To Be, or Not to Be? More Counseling Needed for Gender Dysphoria

Becky McCall

August 19, 2021

Clinicians should not blindly accept a person's self-diagnosis as transgender and desire to medically transition without closer inspection; rather, they should make a distinction between 'acceptance' and conducting an in-depth, respectful, and collaborative exploration of an individual's claims about what they believe will best promote their well-being.

These are the conclusions of two experts in ethics and clinical psychology in an extended essay published in the Journal of Medical Ethics.

"It's not about making life harder for people who wish to transition but about improving care for all people who identify as transgender," said lead author Alessandra Lemma, DClin Psych, visiting professor in the psychoanalysis unit at University College London, UK, speaking to Medscape Medical News.

She stressed that the argument is neither for nor against medical transitioning per se.

"It's an invitation to think about how the medical and mental health care communities can best support anyone considering a transition, whether they eventually pursue that course of action or not. The provision of psychotherapy, irrespective of whether the individual medically transitions or not, makes for a better outcome either way," said Lemma, who cares for adolescents as well as adults with gender dysphoria in her private practice in London.  

Reflective Space Has Been Eroded in Gender Identity Services for the Young

There has been an exponential increase in the number of adolescents who identify as transgender in Western countries in recent years. Medscape Medical News has covered the debate in detail, which has intensified worldwide in the last 12 months, regarding how best to treat youth with gender dysphoria.

This has "raised concern about how the laudable aims of gender affirmative care may be ushering children and young people too quickly into medical transitioning," generally defined as treatment with puberty blockers in minors followed by cross-sex hormones to transition to the opposite sex, "leading subsequently to a wish to detransition with all the attendant physical and psychological complications," write Lemma and her co-author, Julian Savulescu, MD, professor of practical ethics, University of Oxford, UK.

While the UK and other countries such as Finland have tightened regulations regarding the treatment of minors, "these medical interventions continue to be provided in many other countries," they note.

Such affirmative care has recently been interpreted by "influential sections of the transgender community" as forbidding "'questioning' of any kind of the person's stated gender and what will help them," the essayists state.

But Lemma noted that, for teenagers, this is typically a time to "try on" different identities and ways of presenting oneself to the world.

"All this requires a reflective space during the decision-making process, and this has been eroded in many gender identity services for young people especially, with a massive pressure on services."

Family issues, trauma, and comorbid conditions can all influence people too, she notes, adding that what may be happening unconsciously may be driving the decision to modify the body.

"I cannot see that it would be harmful to anyone to have the opportunity to really think about what they are doing before making decisions about medical interventions," she asserted.

Decision to Transition Must Be Judged to Be Autonomous

Lemma notes that even in those instances where medical transitioning, on balance, is the best option, it's important to acknowledge that the process has a psychological impact.

"What matters is that in facing a major life-changing decision, an individual has the opportunity to understand the developmental and social experiences that drive their experience of gender dysphoria such that the decisions they make about medical transitioning can be said to be taken more autonomously," she and Savulescu write.

And for those people who opt for full gender reassignment surgery, they are the first to say, "I don't think I could have got through this as well as I have without psychological support," Lemma remarked.

Ultimately, what's important is to ensure the protection of those individuals whose needs will most likely not be met by medical transitioning, while not making it impossible for those who are suffering to get the care they need in order to transition, she concluded. 

J Med Ethics. Published online July 30, 2021. Full text

Until 2016, Lemma was professor of psychological therapies at the Tavistock and Portman NHS Foundation Trust and Essex University. During that time she worked with adult transgender individuals at the Portman Clinic but not at the Gender Identity Service at the Tavistock Clinic. Currently, she works in private practice with transgender individuals at the Queen Anne Street Practice, London. Savulescu has reported no relevant financial relationships.

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