Atlas›Domain XVI · Historical, discredited & harmful›Guide 073
Guide XVI-073

Gender exploratory therapy

Evans and Evans2021United States
A 28 · L 63 · M 921 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the term "gender exploratory therapy" as its proponents describe it (Therapy First, formerly the Gender Exploratory Therapy Association; Evans and Evans 2021) and as its critics analyse it (Ashley 2023), read against the professional and international statements current in 2024-2026 (UK Memorandum of Understanding on Conversion Therapy, version 2; APA 2021 resolutions; UN Independent Expert report A/HRC/44/53, 2020). There is no single published treatment manual for the approach [uncertain: not verified].

This guide does not teach any therapy aimed at changing or suppressing a gender identity. It gives the psychotherapist what is needed to understand a contested label, to recognise how it reaches clients, and to do their own work: open assessment, consent and assent, safeguarding, suicide-risk assessment, work with clients and families on every side of the debate, and responsible action when practice elsewhere is directed at a fixed outcome.

What the term refers to, by position.

  • Proponents. Therapy First, a US-based non-profit, describes its stance as psychotherapy built on "traditionally open principles of curiosity and exploration", aimed at helping a young person reflect on identity and reach informed, personal decisions, with attention to developmental stage, social and cultural factors, co-occurring psychiatric conditions and the interplay of sexual orientation and identity formation. It contrasts this with what it calls a "one-size-fits all treatment pathway" and rejects the description of its approach as conversion therapy as an "inaccurate and biased characterization" [source: Garcia-Ryan, Therapy First, open letter to WHO, undated]. The organisation was founded in 2021 as the Gender Exploratory Therapy Association and renamed Therapy First in late 2023 [uncertain: secondary, unverified].
  • A psychoanalytic model. Evans and Evans (2021), two psychoanalytic clinicians with long NHS careers, including in the national children's gender identity service and the Tavistock and Portman NHS Foundation Trust, set out a developmental and psychoanalytic model covering family development, adolescence, co-occurring conditions, suicidal ideation, detransition and assessment. The book's preface (by another author) describes its stance as "a kind of deeply engaged neutrality", neither affirming nor opposing the young person's identification; the foreword (also by another author) describes a prolonged exploratory process asking what a trans identification may mean for the young person [source: Evans and Evans 2021, publisher's front-matter preview].
  • Critics. Ashley (2023) describes gender-exploratory therapy as discouraging affirmation and using talk therapy to examine whether a young person's trans identity or gender dysphoria has pathological roots; argues that it has strong conceptual and narrative similarities to conversion practices; and, assessing it against therapeutic neutrality, patient-centred care, loving attention and the therapeutic alliance, concludes it may be unethical. Ashley also notes that few detailed accounts of its parameters exist [source: Ashley 2023, abstract]. A US federal agency (SAMHSA) is reported to have described approaches that discourage youth from identifying as transgender as harmful, sometimes misleadingly labelled "exploratory" [uncertain: secondary, unverified].

Core idea of how change happens, as each side states it. Proponents hold that unhurried, open exploration of the meaning of a young person's gender distress, in its developmental, family and mental-health context, allows a better-informed decision about any next step [source: Garcia-Ryan; Evans and Evans 2021]. Critics hold that where exploration is organised around the expectation that the identity is a symptom to be resolved, it functions as pressure towards a particular outcome, which is the defining feature of conversion practices [source: Ashley 2023]. Professional bodies draw the line not at exploration itself but at a predetermined outcome: the UK MoU protects support for people who want to explore, feel conflict about or are distressed by their gender identity, while requiring practice "free from any agenda that favours one gender identity" [source: MoU v2]; the UN Independent Expert recognises counselling for "exploration, free development and/or affirmation" as distinct from conversion, because none of these claims conversion as an outcome [source: A/HRC/44/53, para. 70].

