Gender-Affirming Care Through Gender Therapy

Gender exists on a spectrum. A person may be male, female, anywhere in between, more than one gender at once, or fluid within the spectrum. Transgender and gender non-conforming (non-binary, genderqueer, and other identities that don't fall within a gender binary) (TGNC) are terms for when a person's gender identity does not fully match the sex they were assigned at birth.

Every major medical association in the United States recognizes the necessity of gender-affirming care for improving the physical and mental health of TGNC people. Despite this, TGNC people often face stigma, discrimination, and violence in and outside medical settings.

Gender therapy is a form of specialized care provided by a therapist with training in multiple areas of gender, including TGNC needs and experiences.

Read on to learn more about gender therapy, how it can help, and where to find it.

What Is Gender Therapy?

It is both common and normal to question your gender identity and/or gender expression, whether or not you are TGNC.

Gender therapy uses gender-affirming social support and psychotherapy to help a person explore these feelings without judgment or pressure to be a certain way.

Gender therapy is provided by a therapist who is specially trained in multiple areas surrounding gender, including but not limited to those pertaining to TGNC people.

The core goals of gender therapy include:

• Gender affirmation
• Providing space for processing and understanding
• Creating a safe and affirming space
• Fostering reflection and empathy
• Providing connections to social support, legal services, healthcare providers, and other specialized areas
• Allowing for diversity

Gender therapy may be beneficial for people who:

• Are questioning their gender identity
• Feel discomfort about aspects of their gender
• Are experiencing gender dysphoria
• Are seeking gender-affirming interventions, such as hormone therapy or surgery
• Want help revealing their gender identity to friends, family, and colleagues

Validating Confusing Emotions 

It's OK not to have your gender identity all figured out. There is no age or stage in which a person must commit to a gender or even know the gender(s) with which they most identify. Gender identity can also change over time, and that's OK too.

Though all of this is normal, it can be confusing. A gender therapist can help you work through your feelings about gender and gender identity without the pressure to "choose" or to identify a certain way. The therapist is there to help you explore your gender identity and expression with the goal of feeling comfortable with yourself.

Gender therapists and psychologists who have training in gender therapy can also help families understand gender diversity, challenge gender norms and stereotypes, correct misinformed or erroneous beliefs, and help family members learn how to support their TGNC loved one(s).

TGNC individuals can have different needs depending on their stage in life. For example, a person in their 40s who is married with children may want to talk to a gender therapist about how to tell their spouse and family that they are TGNC and involve their therapist as the family adjusts to these changes. A person who transitions in late adulthood may face unique stigmas and have conflicting feelings about having waited to do so.

Role of a Gender Therapist 

In addition to exploring your feelings about your gender identity, a gender therapist can help with mental health concerns that may or may not be related to gender, including substance use, suicide ideation, body dysphoria, gender dysphoria, and more.

When you first meet with your gender therapist, they will ask questions regarding:

• Your medical history
• If you are taking any medications (and which ones)
• Whether you have any mental health concerns
• Your gender expression (such as which pronouns you use, clothing, hairstyle, etc.)
• How your gender expression aligns with how you feel
• Your internal sense of gender and how it compares to your sex assigned at birth
• Other questions that help your therapist get to know you
  

In Gender Dysphoria Treatment 

You do not need to be experiencing gender dysphoria to see a gender therapist, but if you are experiencing it, a gender therapist can help.

A gender therapist can help TGNC people and people who are exploring their gender identity determine what is contributing to their feelings of dysphoria and how to address it.

For example, a trans man who stops hormone therapy in order to become pregnant may experience gender dysphoria with the resulting loss of physical masculinization and/or with his growing belly while he is pregnant.

A person who has not yet affirmed their gender (sometimes called "transitioned") may experience gender dysphoria surrounding their internal sense of gender and how others perceive them or aspects of their body.

Gender therapists are trained in recognizing and treating gender dysphoria however it is experienced.

As a Medical Advocate 

Some TGNC people seek medical gender-affirming interventions, such as hormone therapy and/or surgery. A gender therapist can discuss these options, including benefits, risks, details about the interventions, etc. They can help a TGNC person make informed decisions about these interventions and help the person determine for themselves if these options are right for them.

Gender therapists can make referrals to gender-affirming healthcare providers, both for gender-affirming medical interventions and for other areas, such as:

• Primary care (general practitioners, family doctors, etc.)
• Gynecology
• Urology
• Reproductive/fertility
  

In some cases, a letter from a mental health professional is necessary to receive certain interventions, such as gender-affirming surgery, and/or to send to insurance providers to cover the procedure. A gender therapist can provide this letter. They can also advocate for the TGNC person if they are facing obstacles or prejudice in receiving the care they need from healthcare professionals.

Gender therapists may also collaborate with a person's healthcare or mental healthcare providers in other areas.

Gender therapists and gender-affirming mental health providers can also advocate for TGNC people in other ways, such as:

• Addressing transphobia, harassment, and discrimination (in the workplace, housing, or anywhere else)
• Helping to seek legal services
• Educating healthcare providers and other mental health professionals on how to provide gender-affirming care
• Educating workplaces and schools on how to create gender-affirming spaces and supports
• Accessing social service systems
• Becoming involved in the development of public policy
• Advocating for LGBTQIA+ rights
  

Where to Find Gender-Affirming Care 

Gender-affirming care refers to any care in which a TGNC person has their needs properly met, feels safe and comfortable, and feels their gender is respected. Gender-affirming care can also refer to specific interventions regarding gender affirmation, such as hormone therapy.

