Challenges in working with gender diverse young people and their families

In recent years, the rate of young people questioning their gender identity has risen exponentially (Di Ceglie, 2018). Clinicians supporting these young people face a multitude of challenges, with developmental, empirical, clinical, professional, cultural, ethical and therapeutic dimensions. From a developmental perspective, as alluded, distress around body development at the onset of puberty, as well as a level of uncertainty regarding one’s sexuality/sexual orientation and gender are often typical of the process of adolescent identity formation, experienced by many young people regardless of their assigned and self-identified gender.

Empirically, the factors contributing to the persistence and desistance of gender dysphoria are still largely unknown. Because of this uncertainty and evolving evidence base, clinicians are left to make recommendations, sometimes based upon anecdotal clinical experience or untested or partially tested theories (Marcus, Marcus, Yaxte, & Marcus, 2015).

When working with gender diverse young people with significant associated difficulties, such as social difficulties or mental health struggles, it can sometimes be very difficult to unpick where these different parts of the self may overlap and intersect. Sometimes young people with complex experiences and problems may attribute all their struggles (which can understandably make them feel hopeless and even suicidal at times) solely to the mismatch between their gender identity and their body.

Supporting the parents of gender diverse young people can also be complex. Seeing their child in distress can instil fear and panic in caregivers, which can often make them either completely reject their child’s non-typical gender identification, or alternatively be drawn towards a possibly premature resolution (Wren, 2019). Parents may also feel guilty or disloyal to their child unless they fully affirm and advocate for the child’s wishes. In contrast, some other parents may feel paralysed by religious or other cultural expectations about how their children should present themselves and behave, depending on their assigned genders. Finally, in some families, unmentalized trauma (Silverman, 2015) can, at times, become transferred and expressed through the parent’s relationship to the child’s body, and complex safeguarding concerns may emerge.

From a professional perspective, the new Memorandum of Understanding on Conversion Therapy (UK Council for Psychotherapy [UKCP], 2017, p. 1), understandably describes conversion therapy as “unethical and potentially harmful” (ibid. p. 1), while also suggesting that “some people might benefit from the challenge of psychotherapy” and that ... “clients make healthy choices when they understand themselves better” (ibid. p. 1). These recommendations leave a large grey area as to the self-understanding that clinicians can aim for, especially given the shifting dynamics of adolescent identity development. Widening the lens to reflect on wider cultural challenges, many young people still live in marginalising and social environments, characterised by homophobia, misogyny, and intolerance of gender neutrality and fluidity (Wren, 2019).

Online platforms have enabled young people to access information about transgender issues and the associated activism, helping them feel less ashamed and isolated. However, cyberspace can also become all-consuming, allowing or even implicitly encouraging a level of self-diagnosis to address the nature of young people’s distress (Lemma, 2018) with premature certainty. Young people have described such experiences of labelling themselves as being “lost and found at the same time” (Marcus et al., 2015). Peer relationships olfer invaluable opportunities for exploring and expressing one’s developing identity, but peer pressures and the possibility of a gang-like mentality can also be a concern, with the danger of the development of the adolescent’s individuality becoming derailed by the need for uniformity and fitting in (Churcher Clarke & Spiliadis, 2019).

In this context, a linear medical pathway can sometimes become, in young people’s (and their parents’) mind, the only acceptable way of managing their experience of difference and/or distress. On this teleological mode (described in Chapter 1), only concrete acts, e.g. a referral to a specialist sendee or a referral to the endocrinology' clinic, may come to ‘count’ as evidence that the clinician cares and wants to help.

The dilemmas around how to respond to requests for even earlier medical inten'ention can bring to the fore significant ethical challenges. The process of informed consent regarding treatments that can have life-changing effects and side-effects on healthy young people’s bodies can be highly complex, and clinicians then have to manage difficult tensions between wanting to respect the young person’s autonomy versus feeling responsible for protecting them from potential future harm (Wren, 2019).

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