What the bodies state about change efforts. The APA (2021) adopted a Resolution on Gender Identity Change Efforts opposing biased or coercive efforts to change gender identity, reporting that people who experienced pressure to conform to their sex assigned at birth described harms including "emotional distress, loss of relationships, and low self-worth"; its updated sexual-orientation resolution found "no evidence of sexual orientation change" in research since 2009 [source: APA press release, 2 March 2021]. The UK MoU calls conversion therapy, whether aimed at sexual orientation or gender identity, "unethical and potentially harmful" and states that neither is in itself an indicator of mental disorder [source: MoU v2]. The UN Independent Expert concludes that no approach can claim conversion as an outcome, reports suicidal ideation and attempts, depression, anxiety, self-hatred and post-traumatic symptoms among those subjected to such practices, records that UN anti-torture mechanisms and the Independent Forensic Expert Group consider they may amount to torture or cruel, inhuman or degrading treatment depending on the circumstances, and recommends that States ban them [source: A/HRC/44/53, paras. 19, 56, 62, 70, 87]. A 2020 IRCT statement on the same point is cited in the literature [uncertain: not verified]. Whether gender exploratory therapy falls within these definitions is the contested question: critics say it does in its practice; its proponents deny it.

2. Framework

The framework below is the psychotherapist's own work with this topic, not a framework of the contested approach. Session number and length follow the client's needs and the setting [synthesis].

Phase A: Orientation and literacy (before and alongside any case). Goal: know the positions, the professional statements and the law where you practise, and know your own stance. Move on when you can describe each position in its own terms and state what your regulator requires [synthesis].

Phase B: Recognition and assessment. Goal: an open assessment of the gender-questioning client or a client with a history of therapy around gender: what they want, what they have experienced, co-occurring difficulties, family context, risk. Holistic, bio-psycho-social assessment is common ground: the Cass Review's holistic model was welcomed by the Royal College of Psychiatrists and the British Psychological Society, and was described in a compilation of responses prepared for NHS Wales as "uncontested" [source: NHS Wales committee paper, Appendix 1, July 2024]. Move on when risk is assessed, consent or assent is in place, and the client's own goals are stated in their words [synthesis].

Phase C: Safety and safeguarding. Goal: suicide-risk assessment and safety planning, child-protection action where required, and, if the client reports change-directed practice elsewhere, a decision about reporting. Runs throughout; it takes priority over every other phase [synthesis].

Phase D: Open exploration and processing, without a predetermined outcome. Goal: the client understands themselves better and reduces distress, whatever identity or path they arrive at; the MoU's phrase is that "Clients make healthy choices when they understand themselves better" [source: MoU v2]. For clients harmed by past therapy, this phase includes processing and repair. Move on when the client's distress has reduced and their decisions are their own [synthesis].

Phase E: Family, community and referral work; follow-up and advocacy. Goal: parents, partners and faith communities are supported without the therapist becoming an agent of any one party's preferred outcome; referral to appropriate specialist services; follow-up. Close when the client's agreed goals are met or care is handed over safely [synthesis].

