Therapeutic Needs of Desisters and Detransitioners

This section has been contributed by Sasha Ayad, a Licensed Professional Counselor. She has worked with several dozen gender dysphoric clients in private practice, including several who desisted from a transgender identity. Based on her clinical experience with this population, she believes the following themes may be relevant for other practitioners working with desisting or detransitioning individuals.

Desisters and detransitioners are a varied group and clinicians working with these individuals should be careful to understand the specifics of each client’s story and presenting concerns. Mutual trust and safety must initially be established, and this therapeutic work may unfold slowly. Desisters and detransitioners should be supported in cultivating curiosity and self-compassion, understanding what they’ve experienced, working with underlying mental health issues and behavior patterns, and ultimately creating a meaningful path forward. Much like a grief process, individuals may move in and out of phases in a non-linear manner as they heal from and make meaning of their experience with gender.

Below are some considerations for therapeutic exploration with desisted or detransitioned clients. They are listed in no particular order. Therapists can draw on a broad range of therapeutic modalities when working with detransitioned and desisted clients, and incorporating a holistic, mind-body, experiential perspective has been effective in my experience.


Establishing Trust

Taking things slowly is particularly important considering how quickly many people were initially affirmed as transgender and encouraged to medically transition. A gentle pace can establish a tone of careful exploration and give the client room to disclose intense and painful material in a safe and self-directed manner.

Since many desisters and detransitioners reject the belief in gender identity, clinicians should not assume a shared understanding of gender-related language. Ask clients to define unfamiliar words or explain what a term means to her/him. This signals that you are not ideologically driven and helps you better understand your client’s current experience of her/himself.

Follow the client’s lead when discussing how transition has impacted them. For example, if a client feels relieved about having had a mastectomy, avoid calling her breasts “damaged.” On the other hand, if a client feels deeply troubled by her facial hair, be mindful not to reassure her immediately that it’s barely visible.  Giving clients the permission to express any emotional reaction to their body will help them feel supported and that the therapeutic relationship is not pushing them in any particular direction. As therapy proceeds, there will be room to explore these narratives more fully, but initially, honor the client’s experience of her/himself.


Self-Care and Wellness

Detransition and desistance can be a complex and destabilizing process for some. It may be useful to help a client establish self-care practices if life feels chaotic and unpredictable. Routines around sleep, nutrition, movement, hygiene, or other basic needs may cultivate stability in daily life and foster emotional and psychological grounding.


Emotional Dysregulation

The struggle to experience, metabolize, and process difficult emotions lies at the core of many desister and detransitioner stories. Some young people transitioned because they believed it would rid them of unpleasant feelings like shame, anxiety, sadness, or anger. Basic education on emotions can help a client access, identify, and normalize overwhelming emotional experiences. Experiential work with emotions allows clients to understand themselves in a richer and more self-compassionate way.

Working with emotions in the therapy room can help clients develop their emotional vocabulary and a more mindful awareness of how emotions are experienced and can influence our behaviours. Additionally, emotions can be worked with in a retroactive or chronological way, looking back at the client’s historical narrative, and focusing on their emotions along the pathway to transition and detransition.

Body Image Issues & Disordered Eating

Some desisters and detranstioners understand their experiences as part of a coherent and helpful process that allowed them to get through a difficult time.  Others may come to view their transition as a form of self-harm, or even a trauma in and of itself. Since many people developed gender dysphoria after having struggled with disordered eating or body image issues, addressing mind-body dissociative patterns continues to be relevant to many at all stages of the detransition process. By definition, transition is a way to physically alter one’s body in an attempt to alleviate psychological and emotional suffering. Even if a client had not been diagnosed with an eating disorder before they became gender-dysphoric, cultivating a realistic and compassionate relationship to the body is important in therapeutic work.

When detransitioned clients no longer physically appear to be their natal sex, they will be dealing with another experience reminiscent of gender dysphoria: they are, once again, perceived by others differently from how they understand themselves to be. This can maintain a familiar hyperawareness of the surface image of the body. While some desisters may use makeup, clothing, hairstyles and further cosmetic intervention to align their body’s appearance with their natal sex in a socially conventional way, it’s important to work on a deeper level of self-understanding. Developing an embodied sensory awareness and radical self-acceptance can provide a necessary counterpoint to the image-based fixation of outward appearance and gender.

Therapeutic modalities that can explore the meaning behind disordered eating and body image, such as Jungian, psychodynamic approaches, or even narrative therapies, may also help a client gain a deeper understanding of old and new patterns with food and body.


