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. 2022 Sep 6;18(2):472–481. doi: 10.1177/17456916221102325

Interrogating Gender-Exploratory Therapy

Florence Ashley 1,✉
PMCID: PMC10018052  PMID: 36068009

Abstract

Opposition to gender-affirmative approaches to care for transgender youths by some clinicians has recently begun to consolidate around “gender exploratory therapy” as a proposed alternative. Whereas gender-affirmative approaches follow the client’s lead when it comes to gender, gender-exploratory therapy discourages gender affirmation in favor of exploring through talk therapy the potential pathological roots of youths’ trans identities or gender dysphoria. Few detailed descriptions of the approach’s parameters have been offered. In this article, I invite clinicians to reflect on gender-exploratory therapy through a series of questions. The questions are followed by an exploration of the strong conceptual and narrative similarities between gender-exploratory therapy and conversion practices. Finally, the ethical dimensions of gender-exploratory therapy are discussed from the lenses of therapeutic neutrality, patient-centered care, loving attention, and therapeutic alliance, suggesting that the approach may be unethical.

Keywords: assessment/diagnosis, clinical ethics, conversion practices, culture/diversity, gender exploration, sex/gender, transgender

Challenging trans health’s convergence on gender affirmation, some clinicians working with trans youths have begun advocating for what they call “gender exploratory therapy” as a distinct clinical paradigm (Edwards-Leeper & Anderson, 2021; Spiliadis, 2019). The approach is presented as a neutral ground between the “radical” gender-affirmative model and “unethical” conversion practices (D’Angelo et al., 2021). Its proponents describe it as an “agenda-free, neutral therapy” and “ethical non-affirmative” approach—contrasting it with gender-affirmative approaches, which they characterize as political and agenda-driven to the detriment of adolescents (D’Angelo et al., 2021). 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 (Ashley, 2019b; St. Amand & Ehrensaft, 2018).

The conceptual fulcrum of the gender-exploratory approach lies in gender exploration through talk therapy, with the goal of identifying why youths have gender dysphoria and/or believe themselves to be trans. Gender dysphoria and self-identification as trans are approached with suspicion and associated by proponents of the approach with unprocessed trauma, childhood abuse, internalized homophobia or misogyny, co-occurring mental illness, social contagion, autism, sexual fetishism, and unconscious drives (D’Angelo et al., 2021; Edwards-Leeper & Anderson, 2021; Gender Exploratory Therapy Association [GETA], 2021; Lemma & Savulescu, 2021; Marchiano, 2017; Withers, 2020). Until gender exploration is completed, youths are not offered transition-related medical services, and social gender affirmation is typically discouraged. In many cases, medical transition and social gender affirmation will be pushed back even further because psychotherapy “should be the first-line treatment for all cases of gender dysphoria” and transition-related medical care “should be avoided if possible” (GETA, 2021). The mandatory nature of gender exploration is what distinguishes gender-exploratory therapy from gender-affirmative approaches, which often hold space for gender exploration and encourage individuals to explore what gender means to them while simultaneously providing transition-related medical services and social gender affirmation (Ashley, 2019b). Gender-exploratory therapy does not include every clinical approach that facilitates gender exploration.

Critics of the paradigm have emphasized that affirmation is far more neutral than the proposed alternatives because it emanates from clients rather than being imposed on them and have argued that there is no evidence to support nonaffirmation. Although couched in the language of exploration, gender-exploratory therapy seems more akin to interrogation or perhaps even inquisition. Gender-exploratory therapy also sits uneasily with the dominant view among scientists that being trans is not pathological (American Psychological Association, 2021; Coleman et al., 2012, p. 168). Describing trans identities as commonly or always being a pathological or maladaptive response is a long-standing view that has been extensively criticized in the scientific literature and for which no compelling evidence exists (Arnoldussen et al., 2020; Ashley, 2020; Bauer et al., 2022; Olson et al., 2016; Rae et al., 2019; Serano, 2020). The surge of gender-exploratory therapy coincides with ongoing attempts to criminalize gender-affirming care for trans youths, sometimes masquerading as a compromise between gender-affirmative care and conversion practices and at other times functioning as the intellectual arm of political movements calling for the criminalization of gender-affirming care (e.g., Brejcha & Breen, 2021).

