Psychotherapeutic and Behavioral Approaches to Treating Gender Dysphoria

The author of this report is an epidemiologist consultant to ACPeds who prefers to remain anonymous.

BACKGROUND: For decades, many of transgenderism’s researchers and clinicians have promoted a false ideology: if a man, woman or child claims to be a member of the opposite sex, or expresses a keen desire to “change sex” through hormonal and surgical intervention, then there is nothing one can do but “affirm” or facilitate that person’s belief and desire. A key component of this ideology is that psychotherapeutic interventions have been tried exhaustively in such patients and that nothing worked.

In reality, none of this is true. The basis of this belief system is the repeated statement of transgenderism’s “godfather,” doctor Harry Benjamin. Despite never having offered such therapies himself, Benjamin famously declared psychotherapy to be a “useless undertaking” in patients with “transsexualism” (a term formerly used for what is now called “gender dysphoria”).

The organization that has been the most influential in promoting transgender ideology, and the notion that psychotherapy is of no use, is the World Professional Association for Transgender Health (WPATH). Until 2007, this organization was known as the Harry Benjamin International Gender Dysphoria Association (HBIGDA). WPATH’s inherited dogma that psychotherapy is a “useless undertaking” in patients with gender dysphoria has caused tremendous damage to vulnerable patients, particularly in recent years, when purported “informed consent” models advanced by WPATH and other activist clinicians have replaced or influenced the older models of “gatekeeping.”

The truth is that many clinicians have offered psychotherapy and behavioral therapies to help their patients with identity disturbances fixated on “gender” or “change of sex,” and often with success.

METHODS: This was a narrative (non-systematic) review of the literature. The objective was to compile a list of all published studies in the scientific literature reporting results of psychotherapeutic or behavioral approaches that were used to help adult and adolescent patients with gender dysphoria (including gender identity disorder, “transsexualism,” and desire for “sex change”) to overcome these identity disturbances. Studies with negative findings were eligible for inclusion. Studies published in any language were eligible for inclusion. Studies that focused primarily on pre-adolescent children were not included. Studies that used electric shock, induction of nausea or other potentially unethical strategies were excluded.

The initial source of these studies was a bibliography of psychotherapy reports compiled by the late French psychotherapist Dr. Colette Chiland. She published this simple list of about a dozen studies in her book Transsexualism: Illusion and Reality (SAGE Publications, 2004). A range of relevant keywords was gleaned from those dozen studies to search PubMed, Embase and PsycINFO in order to identify additional research articles. To find other articles citing the studies that were already obtained, forward citation-tracking was used. After identifying all relevant studies, key details of study populations, interventions offered and reported outcomes were extracted.

RESULTS: A total of fifteen research articles were identified. Please see the attached document. Studies were published between 1964 and 2012. Study population sizes ranged from n = 1 to n = 82. Most studies were case reports and small case series. One study (n = 50) was a retrospective cohort. Two studies (n = 82; n = 28) were descriptive in nature. Participants ranged in age from 12 through late adulthood. One study (n = 50) may have included one or more pre-adolescent children. Studies used a range of psychotherapeutic and behavioral approaches, including psychotherapy, psychoanalysis, group therapy, hypnosis and behavioral therapy tied to stereotypes. Only one study (Shtasel 1979) used cognitive behavioral therapy, which is the foundation of many current psychotherapies.

All studies reported complete or mixed success in resolving the “gender” or “transsexual” troubles of their participants. No studies reported only failure. The case report using cognitive behavioral therapy (Shtasel 1979) reported success with that female participant.

DISCUSSION: After comprehensive searches of the scientific literature, it is striking to realize that there has never yet been even one rigorous study comparing the use of psychotherapy in patients with gender dysphoria to any kind of control condition. It also becomes clear that Harry Benjamin’s dogmatic assertion (and similar ones of WPATH and other activist clinicians), that psychotherapy is a “useless undertaking,” is false. Given the positive results of these studies, most of which used old-fashioned types of psychotherapy, there is every reason to believe that these patients can be helped to resolve their “gender” identity problems. Cognitive behavioral therapy-based approaches are a global standard in psychotherapy, and it is surprising that no studies after Shtasel 1979 have reported its use in patients with “gender” identity issues.

The “affirmative” model of care for patients with “gender” identity disturbances essentially fast-tracks vulnerable people into a life dependent on exogenous hormone supplementation and surgical after-care, without helping them resolve their underlying psychological issues. The supposed scientific evidence supporting these “affirmative” approaches is based on smoke and mirrors. This has resulted in many harms.

CONCLUSION: There is compelling evidence to suggest that psychotherapy may be efficacious in treating gender dysphoria. Psychologists should offer cognitive behavioral therapy-based care to patients presenting with “gender” concerns, and other clinicians should refer these patients for such care.