gender development.