The literature on gender-exploratory therapy has focused predominantly on criticizing gender-affirmative approaches and defending the need for psychotherapeutic gender exploration. Detailed discussions of the parameters of this therapeutic mode—how it is done, what it looks like in practice—are, by contrast, scarce. In this article, I offer questions for clinicians and then offer my personal reflections on gender-exploratory therapy. These questions, which form the first section, aim to foster self-reflection and spark ongoing critical discussions around gender-exploratory therapy. Readers should not merely skim through the questions but instead sit with them. Writing down answers or walking through them with a colleague may be helpful. I readily acknowledge that they are leading questions but hope that proponents of the approach will nonetheless approach answering them in good faith. In the second section of the article, I offer reflections of my own as an expert on conversion practices and scholar of clinical ethics. I emphasize the conceptual and narrative parallels between gender-exploratory therapy and conversion practices and explore the approach’s ethical dimensions from the lenses of therapeutic neutrality, patient-centered care, loving attention, and therapeutic alliance.

Questions for Clinicians

  1. What do you do if a client refuses to engage in gender exploration with you? Do you refuse them gender-affirming care, even if it may be necessary to their well-being?

  2. How long does gender-exploratory therapy last? How do you know if it has gone on long enough? Do you go until you find a “root cause” of the client’s trans identity or gender dysphoria?

  3. How do you distinguish, for example, trauma that caused someone to be trans from trauma that a trans person happens to have? Do you trust the client’s views? Would you equally trust clients’ view that their gender identity or gender dysphoria is and is not grounded in trauma? Why or why not?

  4. If you conclude that trans identity or gender dysphoria is rooted in, for example, trauma, how do you assess whether this response is adaptive or maladaptive? How do you determine whether the person can safely and effectively be encouraged or helped to reidentify with the gender they were assigned at birth? Is there any evidence that gender-exploratory therapy is safe or effective?

  5. If clients eventually come to identify as cisgender, do you wind down gender-exploratory therapy, or do you continue at a similar pace to ensure that their reidentification is genuine and not itself a coping or adaptive/maladaptive response? Why or why not?

  6. Relatedly, do you consider self-identification as transgender more suspect or deserving of exploration than self-identification as cisgender? Why or why not? How is this reflected in gender-exploratory therapy?

  7. Is it possible that the, for example, trauma permanently altered the person’s sense of self?

  8. If the psychotherapeutic attempt to treat gender identity and/or gender dysphoria proves unsuccessful, would you consider recommending gender-affirming care? Under what conditions?

  9. Do you see refusing to affirm someone’s expressed sense of self and experiences of gender as an appropriate response to individuals who may be experiencing trauma? Does nonaffirmation conflict with trauma-informed care’s emphasis on fostering clients’ sense of choice, empowerment, and acceptance (Levenson et al., 2021)? Do you think nonaffirmation poses risks of retraumatization?

  10. Is there any evidence that gender-exploratory therapy leads to better outcomes, however you define them, than gender-affirming approaches? Is there any evidence that it can successfully identify youths who are not “truly” trans, whose identification is maladaptive, or who would be harmed by gender-affirming interventions?

  11. Do you believe that gender-exploratory therapy can create psychological, social, and emotional pressures to reidentify with one’s gender assigned at birth? Do you believe that it can create pressures to misreport reidentification or alleviation of gender dysphoria? Do you believe that it can create pressures to identify specific factors, for example, trauma as a cause of trans identity or gender dysphoria?

  12. Do you believe that gender-exploratory therapy can create pressures to lie, misrepresent, or otherwise engage in gender-exploratory therapy in bad faith to obtain gender-affirming care? Do you believe it can lead clients to suppress their doubts and worries and, as a result, make decisions regarding gender-affirming care that are less informed and thoughtful?

  13. What do you make of the distress of the numerous youths who are “truly” trans, who will experience ongoing distress during gender-exploratory therapy, and who form a strong majority of individuals seeking gender-affirmative care? High-end estimates of detransition are around 3% (Brik et al., 2020; Narayan et al., 2021). There are some suggestions that up to 76% of people who detransition do not tell their clinicians that they have done so (Littman, 2021). Even if one assumes, for the sake of argument, that these upper-bound estimates are accurate, one is left with a large 88% of individuals who do not detransition. Detransition seems rare.