3. Guiding principles

  • No predetermined outcome. Practice must be "free from any agenda that favours one gender identity or sexual orientation" [source: MoU v2]. Practical meaning: before each phase ask whether you are hoping for a particular answer; if you are, take it to supervision [synthesis].
  • Exploration is legitimate; pressure is not. The MoU protects help for people who want to explore, feel conflict or are distressed, and the UN Independent Expert distinguishes counselling for exploration, free development or affirmation from conversion [source: MoU v2; A/HRC/44/53, para. 70]. Practical meaning: open questions are fine; questions designed to lead to a conclusion are not [synthesis].
  • Identity is not in itself a disorder. Neither sexual orientation nor gender identity is in itself an indicator of mental disorder [source: MoU v2]. Practical meaning: assess co-occurring conditions as conditions in their own right, not as proof about the identity [synthesis].
  • Holistic assessment. Gender-related distress is placed within the whole of the young person's life and needs [source: BASW on the Cass Review, April 2024; NHS Wales committee paper]. Practical meaning: assess mood, neurodevelopment, trauma, family and school as well as gender, and address each need on its merits [synthesis].
  • Co-occurrence is not causation. One response to the Cass Review reports that it does not suggest a causal link with neurodiversity, mental-health conditions or trauma, while those needs should still be addressed [source: NHS Wales paper, KITE Trust response; uncertain: second-hand summary of the Review]. Proponents give co-occurring conditions a larger explanatory role [source: Evans and Evans 2021, contents; Garcia-Ryan]. Practical meaning: hold both possibilities open and let the client's account lead [synthesis].
  • Client autonomy and self-determination. Both sides invoke it: proponents speak of autonomy and informed personal decisions [source: Garcia-Ryan]; critics stress patient-centred care and following the client's lead [source: Ashley 2023]. Practical meaning: the client's goals, not the therapist's or the family's, set the agenda [synthesis].
  • Transparency about a contested field. Practical meaning: tell clients and parents plainly that the field is contested, what you will and will not do, and why [synthesis].
  • Consent and assent. Practical meaning: with minors, obtain parental consent where required and the young person's own assent, revisited as therapy proceeds [synthesis].
  • Safety first. Change efforts are associated in the literature with suicidal ideation and attempts [source: A/HRC/44/53, para. 56; APA 2021 press release]. Practical meaning: assess suicide risk early and repeatedly, using safe-messaging principles [synthesis].
  • Even-handedness without false balance. Practical meaning: represent each position accurately; do not present professional consensus statements as mere opinion, and do not present a contested empirical question as settled where the cited bodies have not settled it [synthesis].
  • Never provide, supervise or refer to change-directed practice. Practical meaning: if a client or family asks for therapy to remove or reverse a gender identity, you explore the request and decline the goal, and you do not refer on to anyone who would pursue it [synthesis; source: MoU v2 on conversion therapy as unethical].
  • Know the law where you practise. Practical meaning: check your jurisdiction's current rules before each new case type; in the US they changed in 2026 [source: CLEAR on Chiles v. Salazar] [synthesis].
  • Supervision and self-scrutiny. Practical meaning: bring cases in this area to supervision routinely, including your own beliefs and reactions [synthesis].

4. Intervention inventory

The interventions below are the psychotherapist's own work; steps not drawn from a cited source are marked [synthesis].

4.1 Building historical and conceptual literacy

  • Purpose / when: before taking gender-questioning clients, and whenever a client, parent or colleague uses the term "exploratory therapy". You need to understand why one label carries opposite meanings for different people.
  • Steps: (1) Read each position in its own words: Therapy First's description of open, curious psychotherapy and its rejection of the conversion label [source: Garcia-Ryan]; the developmental and psychoanalytic scope of Evans and Evans (2021); Ashley's (2023) argument that the approach resembles conversion practices. (2) Read the bodies' definitions: the MoU's definition of conversion therapy as an approach assuming one identity is preferable and attempting to change or suppress it [source: MoU v2]; the UN Independent Expert's umbrella definition covering gender identity and expression [source: A/HRC/44/53, para. 17]. (3) Note the point of agreement (exploration without a predetermined outcome is legitimate) and the point of dispute (whether a given practice has a predetermined outcome). (4) Write a one-paragraph summary of each position you could show to someone who holds it [synthesis].
  • Example language (illustrative): "People use 'exploratory therapy' to mean quite different things. Some mean open, curious therapy with no fixed destination; others use it for therapy that sets out to talk a young person out of a trans identity. I'd like to understand what it means to you."
  • Watch for: your own reaction to the label colouring your view of the person using it; relying on advocacy summaries of either side rather than the primary statements. Working: you can explain each position accurately and neutrally [synthesis].

4.2 Recognising change-directed practice behind any label

  • Purpose / when: when a client describes past or current therapy, a programme, or a faith or family intervention concerning their gender identity, whatever it was called.
  • Steps: (1) Listen for the defining features the bodies name: an assumption that one gender identity is preferable, and an attempt to change or suppress the person's identity or its expression [source: MoU v2; A/HRC/44/53, para. 17]. The MoU notes such practice may be carried out covertly under mainstream labels [source: MoU v2]. (2) Ask what the stated goal of that therapy was, who set it, whether the client could say no, and what happened when they disagreed. (3) Distinguish therapy the client experienced as open, even if challenging, from therapy they experienced as steering; record their account in their words. (4) Do not decide the matter on the label alone, in either direction [synthesis].
  • Example language (illustrative): "What did you understand the aim of that therapy to be? Did it feel like you could arrive at any answer, or that there was an answer you were meant to reach?"
  • Watch for: clients who minimise harm out of loyalty to a therapist or parent; clients who valued exploration and fear you will reinterpret it as abuse. Working: the client gives a fuller account and feels their own judgement of the experience was respected [synthesis].

