Prologue –
As I write this, it is Pride month. Silva Neves, Pink Therapy Clinical Associate and author of Sexology: The Basics (Neves, 2022) has articles in the current editions of both Therapy Today (Neves, 2023a), the BACP’s main journal and in The New Psychotherapist (Neves 2023b), published by the UKCP. The former begins with a question to the reader, ‘Are you GSRD competent?’, the latter is a question-and-answer piece on Neves’ work and on the shortfalls of generic therapy services working with the LGBTQ+ community. Reading both articles, it struck me that ‘gender, sexual and relationship diversity’ has very rapidly become central – and rightly so – to the psychotherapy and counselling conversation. To be perfectly honest, too, I was also struck by how much the UKCP particularly appears keen to have Neve’s endorsement. In the New Psychotherapist article, he confirms that he feels very supported by them in ‘driving forward change’. I am writing this essay because I want to raise some questions about the nature and, in part, the pace of that change.
Now that I’m doing this, I am aware of a very strong sense of self-censure over what I want to say. I’m afraid of condemnation from my peers. As Chimamanda Ngozi Adichie (BBC, 2022) has suggested recently, it is very difficult to speak to the truth when it does not align with views held by members of our political tribe. I know that I may be regarded as transphobic by some people even though what motivates me now is the same thing that motivates me elsewhere in my life and as a therapist: the pleasure and importance of connecting with other people, of imagining that out of human contact can come an elevated sense of mutual appreciation and understanding.
I am wholly behind current legislative plans to outlaw all conversion therapies, including those that relate to trans people. The idea that therapists should treat as wrong a person’s sexual preferences or try to correct a client or patient’s sense of their own identity from a gender normative perspective is clearly objectionable. Like most therapists, I want to be as transparently inclusive as possible. What I find disappointing, nonetheless, is that two important therapy journals, publications that represent counsellors and psychotherapists nationally, seem wholeheartedly to have taken on, in an uncritical way, a relatively new – or perhaps emerging – language for psychotherapy, in this case, ‘GSRD’, and also new principles of psychotherapeutic practice.
My particular concerns relate to some of the underlying assumptions behind GSRD, as described by Neves. For instance, in his piece in Therapy Today, he tells us that:
‘[A] GSRD-informed therapist does not collude with clients’ sense of brokenness; instead, they help their clients locate the source of their distress in the heteronormative, mononormative and cisgenderist[i] world rather than within themselves’ (Neves, 2023a, p22).
He goes on further to say that helping clients to:
‘shift their mindset from “I am broken” to “heteronormativity is hurting me” reduces clients’ shame about their struggles and helps them relocate the source of their distress in the appropriate place, which is external oppression [my italics]’ (Neves, 2023, p22).
What goes unnoticed in both articles, I believe, is that Neves seems to be exchanging one prejudicial agenda, that of homophobic and transphobic conversion practices, for another, a homogenising two-dimensional view of the mental health needs of LGBTQ+ people. Neves is undoubtedly a very skilled therapist and what he has to say is of interest and importance. It would nonetheless be difficult not to conclude, in the current polarised discourse around this issue, that simply to cross the line and come out as LGBTQ+ affirming means, at least to a certain degree, that you’re ‘in’, where not to do so means that you’re ‘out’.
What is missing here, I would argue, is an understanding of the nuances of the therapeutic relationship and of the context in which many counsellors and psychotherapists work. I fear we are becoming a little deaf to the ongoing debate about gender and sexuality which, as the experiences of people such as the philosopher and author Kathleen Stock will testify, divides not only different groups in society at large but also within the LGBTQ+ community itself (Stock, 2021). If, as the BACP’s former Chair Natalie Bailey (Bailey, 2021) has suggested, working ethically is simply a matter of ‘competence’, my respectful response would be that we need do more than to induct therapists into GSRD competencies as best practice when, as will be shown, those practices themselves raise some serious questions and concerns. It is my view that, in effect, we are at risk of simply stating and restating our conclusions without – as my erstwhile maths teacher would have said – showing our ‘working out’.
Like many other therapists, my aim is always to be inclusive and to practise in an ethical and humane way. For what it’s worth, this for me means resisting the blandishment of political correctness, just as I resist racism, sexism, ageism and prejudices suffered by people with seen or unseen disabilities. To this end, I wish to write about things that concern me in a genuine attempt to make a meaningful contribution to debate. And, to echo Adichie’s views, I don’t ever want to be afraid to attempt to discern the truth of things.