  14. What pronouns and gendered terms do you use during gender-exploratory therapy? Do you use terms desired by clients or terms that reflect their gender assigned at birth, or do you avoid pronouns and gendered terms altogether? Do you see using terms reflecting the client’s gender assigned at birth as a neutral option? Why or why not?

  15. Do you believe that transition-related medical interventions, such as hormones, can be offered in parallel to exploratory therapy either as a means of reducing current gender dysphoria and/or as a way of helping clients explore their gender identity and ascertain whether gender-affirming care is right for them? Do you think social and medical transition being temporary is an inherently undesirable outcome? Why or why not? Is this related to a belief that bodies that have undergone medical transition are less desirable and should be avoided if possible?

  16. Given concerns that premature affirmation may foreclose gender identity and exploration and considering that puberty blockers arguably have far less of a foreclosing impact on gender than endogenous puberty, do you think that clinicians should offer and encourage puberty blockers for all questioning and even perhaps all cisgender kids? Would your answer change if you were absolutely certain that puberty blockers had no negative long-term side effects?

Exploring Perspectives

Conversion practices

Critics consider gender-exploratory therapy a form of conversion practice, and opponents of proposed bans on conversion practices have claimed that the laws would prohibit gender-exploratory therapy (Ashley, 2022; Brejcha & Breen, 2021; Edwards-Leeper & Anderson, 2021). Conversion practices that aim to change, discourage, or repress someone’s gender identity have been associated with serious risks of severe psychological distress and suicidality (Green et al., 2020; Lee et al., 2022; Turban et al., 2020). As someone with extensive scholarly and policy experience surrounding conversion practices, I am struck by how much gender-exploratory therapy and conversion practices resemble one another from a conceptual and narrative standpoint.

Conversion practices have long associated same-sex attraction with pathological causes, often focusing on childhood trauma and sexual assault (e.g., Nicolosi & Nicolosi, 2002). Other proposed causes include family dynamics, disrupted relationships to femininity and masculinity, co-occurring mental illness, social contagion, and unconscious drives. Survivor Peter Gajdics explained how his therapist tried to depict his sexual orientation as a by-product of trauma, telling him that his

history of childhood sexual abuse had created a false homosexual identity and so my therapy’s goal would be to heal old trauma in order, as he said, to correct the error of my sexual orientation and revert to my innate heterosexuality. (House of Commons of Canada, 2020; see also Gajdics, 2017).

Proponents of conversion practices contrast them with mainstream practices that promote affirming sexual orientation, which they describe as politically motivated and ideologically captured:

A 16-year-old young man came into my office, concerned that he might be homosexual. I told him that if he was, he could choose Gay Affirmative Therapy, or he could seek to grow out of homosexuality. . . . The young man had been confused by the popular rhetoric that assumes that if you are homosexual, then the only honest response is to live out the gay identity. Believing this, he was surprised to hear that there are men who, out of the fullness of their identities, choose a different struggle. . . . The mental health profession is largely responsible for the neglect of the non-gay homosexual. In its attempt to support the liberation of gays, it has pushed underground the other population. (Nicolosi, 1991, pp. 4–6)

The passage bears a striking resemblance to the narrative surrounding gender-exploratory therapy, which includes claims that “trans activists want to silence detransitioners or deny their existence” and portrays gender-affirming care as “an overcorrection” that is being “pushed by activists” (Edwards-Leeper & Anderson, 2021). And just as proponents of gender-exploratory therapy depict clinicians as being “afraid of being cast as transphobic bigots by their local colleagues and referral sources if they engage in gender exploring therapy,” (Edwards-Leeper & Anderson, 2021) so did Joseph Nicolosi claim that “the sexual revolution and the ‘rights’ movements—civil rights, minority rights, feminist rights—have resulted in an intimidating effect upon psychology” (Nicolosi, 1991, p. 9).