4.3 Open, non-directive initial assessment of a gender-questioning client

  • Purpose / when: first sessions with any client distressed, uncertain or questioning about gender.
  • Steps: (1) Invite the client's own account of their gender experience, its history and what they want from therapy. (2) Assess holistically: mood, anxiety, eating, self-harm, neurodevelopment, trauma, relationships, school or work, family and faith, in line with the holistic model welcomed across UK bodies [source: NHS Wales paper on Cass responses; BASW]. (3) Record co-occurring difficulties as needs to address, without treating them as evidence for or against the identity [source: MoU v2 on identity not being a disorder] [synthesis]. (4) Agree goals stated in the client's words, which may concern distress, relationships, decisions, or understanding themselves better [source: MoU v2]. (5) State what you will not do: try to change their identity in any direction [synthesis].
  • Example language (illustrative): "My job isn't to move you towards any particular identity. It's to help you understand yourself and feel less distressed, wherever that leads. What would you like to be different?"
  • Watch for: your questions clustering around one hypothesis; the client answering what they think you want to hear. Working: the client sets the agenda and corrects you freely [synthesis].

4.4 Informed consent and transparency about stance

  • Purpose / when: at the start of therapy and whenever the frame shifts (new family involvement, new referral, a request about medical steps).
  • Steps: (1) Explain your approach: open exploration, no predetermined outcome, attention to all areas of life [source: MoU v2] [synthesis]. (2) Say plainly that the field is contested and that you follow your professional body's position on conversion practices. (3) Explain confidentiality and its limits, including safeguarding. (4) Explain what you cannot do (prescribe, make medical assessments outside your role) and how specialist referrals work. (5) Invite questions and record consent [synthesis].
  • Example language (illustrative): "You may have read strong views about therapy in this area. Mine is that therapy shouldn't be aimed at changing who you are. I'll ask about many parts of your life, and you're always free to tell me a question isn't helpful."
  • Watch for: clients or parents assuming you share their view because you did not state yours. Working: the client can describe your approach back to you [synthesis].

4.5 Consent and assent with children and adolescents

  • Purpose / when: any work with a minor, especially where parents and young person want different things.
  • Steps: (1) Establish who holds legal consent in your jurisdiction and obtain it. (2) Seek the young person's own assent separately, in age-appropriate words, and revisit it regularly. (3) Agree with both what will be shared with parents and what stays confidential, within safeguarding limits. (4) Make clear to both that therapy will not be used to deliver a parent's preferred outcome; the UN Independent Expert finds subjecting children to conversion practices contrary to international human rights law [source: A/HRC/44/53, para. 74] [synthesis]. (5) If assent is withdrawn, pause and review rather than continue under pressure [synthesis].
  • Example language (illustrative): "Your parents have agreed to these sessions, but I also want to know whether you want to come, and what you'd want to use them for."
  • Watch for: a young person attending only under compulsion; parents requesting reports of session content. Working: the young person attends willingly and uses the time for their own concerns [synthesis].