A 2020 qualitative review found that generally, TGNC people prefer receiving hormone therapy and referrals for surgery provided by their primary care physicians because these physicians know more about them in a holistic sense, see them as a whole person, have an established relationship with them, and are more accessible.

Though this was preferred in theory, finding gender-affirming healthcare providers was often difficult. Many lacked knowledge and training on TGNC needs and experiences, some were discriminatory, and there was often no indication when entering the space that the provider was gender-affirming.

Some ways to make healthcare spaces more gender-affirming include:

• Place signifiers of a positive space, such as a rainbow flag or sign
• Have posters or pamphlets available relating to TGNC health
• Provide gender-neutral bathrooms
• Alter paperwork to include more than just male and female gender options (particularly an option for non-binary)
• Diversity training for all staff
• Staff use of patient-asserted name and pronouns
• Use of patient-asserted name and pronouns in medical records without creating duplicate charts
• Explaining and maintaining confidentiality
  

Resources to help find gender-affirming care include:

• Referrals from your healthcare provider, mental health professional, or gender therapist
• Referrals from other TGNC people
• College or university campuses (many of them have gender-affirming care programs, some of which are available to non-students)
• The World Professional Association for Transgender Health provider search directory
• CenterLink
• PFLAG
  

Therapist Credentials and Questions to Ask 

Gender therapists are mental health professionals who have additional training in gender therapy. Mental health professionals who don't have the title of gender therapist can also be helpful if they have sufficient training and experience working with TGNC people.

Some questions to ask potential therapists include:

• What is your experience with TGNC and gender-questioning clients?
• What is your education in TGNC health and gender therapy and where did you receive it?
• What is your approach to supporting gender-affirming interventions (including referral letters)?

Finding a therapist with whom you feel comfortable and can form a good relationship is just as important. You don't need to choose the first therapist you see. If you don't feel one therapist is a good fit for you, try another one.

Gender Therapy Looks Different for Everyone

Gender-affirming care is very individualized. Gender affirmation may or may not involve medical procedures.

Medical vs. Non-Medical Interventions 

Gender affirmation can happen in a number of different ways.

Social Affirmation

This can involve:

• Gender-affirming clothing, hairstyle, and/or makeup
• Name and/or pronouns
• Speech therapy to help match desired vocal characteristics
• Cosmetic procedures such as hair removal
• Chest binding or breast padding
• Genital tucking
• Hip or buttocks padding

Legal Affirmation

This involves changing a person's name and/or gender on legal documents such as birth certificates, passports, ID cards, school documents, etc.

Pubertal Suppression

"Puberty blockers" (gonadotropin-releasing hormones, such as leuprolide and histrelin), can be taken to delay puberty. They are started when puberty begins.

Pubertal suppression may be chosen for a number of reasons, including:

• Giving a gender-questioning adolescent more time to explore their gender identity, access supports, develop coping skills, define treatment goals, and further their cognitive and emotional development
• Preventing permanent physical changes that would be irreversible without surgery, such as breast development, a prominent Adam's apple, voice change, etc.
• Reduce the need for more invasive procedures

Pubertal suppression is reversible. When the hormones are stopped, puberty and associated development will begin again. At this time, the adolescent may want to begin gender-affirming hormone therapy, a different form(s) of gender affirmation, or stop interventions altogether.

Gender-Affirming Hormone Therapy 

Masculinizing hormones (testosterone) or feminizing hormones (estrogen plus androgen inhibitor) may be taken from early adolescence onward (or start any time after early adolescence).

These hormones help TGNC people who have already started or been through puberty develop traditional physical characteristics of their gender, such as voice changes, fat deposition, muscle mass, face and body hair, breast development, etc.

This process is partially reversible. If the hormones are stopped, some characteristics can change (such as muscle mass and fat deposition), and some are permanent when developed (such as voice change and breast development).

Gender-Affirming Surgeries

Surgeries that TGNC people may choose include:

• "Top" surgery: Breast augmentation or creating a male-typical chest shape
• Removal of sex organs such as ovaries, uterus, or testicles
• Metoidioplasty: A small penis is formed using the clitoris and sometimes a skin graft
• Phalloplasty: An average-sized penis is formed using a skin graft (usually from the forearm, belly, or thigh)
• Vaginoplasty: An outer and inner vulva/vagina is created using the skin and tissue from the penis and scrotum
• Vulvoplasty: Skin and tissue from the penis and scrotum are used to create all of the parts of the vulva (external) but not the internal vaginal canal
• Facial feminization: Changing facial features to look more traditionally feminine
  

Summary

Gender diversity is normal and questioning your gender identity is common.

A gender therapist is a mental health professional who has training and experience in gender issues, gender identity, and the needs and experiences of TGNC people.

A gender therapist can help TGNC people and those who are gender-questioning work through confusing feelings, address gender dysphoria (if present), feel more comfortable with themselves and their identity, determine gender affirmation goals, and more.

Gender affirmation looks different for everyone, and may include social, legal, hormonal, and/or surgical gender-affirming interventions.

A Word From Verywell 

If you are questioning your gender identity, are experiencing gender dysphoria, have questions or concerns regarding gender, or even if you just want to talk, a gender therapist can help. If you are interested in this type of therapy, talk to gender therapists in your area to find a therapist that's a good fit for you.