Proponents of conversion practices often appeal to the accounts of “ex-gay” clients to bolster their claim that same-sex attraction can be and therefore frequently is caused by trauma or other external factors—a move that is reminiscent of how proponents of gender-exploratory therapy select and deploy detransitioners’ accounts. For instance, Joseph Nicolosi described how one of his clients never believed his orientation to be ingrained and quoted another as saying that “embracing a homosexual lifestyle has been like living a lie” and that “only since I have started to look at what is behind these homosexual feelings have I really begun to find peace and self-acceptance” (Nicolosi, 1991, p. 5; see also Fetner, 2005). Compare this passage with the research of Lisa Littman (2021), which draws on detransitioners’ reports as evidence that their trans identity or gender dysphoria was caused by trauma, abuse, mental-health problems, or internalized homophobia. Such reliance on self-report contrasts with the distrust proponents of gender-exploratory therapy have displayed toward self-report when clients assert a trans identity or when they reject the suggestion that their gender dysphoria is a pathological response.

Studies and collated anecdotal accounts from detransitioners often represent a subgroup that is particularly hostile to gender-affirming care (Leveille, 2021; Restar, 2020). Ky Schevers (2021b), who was heavily involved in detransitioner advocacy for 6 years, described the subculture as “heavily invested in transphobic radical feminist ideology.” Schevers explained that people in radical feminist detransitioned women’s communities were “encouraged to see themselves as women struggling with gender dysphoria and to see any sense of being a gender other than woman as a symptom to be managed, not an identity to express” and that she came to believe that “my being trans was a result of trauma and misogyny” (Schevers, 2021a, 2021b). The accuracy of detransition narratives being promoted is sometimes dubious. For instance, detransitioner Keira Bell has advocated against access to gender-affirming care on account that she was “rushed” into medical transition. However, this narrative eludes important facts. She was assessed over 21 months in addition to being on the clinic’s waitlist—which is now 26 months long—seemingly contradicting the claim that she was rushed. More critically perhaps, she identified challenges to her gender identity as entrenching her decision to transition, telling the court that

the psychiatrist attempted to talk of the gender spectrum as a way of persuading me to not pursue medical transition. I took this as a challenge to how serious I was about my feelings and what I wanted to do and it made me want to transition more. Now I wish I had listened to her. (Bell v. Tavistock, 2020)

Suspicion toward Bell’s gender identity seems to have backfired and played a foreclosing role on gender exploration, in contradiction to the conceptual underpinnings and justifications of gender-exploratory therapy.

Detransition is a heterogeneous and complex experience that is frequently obscured by ideological commitments. Contrary to the assumption that detransition necessarily reflects the individual’s authentic identity, Ky Schevers now identifies as a “genderqueer transmasculine butch,” regrets having detransitioned, and views the subculture’s ideology as akin to conversion practices (Schevers, 2021a, 2021b). This not to say that detransitioners are generally misguided trans people or victims of internalized transphobia. My point is more mundane: The deployment of detransition narratives by proponents of gender-exploratory therapy belies the complexity of detransitioners’ experiences. The suggestion by proponents of gender-exploratory therapy that gender-affirmative approaches are to blame for detransition is unconvincing, especially once one considers how detransitioners’ stories are being curated in ways reminiscent of how ex-gay narratives are used to support conversion practices.

The attempt to distance and distinguish gender-exploration therapy from conversion practices is also familiar. After California banned conversion practices, Joseph Nicolosi wrote an essay claiming that his reparative therapy did not directly aim at altering same-sex attraction but, rather, encouraged inquiry and exploration into its underlying cause. The positive-sounding language of inquiry and exploration sanitizes his approach despite him viewing “most same-sex attractions as reparations for childhood trauma” (Nicolosi, 2015). “Exploring, isolating and resolving these childhood emotional wounds will often result in reducing unwanted same-sex attractions,” he explained.

His son, Joseph Nicolosi, Jr., also sought to distance himself from conversion practices, coining a new approach termed “reintegrative therapy” that he insists is not equivalent to conversion therapy (Nicolosi, Jr., 2018). Reintegrative therapy is described as a form of “sexual attraction fluidity exploration” and is purported to “significantly decreases unwanted sexual behaviors while improving psychological well-being” (Reintegrative Therapy Association, 2021). Paralleling the rhetoric around gender-exploratory therapy, proponents of reintegrative therapy describe it as a “sexual orientation-neutral approach, designed to treat trauma and addiction for males and females regardless of the client’s sexual orientation” and use the positive-sounding language of “exploration” in explaining it (Nicolosi, Jr., 2018, p. 61). According to Nicolosi, Jr. (2018), “the protocol involves exploring the client’s attractions from a neutral stance of curiosity and then seeking to resolve the trauma memories which lie beneath with standard trauma treatments” (p. 61). According to him, reintegrative therapy is distinct from conversion practices because conversion practices “seek to modify the sexuality,” whereas reintegrative therapy only alters sexual orientation “as a byproduct [sic] of resolving the core unmet need” (p. 66). This may seem like a distinction without a difference. After all, clinicians have always justified conversion practices by claiming that same-sex attraction is rooted in underlying trauma, psychological disturbances, and other pathological factors. The insistence that reintegrative therapy is practiced in the same way regardless of whether the person is gay, bisexual, or straight also falls flat given Nicolosi, Jr.’s father’s recognition that in the history of psychiatry no “heterosexual ever sought treatment for distress about his heterosexuality and wished to become homosexual” (Nicolosi, 1991, p. 9).