4.6 Suicide-risk assessment and safety planning

  • Purpose / when: at intake and regularly with gender-questioning clients and with anyone who has experienced change efforts. The UN Independent Expert reports suicidal ideation and attempts among those subjected to conversion practices [source: A/HRC/44/53, para. 56]; the APA reports that young LGBTQ people who experienced sexual-orientation change efforts were significantly more likely to report attempted suicide [source: APA press release 2021]; Blosnich et al. (2020) found sexual-minority adults who had experienced change efforts nearly twice as likely to report suicidal ideation and attempts, in a sample of non-transgender LGB adults, so it does not measure gender identity change efforts directly [source: Williams Institute summary]. A published reanalysis disputes the causal reading of that finding (Sullins 2022) [uncertain: not verified]. Evans and Evans (2021) devote a chapter to suicidal ideation and gender dysphoria [source: front matter].
  • Steps: (1) Ask directly about suicidal thoughts, intent, plans and past attempts, using your service's standard risk framework. (2) Identify current stressors, including family conflict, rejection, bullying and experiences of therapy. (3) Build a written safety plan with warning signs, coping steps, people to contact and crisis lines. (4) Discuss safe storage or removal of means at the level lethal-means counselling requires, never method detail. (5) Give crisis resources: 988 Suicide and Crisis Lifeline (US); Samaritans 116 123 (UK and Ireland). (6) Follow safe-messaging principles in all discussion: no method detail, no glamorising, emphasise help and recovery [synthesis].
  • Example language (illustrative): "Sometimes when people feel this much pressure about who they are, they think about ending their life. Have you had thoughts like that?"
  • Watch for: risk rising after family disclosure, after a change of service, or after any therapy the client felt was trying to change them; risk being used by any party as an argument in the debate rather than assessed for this person. Working: the client uses the plan and discusses thoughts openly [synthesis].

4.7 Responding to a client who asks to change or be rid of their gender identity

  • Purpose / when: a client says they want therapy to stop them being trans, or to make their identity go away.
  • Steps: (1) Take the request seriously and explore it: what is driving it (family, faith, fear, discrimination, internal conflict, distress about the body, uncertainty)? (2) Explain that you will not work towards changing their identity, which the bodies regard as unethical and potentially harmful [source: MoU v2; APA 2021], and that you can work on the distress and the conflict. (3) Keep all outcomes open: the client may come to a clearer trans identity, a non-binary identity, a decision not to transition, or something else; none is your target [source: MoU v2; A/HRC/44/53, para. 70] [synthesis]. (4) Assess risk (4.6). (5) Do not refer to anyone offering change efforts [synthesis].
  • Example language (illustrative): "I hear how much you want this feeling to stop. I won't try to make you into someone you're not, but I can help you understand what's making this so painful and what you want for your life."
  • Watch for: the client experiencing your refusal of the goal as rejection; quiet steering on your part in either direction. Working: distress and self-criticism fall, and the client talks about their own wishes rather than others' demands [synthesis].

4.8 Working with a client who experienced therapy they felt was change-directed

  • Purpose / when: a client reports earlier therapy, religious counselling or a programme they experienced as trying to change or suppress their gender identity.
  • Steps: (1) Let the client describe it at their own pace; do not press for detail. (2) Assess for the harms the bodies report: depression, anxiety, self-hatred, post-traumatic symptoms, suicidality, loss of relationships, low self-worth [source: A/HRC/44/53, para. 56; APA 2021]. (3) Validate the experience and name that the bodies regard change-directed practice as unethical and potentially harmful [source: MoU v2]. (4) Rebuild trust in therapy through transparency, choice and control over pace. (5) Work on shame, self-acceptance and relationships with standard evidence-based methods for the presenting problems (e.g. trauma-focused work if PTSD is present). (6) Discuss reporting options if the client wishes (4.15) [synthesis].
  • Example language (illustrative): "You went to therapy for help and came away feeling there was something wrong with you. It makes sense to be wary of me. You decide what we talk about and when."
  • Watch for: re-traumatisation through detailed retelling; the client testing whether you, too, have an agenda. Working: the client reports less shame and more self-trust [synthesis].

