“Exploratory” Therapy and the Myth of Talk Therapy’s Harmlessness
Some anti-trans activists promote talk therapy as the first or best treatment for gender dysphoria. In addition to not being evidence based, this approach relies on a common misunderstanding of talk therapy as benign and harmless.
by Evan Urquhart
The Epoch Times, a far right news site associated with the Falun Gong religious movement, published a piece yesterday about clinical guidelines released by a group called the Gender Exploratory Therapy Association in early December. GETA is a newcomer to transgender care, having formed about a year ago. Their recommendation is that something called exploratory therapy is the first and best treatment for gender dysphoria. Exploratory therapy is an approach that emerged recently as a rebranding and/or watering down of conversion therapy. Rather than openly stating an intent to change trans patients' gender identities, exploratory therapy claims that transition might be right for some patients, but that gender dysphoria has an underlying psychological cause, and this must be explored in great depth over months or years before a patient can be allowed to access medical transition. The approach is quite subtle, and many people who are unfamiliar with trans issues may be vulnerable to the misleading frame it offers.
For ordinary people, the suggestion that therapy would be an effective treatment, or that it should be tried first before considering gender affirming care, feels very intuitive. However, GETA fails to engage with the risks associated with any patient waiting to access an effective, evidence based treatment, and with the fact that talk therapy itself should be seen as a treatment like any other, meaning that it comes with its own risks, and with potentially negative effects on the patient if the approach used is inappropriate.
To get a sense for why this is, imagine you’ve been diagnosed with strep throat and given two professional medical opinions. One doctor suggested antibiotics. In the interests of making sure you’re giving informed consent, she explained the strep throat test you’ve taken is not 100 percent accurate, that common side effects of antibiotics include diarrhea, nausea, and difficulty sleeping, and that some strains of strep might be resistant to the antibiotics she is prescribing, necessitating another doctor visit and a new prescription for antibiotics with even more side effects.
The second doctor told you that talk therapy, while it hasn’t been studied and found effective in treating strep throat, is harmless and had no side effects. He recommended you try talk therapy first, and see if it cures your strep. The talk therapy would be focused on your feelings about your throat the possible non-bacterial causes for the throat pain, exploring new ways of feeling more connected to your throat, accepting your throat as it was and not trying to change it, and eventually, if the throat pain persisted, treating the strep with antibiotics might be considered.
Is it just me, or does the second doctor sound actively dangerous? The idea that talk therapy is harmless makes little sense in the context of a painful and worsening bacterial infection. With gender dysphoria talk therapy is often presented this way, not as an evidence-based treatment (because the evidence does not support the idea that talk therapy improves outcomes or reduces symptoms), but as a harmless alternative to real medical treatments. This allows proponents of exploratory therapy to bypass a discussion of comparitive efficacy, which they need to do because that comparison clearly supports an individualized medical transition plan in accordance with the patients goals, with therapy as a supportive option for patients who want it.
Therapy can be incredibly powerful, and useful. Many if not most trans people would benefit from a supportive therapist, because transition is difficult and stressful and often involves severe social harm due to the stigma that comes with living as a trans person. However a therapy that seeks to delay and deny medical evidence is not neutral. For trans people, as for any patient, the experience of being asked to find the root cause of a fundamentally medical problem is distressing. It’s actually worse to force a person with strep throat to explore whether there were any childhood traumas that caused them to believe their throat was sore than it would be to simply ignore them and give them no treatment.
Opponents would say that strep throat is not the same as gender dysphoria. Strep throat is widely accepted as a physical problem caused by a bacterial infection, and gender dysphoria is currently culturally fraught. Its causes are unclear and its treatments, while effective in most patients and supported by robust evidence going back many decades, are politically opposed by conservatives.
This lends efforts like GETA, which stress they’re not against all transition but focus on delaying treatment and obfuscating the evidenciary picture, a mainstream appeal. It would be easier of gender dysphoria could be treated by talk therapy. It can’t, and we know this because talk therapy was tried first, and has always proven to be a failure. Only the very slow assemblance of massive evidence that talk therapy alone doesn’t work, and transition does, turned the tide for mainstream medical organizations, who slowly came to support affiming care as a result. The political resistance and ambient transphobia in the public means we’ll likely continue to argue about therapy as an alternative, despite its total lack of efficacy, indefininately.