Descriptions of reintegrative therapy by people who offer it are reminiscent of how gender-exploratory therapy is described by its proponents. Clinicians promoting gender-exploratory therapy have notably insisted that the approach is “not the same as ‘conversion,’ as the latter implies a therapist agenda and an aim for a fixed outcome” (D’Angelo et al., 2021, p. 10) and emphasized that they “do not aim to change someone’s gender or sexuality related feelings but rather engage in a dialogue exploring the meaning-making around identity development” (Spiliadis, n.d.). Such statements overlook the fact that gender-exploratory therapy is predicated on suspicion toward trans identities and gender dysphoria and is neither developed for nor applied to cisgender individuals who do not report gender dysphoria.

I leave readers to conclude for themselves whether reintegrative therapy is tantamount to conversion practices. In any case, the conceptual and narrative similarities between reintegrative therapy and gender-exploratory therapy are hard to miss.

Clinical ethics

Proponents of gender-exploratory therapy situate their approach as neutral, agenda-free, and more in line with foundational principles of psychotherapy (D’Angelo et al., 2021). Yet approaching trans identities and gender dysphoria from a position of suspicion—suspicion that, regardless of indication, they may be attributable to pathological causes and should be explored as such—is incompatible with therapeutic neutrality. One of the sources quoted by D’Angelo and colleagues (2021), for instance, explained therapeutic neutrality as “knowing one’s place and staying out of the patient’s personal life,” allowing “for the patient’s agenda to be given primary consideration” (Simon, 1992, p. 273). However, gender-exploratory therapy seems to interject itself into clients’ lives by doubting that their gender identity and experience of gender dysphoria are authentic and not pathological. Gender-exploratory therapy also fails to give primary consideration to the client’s agenda of self-actualization by placing undue weight on the risk of detransition. As I showed with the psychiatrist who tried to convince Keira Bell not to transition, discouraging or delaying transition can severely undermine the therapeutic relationship and foreclose the client’s free, self-directed gender exploration. On that account, gender-exploratory therapy seems inconsistent with therapeutic neutrality.

Therapeutic neutrality is a complex and fraught concept. Not all agree on whether and how it should be pursued. According to psychiatrists Frank Yeomans and Eve Caligor (2016), therapeutic neutrality comes only after a treatment frame is set in place. Neutrality vis-à-vis treatment goals and approach is fundamentally different from neutrality in treatment because clinicians may view clients’ goals as unacceptable—Yeomans and Caligor gave the example of suicide. Historically, therapeutic neutrality is intertwined with psychoanalysis and was developed as a response to risks associated with transference and countertransference (Meissner, 1998). Therapeutic neutrality referred to “a point equidistant from the id, the ego, and the superego” (Anna Freud, as cited in Greenberg, 1986). Critics of therapeutic neutrality have also pointed out that the concept can be counterproductive insofar as clinicians may obscure and fail to examine how they project, impart, and impose their own values onto clients by appealing to therapeutic neutrality (Fancher, 2015; Humphries, 1982; Meissner, 1998; Wachtel, 1986; see also Ashley, 2019a). This remark is particularly salient given the conceptual and normative relationship that gender-exploratory therapy entertains with gender dysphoria and being trans. Although neutrality can be a beneficial aspiration, it is prone to distortions and misuse and cannot stand alone as a consideration for clinical ethics. Appeals to therapeutic neutrality in highly politicized contexts are too often a preemptive rejoinder to potential critics, cynically turning the concept against its very purpose. As psychoanalyst Paul L. Wachtel (1986) wrote, “one cannot stay outside the field, one cannot avoid influencing what one is observing” (p. 61). Unless situated in a broader normative philosophy, therapeutic neutrality is neither a helpful nor a realistic goal. Neutrality, much like the cake, is a lie.