4.9 Working with a client who valued exploratory therapy, or who has detransitioned or desisted

  • Purpose / when: a client who found an exploratory approach helpful, or who has stopped or reversed a social or medical transition, or who no longer identifies as trans. Evans and Evans (2021) include a chapter on detransitioners [source: front matter]; the MoU's protection of support for people who are uncertain or in conflict applies equally to them [source: MoU v2].
  • Steps: (1) Hear their account without reinterpreting it to fit either side of the debate. (2) Assess current needs: grief, regret, anger, body-related distress, medical follow-up needs (route to medical services; never advise on medicines), social isolation, online hostility. (3) Support self-acceptance of their present identity, whatever it is, on the same no-predetermined-outcome principle [source: MoU v2] [synthesis]. (4) Assess risk (4.6).
  • Example language (illustrative): "Your experience doesn't have to prove anything for anyone else. What matters here is what it's been like for you, and what you need now."
  • Watch for: the client feeling used as evidence by either side; your own assumptions about why they changed course. Working: the client describes their history in their own terms and plans their next steps [synthesis].

4.10 Holistic assessment of co-occurring difficulties without pathologising identity

  • Purpose / when: the client has depression, anxiety, an eating difficulty, trauma, autism or other neurodevelopmental needs, or personality difficulties alongside gender distress. Proponents emphasise these conditions [source: Evans and Evans 2021, Part III; Garcia-Ryan]; one response to the Cass Review reports it found no causal link while urging that the needs be met [source: NHS Wales paper, KITE Trust response].
  • Steps: (1) Assess each co-occurring difficulty with standard tools and offer or refer to evidence-based treatment for it. (2) Explore with the client how, in their own experience, these difficulties and their gender experience relate, without supplying an answer. (3) Avoid making treatment of a co-occurring condition conditional on any change in identity, or presenting it as a route to one [synthesis]. (4) Screen for disordered eating and refer to a medical or eating-disorder service where indicated; for support, the National Alliance for Eating Disorders. (5) For autistic clients, adapt communication and check understanding [synthesis].
  • Example language (illustrative): "Let's work on the panic attacks because they're making your days hard. That isn't a way of getting at your gender; it's about you having an easier time."
  • Watch for: treating the gender identity as a symptom to be cleared, or ignoring co-occurring needs for fear of seeming to. Working: co-occurring symptoms improve and the client feels their identity was not put on trial [synthesis].

4.11 Working with parents who seek "exploratory" therapy for their child

  • Purpose / when: parents ask you to see their child specifically for exploratory therapy, sometimes hoping the identity will pass, sometimes worried about hasty decisions; or parents ask for affirmation-only work and fear any exploration.
  • Steps: (1) Meet parents separately first and hear their fears, hopes and values without judgement. (2) Explain your frame: open exploration with no predetermined outcome; you will not work towards any identity outcome, theirs or anyone's [source: MoU v2] [synthesis]. (3) Clarify that the young person's goals and assent shape the work (4.5). (4) Offer parents their own support: their worry, grief, conflict between parents, and how to stay connected to their child whatever happens. Evans and Evans (2021) give attention to family context and to helping parents understand the work [source: front matter]. (5) If parents insist on a change goal, decline it, explain why, and continue to offer support to them [synthesis].
  • Example language (illustrative): "I can see how much you love your child and how frightened you are of getting this wrong. I won't promise you any particular outcome, but I can help your child think clearly and help you stay close to them while they do."
  • Watch for: triangulation, with the therapist cast as ally of one party; pressure for reports; risk to the young person from family conflict (4.14). Working: parents tolerate uncertainty and the young person reports feeling less pressured at home [synthesis].

4.12 Religious clients and families

  • Purpose / when: a client or family whose faith shapes their response to gender questioning, or a client harmed by faith-based change efforts. Most people reporting sexual-orientation change efforts in the Generations Study received them from a religious leader [source: Williams Institute summary of Blosnich et al. 2020].
  • Steps: (1) Assess the place of faith with cultural humility, using the DSM-5-TR Cultural Formulation Interview with its supplementary module on spirituality, religion and moral traditions. (2) Where faith and identity conflict is the focus, the DSM-5-TR "Religious or Spiritual Problem" may be recorded as Z65.8 [source: ICD-10-CM Z65.8 (Unbound Medicine)]. (3) Help the client explore their own relationship to faith and to identity without asking them to give up either [synthesis]. (4) Where useful and wanted, help the client find affirming voices or communities within their own tradition, as the client chooses [synthesis]. (5) Draw on spiritual and religious competencies (Vieten et al. 2013).
  • Example language (illustrative): "Your faith matters to you and so does being honest about who you are. We don't have to decide that one must win. Can we look at what each of them means to you?"
  • Watch for: the therapist's own views about religion or gender entering the room; spiritual distress and loss of community after disclosure. Working: the client holds faith and identity with less conflict, in whatever form they choose [synthesis].