Early Trauma

Major and minor instances of trauma might have been contributing factors in an individual’s development of gender dysphoria. In hindsight, desisters and detransitioners often recognize the role early traumas played in their decision to transition. Social ostracization, bullying, harassment, sexual trauma, or physical abuse often remain unresolved if medical transition was the only intervention pursued. Addressing trauma should not be the first focus of therapy, but may need to be addressed once the patient is stable and rapport is well established.


Accepting Nonconformity & Sexuality

Familial or societal messages about masculinity, femininity, sexuality, and gender nonconformity sometimes play a role in the development of gender dysphoria or the adoption of a transgender identity. Judgmental or highly prescriptive views on what behaviors are acceptable for males and females can leave nonconforming people feeling alienated from their desires, interests, and bodies. These messages might have come from families, friends, online networks, media, schools, or some parts of the LGBT community.

Detransitioned clients can seek therapy to understand how they developed certain beliefs about their sexuality, personality, identity, and physical appearance. Furthermore, a transgender identity has profound impacts on one’s internal self-image and sexual identity. For example, a detransitioning female who only dates women might have conceptualized herself as a “straight male” for many years while identifying as a transman. Upon detransitioning, she may come to understand herself as a lesbian, gay, queer, or find a different sexual identity that suits her. Much untangling must be done in therapy to help the client align their current self-concept with their authentic orientation and personality.


Working with intensity/giftedness

There is some evidence that androgynous people score higher in overexcitability, a trait associated with giftedness, than do traditionally masculine males or traditionally feminine females. There is also evidence that there are higher rates of giftedness among those who develop adolescent-onset gender dysphoria., and this comes with some special challenges. Perfectionism, emotional intensity, anxiety, and feeling socially alienated are commonly reported by gifted people (misdiagnosis is therefore common). Additionally, grappling with deep existential and moral questions about their lives and experiences can become a central focus of clinical work with gifted clients.


Developmental and Temporal Considerations

Transition can be an all-consuming process that leaves little energy for other important domains of self-development. Some detransitioners may feel they put their life “on hold” in the pursuit of becoming the other gender. The impact transition and detransition has on familial, peer, and romantic relationships, academic and career pursuits, and emotional development can be enormous.

At times, transition represents an attempt to start a new life and bury the distress associated with experiences that occurred in the natal sex. Some detransitioners will need to develop compassion for their pre-transition self and build a temporal continuity between various stages of their life.

Working on developmental tasks appropriate to one’s age and maturity should be done in conjunction with processing past experiences and building a meaningful future.


Autism and Aspergers

Some individuals desisting from a transgender identity may also be autistic, have an Asperger’s diagnosis, or other developmental condition.  Gender non-conformity is common in both males and females on the autism spectrum and may play a role in the development of gender dysphoria. Additionally, individuals on ‘the spectrum’ have difficulty forming and sustaining social relationships, often leading to social isolation and the feeling of being very different from their peers. Concrete, black-and-white thinking makes understanding metaphor, nuance, and subtly a challenge, perhaps further contributing to a fixation on finding the ‘right’ gender identity label. This pattern can be exacerbated by a tendency to ruminate and perseverate on  a narrow set of interests.

When working with clients on the autism spectrum, it can be helpful to use direct language, and avoid complex metaphors. Concrete examples and demonstrations of a concept can help the client grasp meaning when discussing something too abstract. Subtle communications through body language and facial expression may not be noticed, so aim to express your thoughts clearly through unambiguous word choice. Of course, autistic individuals will have rich emotional experiences, as with every other client, so finding a communication style that facilitates the therapeutic work will be important.


Shame and Blame Regarding Transition

Some people feel that aspects of the gender affirmative treatment model are responsible for encouraging young people to medically transition. It’s therefore crucial that therapists model good and cautious clinical practice, reiterate the importance of medical safeguarding, and reduce the potential for self-blame in their detransitioning clients. In other  cases, some feel that  young people  transitioned due, at least in part, to  the influence of powerful online or in-person groups. It may be valuable for clinicians to understand and provide psychoeducation on the impact of undue influence and groupthink.

Many detransitioners feel intense feeling of shame and self-blame regarding their transition. Reducing shame and self-blame may be a major focus on work with desisters and detransitioners, especially for those who have strong feelings of regret for what they lost as a result of transition. Helping them understand the dynamics of undue influence can be useful in making sense of how they made decisions that in hindsight they regret. Using cognitive techniques to accurately assess blame among other parties can help reduce anger and rage directed at themselves.


The Therapeutic Relationship

As with many other psychological issues, there can be a strong relational component to the distress associated with trans identification and desistance/detransition. Some detransitioners may have transitioned in part because they were hungry for an experience of deep mirroring that they had otherwise been unable to find. It may be important for the therapist working with this population to offer this kind of profound connection, and to honor the strong feelings that can arise in the transference as a result.