The notions of patient-centered care, loving attention, and therapeutic alliance are more promising conceptual tools for reflecting on models of care in trans health. Patient-centered care is, in a way, an elaboration on the concept of therapeutic neutrality. Patient-centered care is “characterized by responsiveness to patient needs and preferences, using the patient’s informed wishes to guide activity, interaction and information-giving, and shared decision-making” (Pelzang, 2010, p. 912) and represents “a shift from a traditional, paternalistic, provider-driven and disease-focused approach towards one that fully integrates the patient’s perceptions, needs and experiences” (Fix et al., 2018, p. 301). Patient-centered care is a philosophical and normative orientation rather than a problem-solving algorithm. Its application to particular contexts can be difficult without the aid of additional conceptual tools, notably because of the wide range of care contexts in which it is used.

From a patient-centered standpoint, it is crucial to realize that most individuals who enter a clinical relationship because they are trans or experience gender dysphoria do so for the express purpose of securing access to gender-affirming care and, accordingly, living out their felt gender in everyday life. Although some may view their own trans identity or gender dysphoria as a pathological response, they are a minority. There is little basis for doubting clients who believe that their gender identity or gender dysphoria is nonpathological given the rarity of regret and the absence of proven indicators or validated assessment techniques that could accurately predict future regret (Brik et al., 2020; Bustos et al., 2021; Deutsch, 2012; In re: Kelvin, 2017; Lawrence, 2003; Narayan et al., 2021; Pimenoff & Pfäfflin, 2011; Wiepjes et al., 2018). Imposing gender exploration on clients seems manipulative or coercive and incompatible with patient-centered care. Although patient-centered care is not against exploration or assessments, it emphasizes the importance of centering clients’ desires and perspectives as much as possible. Without a clear and compelling justification, suspicion and paternalism run afoul of patient-centered care. Instead, a patient-centered approach would facilitate access to gender-affirming care; scaffold clients’ self-directed and autonomous gender exploration, including through medical transition; and offer health-care services tailored to the needs of detransitioners (Ashley, 2019b; Hildebrand-Chupp, 2020). Rather than imposing gender exploration, patient-centered therapists support clients in their decision-making process and foster a space for them to explore their gender on their own terms, should they want to do so.

The concept of loving attention, drawn from feminist philosophy, can help operationalize patient-centered care in the trans health context by specifying what it means to be responsive to clients’ needs and preferences and to use them in the development of a clinical model. Philosopher E. M. Hernandez (2021) explained that loving attention entails perceiving and attending to people on their own terms rather than on the clinicians’ terms. Loving attention stands in opposition to arrogant, paternalistic outlooks in which clinicians purport to know better what is in the person’s best interest and whether their self-understanding and desires align with that interest. Loving attention offers a critical outlook on paternalism, good intentions, and benevolence, understanding that—as the saying goes—the road to hell is paved with good intentions.

Instead of drawing on their own understanding of the desirability of gender-affirming care, of the client’s gender identity and gender dysphoria, and of their sources, clinicians working from a stance of loving attention “[seek] the other person through critical checking and questioning of one’s self, not suppressing the perceiver’s wants and desires but recognizing how they lead one astray” (Hernandez, 2021, p. 622). It is not enough to avoid active rejection by adopting a “neutral” stance that neglects differences between persons. Loving attention requires respect for individuals on their own terms, which entails adopting and affirming their self-understanding of gender and desires for gender-affirming care. Hernandez (2021), for instance, pointed out that applying the gender-neutral “they” to a trans woman who uses the pronoun “she” fails to reflect loving attention even if the person calls everyone “they.” Gender-exploratory therapy fails to embody loving attention because it approaches being trans and gender dysphoria with suspicion and a mind turned toward pathological roots even if there is no clear, immediate, or compelling reason to believe that the client’s self-understanding is wrong, besides, perhaps, stereotypes. Gender-exploratory therapy fails to appreciate trans communities on their own terms and thus falls short of loving attention. By contrast, gender-affirmative approaches’ emphasis on trans individuals’ self-understanding and on supporting them on their own terms clearly reflect a form of loving attention.

