To Deny or Affirm? That Is Not the Question

As a sensitive teen boy in the mid-1980’s, my mother was relieved to discover I was not gay. She would have fully accepted me but said she would have been saddened by the thought that my life would be more difficult as a gay man. Social acceptance of homosexuality was still tepid and navigating life as a gay man posed a unique set of challenges.

Being gay in America no longer carries those burdens because society has embraced that kind of diversity. In 2023, homosexuality is simply part of the natural human landscape. My kid does not give a second thought to same sex partnerships. While trans-identifying individuals are afforded the same hard-won legal protections the gay community enjoys, they are still not fully accepted and face discrimination in a variety of settings. Nearly all my peers claim that if we encourage our culture to accept trans identifying individuals in the same way we now accept homosexuality, in just a few years having a “trans” kid would be no different from having a gay kid.

But that is not true.

There is a fundamental difference between being gay and being trans. Being gay does not require medical intervention. Ben Appel, in his post for the LGBT Coalition on Substack, ‘Homophobia in Drag” was asked by a friend, ‘And you don’t think you would’ve been happy as a transwoman?’ as if both options are equal and interchangeable. Is having a preference towards being a feminine gay man, discriminatory towards those who choose to transition? Is T somehow less desirable than LGB?  All things being equal, avoiding lifelong medical care does, in fact, seem preferable.

That one difference is reason enough to be cautious about gender-affirmative care. Helping adolescents explore their conception of gender, how it relates to their identity, and life-long implication of medical transition, is not conversion therapy. It’s good therapy. Therapists like me who encourage self-understanding are not denying people the right to be who they are or discouraging them from being anything they choose to be. If a teen comes into my office and states she is thinking about quitting high school, I don’t express an opinion, I just help her explore the implications of that choice. People will argue this analogy does not hold because being trans is not a choice. But it is. Being naturally gender non-conforming or gender dysphoric may not be a choice, but taking steps to change one’s body to align with an internal sense of gender IS a choice. It is a choice with implications that should be fully explored so any individual who makes that decision has all the information needed to consent to that kind of intervention. That is what therapists do—encourage people to understand their motivations and help them make informed decisions. Self-determination is a fundamental tenet of our code of ethics. To quickly affirm a client’s choice is as damaging to the therapeutic process as dissuading them from any particular choice.

Telling my teen-age client, “Well if you think quitting school is a good choice for you, I think you should drop out” is as nonsensical as telling gender dysphoric male, “Well, if you think you are a girl, then you are a girl.” Does it not make more sense to help individuals explore their thoughts, feelings, and motivations instead of merely affirming them? I was taught to be neutral, be cautious with any opinions, and be hypervigilant toward any kind of bias I bring to a session. It is not our place to “affirm” or “deny.” Both approaches can be damaging. The client’s life is not my life, and they have a right to live it as they please. Gender exploratory therapists are not pushing an agenda, we are just doing good therapy. Those who oppose a “watch and wait” approach express concern that if we delay transition and let puberty takes its course, most kids end up not being trans—most end up gay. In other words, most kids don’t end up being life-long medical patients. Why is that considered a bad thing?

If I had a gender non-conforming child, I would fully accept and celebrate them, just as my mother would a gay son. Would I have concerns about society not being enlightened enough to embrace them as I would? You bet! Would I have concerns about my child’s choice to pursue life-long medical care, sterilization, and possible sexual dysfunction?  Absolutely.  I would want a therapist to help them fully explore all options available in the pursuit of a fulfilling life, including the costs and benefits of a medical transition. That is not conversion therapy or affirmative therapy. It’s good therapy.