In what follows, I will offer a very brief overview, as I see it, of the current debate concerning gender. I will also offer my own thoughts on why affirming people in their preferred gender identity is helpful and appropriate whilst sounding a note of caution as concerns the importance of evidence. Lastly, I will look at the particular implications of the transgender debate for psychotherapeutic practise.
1. History –
In 1990, the philosopher Judith Butler published her seminal work, ‘Gender Trouble’ (Butler,1990), in which she described ‘gender’ as a kind of performance. More radical than other feminist writers before her, Butler argued that it is the performative nature of such socially prescribed binary categories as female/male, gay/straight, feminine/masculine – man/woman, even – that makes them real; these categories are real only because we perform them.
Butler’s thesis opened up the way gender has subsequently been thought about, both inside and outside of academia. The main instrument for the broadening of interest in gender issues, beyond any doubt, has been social media (Faye, 2021).
For two related reasons, women’s experience has been a particular focus of the debate around gender. Firstly, some women feel strongly that their ‘spaces’ are under threat from the trans movement. This is not simply a question of the encroachment of trans women into women’s sports, women’s politics or women’s bathrooms; many women feel that the trans issue itself represents just another way for men to silence women’s voices. Trans women, conversely, regard the term ‘woman’ as being unfairly confined within an exclusive biological category that fails to acknowledge their rights and experience as women. The term ‘gender’ has therefore shifted its ground to emphasise self-experience in preference to categorical notions of biological sex. Sex is about bodies, gender is about ‘identity’.
Effectively, the trans movement has adopted Butler’s idea of the constructed nature of gender to argue that sex is irrelevant, that gender and identity are personal, not biological, that they are to do with feelings and personal ‘truths’, rather than oppressive, reductive ideas of anatomy. For some, this liberating idea was a final step in freeing everyone from ‘binary’ categories, enabling each of us to self-identify[ii].
2. Reasons for caution –
Lots of people – particularly young people – feel liberated by the freedom to express themselves under the rainbow umbrella. A number of issues are, however, worth drawing out. For instance, tensions exist between some members of the trans community and gay and lesbian people who do not wish to drop the biological nature of being either a man or a woman because this is part and parcel of who they feel they are. Some lesbian women particularly have experienced a degree of conflict with the trans movement on the basis that they desire biologically female sexual partners rather than, say, pre-or post-operative trans women. This has led to accusations of transphobia levelled at some women.
It is important to acknowledge, without qualification, the reality of misogyny in some sectors of the trans community, as more widely in society. It is not an accident that, as discussed, the meaning of ‘woman’ rather than ‘man’ has been and remains so contentious. It tends to be women who are attacked for their ‘anti-trans’ views on social media and in the workplace rather than their male counterparts (Davies, 2023). The term TERF – trans-excluding-radical-feminist – has become both a form of attack in the public debate around gender and a form of defence with some feminists embracing it.
*
Any therapist or counsellor working in a medical setting needs to be aware that whilst trans-women are at an elevated risk of prostate cancer as compared with men (and, of course, with women) they are at no risk at all of endometriosis. These facts are obvious but important. Slightly more contentious are NHS findings that show self-identification as transgender amongst young people often to be one factor in a wider picture of mental health and family issues (BBC, 2023). Also, a statistically significant number of trans children are known to be neurodiverse (Wassell, 2023). And, perhaps the most difficult bit of medical evidence to chew on is the fact that the great majority of cases of gender dysphoria in children will desist and resolve without the need for gender reassignment surgery; many of these children are in fact gay and will mature to be happy in their bodies (Soh, 2020).
The feeling of being transgendered, for some young people especially, but also adults, may be something that feels like a solution to underlying problems, whether problems of identity, sexuality or something else. For some, being supported to transition medically will be the best resolution to what may have been a lifetime of struggle. Other people need support to enable them to identify as they wish, to live life to the full, without the need to undergo surgery. And for some people, their problems will stem from being young or immature and misreading the trend toward gender-focused self-appraisal as a way out of difficulty.