Therapeutic alliance is another concept that helps one appreciate the flaws of gender-exploratory therapy. Fostering an atmosphere of trust, comfort, and autonomy in clinical relationships is critical to decision-making and long-term well-being (Ardito & Rabellino, 2011; Ashley & Domínguez, 2021; Kukla, 2021; Martin et al., 2000). Clinicians who are perceived as erecting barriers to gender-affirming care can undermine the client’s decision-making by making them suppress doubts and worries, misrepresent their experiences, react defensively, and even initiate medical interventions earlier than they may otherwise have because of fear that they could be taken away. Whether gender-exploratory therapy falls under the umbrella of conversion practices, even its proponents admit that the approach is commonly experienced as nonaffirmative and that its practitioners are perceived as “transphobic bigots” (D’Angelo et al., 2021; Edwards-Leeper & Anderson, 2021). Gender-exploratory therapy positions the clinician as an antagonist, a gatekeeper of gender-affirming care that clients must overcome if they want to access the desired interventions. The testimony of Keira Bell before the High Court of England and Wales, discussed earlier, attests to this phenomenon. The oppositional dynamic that flows from conceptual and narrative foundations of gender-exploratory therapy can severely undermine the therapeutic alliance. “No one trusts the doctors as the place to work things out,” explained Dean Spade (2006, p. 326; see also MacKinnon et al., 2020). If individuals seeking gender-affirming care do not trust clinicians with their doubts and worries, the quality of their decision-making is undermined, and free, self-directed gender exploration is foreclosed. In addition, fear or hesitancy discussing mental-health needs can create barriers to psychotherapeutic care and keep trans people away from needed mental-health services. By contrast, gender-affirmative approaches can foster greater trust, comfort, and autonomy, reducing the stakes of gender exploration and thus creating more space for it should clients want to explore their gender. The therapeutic alliance cultivated by gender-affirming care can also foster access to mental and physical health-care services for needs unrelated or tangential to gender, such as sexual health services and trauma-informed therapy.

Patient-centered care, loving attention, and therapeutic alliance converge onto gender-affirmative approaches as the most ethical paradigms of trans care, casting doubt on the ethics of gender-exploratory therapy. Approaching trans identities and gender dysphoria from a stance of suspicion under the guise of curiosity and neutrality fails to accord with principles of clinical ethics. It betrays value-laden assumptions that are incompatible with therapeutic neutrality. Clients’ self-described needs and understandings are the starting point of ethical therapy.

Conclusion

Gender-exploratory therapy is an emergent and underdefined paradigm in trans health care. Despite appealing to positive notions such as curiosity, neutrality, and exploration, proponents of gender-exploratory therapy leave many critical questions unanswered and strike a conceptual and normative pose that seems incompatible with evolving understandings of clinical ethics and trans identities. Being trans is not undesirable and should not be approached as if it were.

Proponents of gender-exploratory therapy acknowledge that some consider it a form of conversion practice, paradoxically resenting the suggestion while opposing bans on conversion practices on account that it would prohibit their approach. As for critiques of gender-exploratory therapy, they are presented as evidence of trans health care’s ideological capture. Yet a close comparison of gender-exploratory therapy and conversion practices reveals many conceptual and narrative similarities. How proponents talk about gender-exploratory therapy is nearly identical to how individuals offering conversion practices targeting sexual orientation frame their own work. Despite the language of exploration, gender-exploratory therapy shares more with interrogation, if not inquisition.

When you begin from the premise that trans identities are suspect and often rooted in pathology, your therapeutic approach soon becomes indistinguishable from conversion practices. As a scholar of conversion practices, the uncanny resemblance cannot but give me pause.

Acknowledgments

I thank A. J. Eckert, Emma D. Klein, Lee Leveille, Elliot Marrow, and Maeve Lillian Palmer for their insightful feedback and help polishing the article.

Footnotes

ORCID iD: Florence Ashley Inline graphic https://orcid.org/0000-0001-9189-967X

Transparency

Action Editor: Tina M. Lowrey

Editor: Klaus Fiedler

The author(s) declared that there were no conflicts of interest with respect to the authorship or the publication of this article.

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