3. Therapy –
Prejudice is experienced on a daily basis by trans people themselves who with ample reason feel misunderstood in many ways and who have been frequently subject to abuse and violence. The whole picture is not helped by polemical media-types and hardline trans/anti-trans activists. It is crucially important for therapists – anyone – to understand that the very idea of a ‘trans debate’ is, for some, evidence of a widespread transphobia and an intrinsic inequality in how trans people are treated in society (Faye, 2021). Any form of questioning about the nature of being transgender can feel to some people as offensive as, say, climate change denial or – even, holocaust denial – neither of which is tolerated in society at large to the degree that what we might call ‘trans denial’ is tolerated.
As members of the trans community know as well as anyone and better than many, to be ‘different’ in our society is still to be subject to judgement. To be judged is often painful; it poses many challenges. And psychotherapy, of course, is primarily about looking at those challenges, looking at what is difficult. But, crucially, it is not for the therapist to determine what is difficult; only the client/patient can know that conclusively and this very often changes in the course of therapy. It is for the therapist to know that this person has come seeking help. It is not for the therapist to decide in advance what the client/patient needs or does not need help with. Therapists must treat all people equitably, making no assumptions unduly.
It is telling that Neves’ UKCP article addresses itself to the failings of ‘generic’ psychotherapy services. Doubtless, many of his own patients or clients seek him out for his expertise as a sexologist and as a sex therapist: often because other professionals have lacked sufficient understanding of their experience. Most of us who are not specialists in this area, however, will inevitably meet with the question of gender in our practice in ways that may not be so obvious and may be interwoven with other, possibly more prominent concerns. Our assessment of a particular client or patient may include gender-based identity issues that require clarification, a sense of how they might fit in with the bigger presenting picture. In doing the things that psychotherapists and counsellors of any description do – to question, to hypothesise, to reframe, even to doubt – a therapist might conclude that the person in front of them is quite vulnerable, possibly very immature, demonstrating narcissistic tendencies, someone who wishes to transition because he/she/they see being transgender in idealistic terms, as a way out of difficulty, as an imagined ‘better’ self, as a way of not being themselves when being themselves feels so immensely difficult or painful. We have to be able to ask whether this person’s struggle is purely externally imposed. We have to be able to offer all our clients or patients our fullest understanding of their story. The question posed in this essay is: can we do this effectively if to do anything other than to blame an oppressive society for our patients’ troubles is to risk being seen as an ‘oppressor’?
What is needed now, I would argue, is for the UKCP, BACP and other organisations to clarify – or to clarify again – the aims of psychotherapy and to engage therapists in a period of consultation so that whatever we do to ‘drive forward change’ is drawn from best practice.
NB
[i] cisgenderist – Neves uses this term in reference to what he perceives to be dominant ideological assumptions in society about the binary nature of men and women. In the context in which he uses the term, to be cis is therefore to adhere to those assumptions. For the sake of clarity, my own view is that human beings are binary in nature and are appropriately described as either male/female, man/woman, boy/girl. Consequently, I choose to use these terms throughout the rest of this essay.
[ii] self-identification – The freedom to define one’s own gender has led to an increase of 100+ non-binary gender-based terms, the plurality of which is often described as a spectrum and is reflected in the use of a rainbow as the flag of the LGBTQ+ movement.
NB
References:
Bailey, N. Therapy Today (May 2021, p.11)
BBC (2022) Reith Lecture, Accessed online @https://www.bbc.co.uk/sounds/play/m0 01fmtz
BBC News Online (10th June 2023), ‘Puberty blockers to be given only in clinical research’.
Butler, J. (1990) ‘Gender Trouble’, Routledge.
Davies, S. (2023) ‘Unfair Play’, Forum.
Faye, S. (2021) ‘The Transgender Issue’, Prologue.
Neves, S. (2022) ‘Sexology: The Basics’, Routledge.
Neves, S. (2023a) ‘Are you GSRD competent?’ Therapy Today, Volume 34 (June 23)
Neves, S. (2023b) ‘People working in generic services are not trained enough in working with LGBTQ+ people’, New Psychotherapist, Issue 83 (2023)
Soh, D. (2020) ‘The End of Gender’, Simon & Schuster.
Stock, K. (2021) ‘Material Girls’, Fleet.
Wassell, C. (2023), ‘Nurturing Your Autistic Young Person’, Jessica Kingsley.
Psychotherapist & Trainer 