4.13 Balanced psychoeducation on the evidence and the debate

  • Purpose / when: a client or parent asks what the research says, or what "exploratory" and "affirming" mean.
  • Steps: (1) Ask what they have already read and from where. (2) Summarise accurately: the professional bodies' statements on change efforts (4.1); the existence of a debate about youth gender care and the low quality of much of the evidence noted around the Cass Review, as UK responses record it [source: NHS Wales paper]; that Therapy First and Evans and Evans describe their approach as open exploration and deny it is conversion therapy, while critics argue it resembles conversion practice [source: Garcia-Ryan; Ashley 2023]. (3) Distinguish what is settled in the cited statements (change efforts are regarded as unethical and potentially harmful) from what is contested (how to support young people's decisions about medical care). (4) Point to primary documents rather than commentary [synthesis].
  • Example language (illustrative): "Here is what the professional bodies have said, and here is where people genuinely disagree. I'd rather you read the original documents than take my word or anyone's summary."
  • Watch for: the session turning into a debate; the client seeking a verdict to use against a family member. Working: the client feels better informed and less polarised [synthesis].

4.14 Safeguarding of children and young people

  • Purpose / when: a young person faces rejection, threats, being made homeless, exclusion, coercion into change-directed practice, being sent abroad or to a residential programme, or self-harm risk.
  • Steps: (1) Know your local child-protection procedures and mandatory-reporting duties before you need them. (2) Assess immediate safety and suicide risk (4.6). (3) Where you suspect significant harm, follow your service's safeguarding route and your jurisdiction's statutory child-protection reporting; consult your safeguarding lead. (4) Record the young person's own account in their words. (5) Keep the young person informed, as far as safety allows, about what you will share and why [synthesis]. The UN Independent Expert regards subjecting children to conversion practices as contrary to international human rights law [source: A/HRC/44/53, para. 74].
  • Example language (illustrative): "What you've told me makes me worried about your safety. I need to talk to someone whose job is to help keep young people safe. I'll tell you what I'm going to say before I say it."
  • Watch for: treating disagreement about gender as abuse in itself, or overlooking coercion because it is framed as therapy or faith; thresholds differ by jurisdiction. Working: the young person is safe and stays engaged [synthesis].

4.15 Duties when a colleague or institution uses change-directed practice

  • Purpose / when: a client reports, or you observe, a colleague or service working towards changing or suppressing a gender identity, under any label.
  • Steps: (1) Gather facts carefully; distinguish open exploration from a predetermined goal (4.2). (2) Seek supervision and consult your professional body's guidance; in the UK, MoU signatories (including the BACP, BPS, BPC, the Royal College of Psychiatrists, NHS England and others listed) commit to regarding conversion therapy as unethical [source: MoU v2] [uncertain: check the current signatory list]. (3) Where appropriate, raise the concern informally with the colleague. (4) If concern persists, use your regulator's or professional body's complaints route; with the client's consent, support them to complain themselves. (5) Where a minor is involved, use safeguarding routes (4.14). (6) If you hold more than one role with the colleague or client (e.g. supervisor, employer, family member), consider APA Ethics Code Standard 3.05 on multiple relationships [source: APA Ethics Code]. (7) Never supervise, co-work or refer into such practice [synthesis].
  • Example language (illustrative), to a colleague: "From what I'm hearing, the aim in your work with this young person sounds like a particular outcome. Can we talk through how you're keeping it open?"
  • Watch for: reporting on the basis of a label alone; failing to report out of collegial loyalty. Working: concerns are assessed through proper channels and the client is protected [synthesis].

4.16 Knowing the legal and regulatory position where you practise

  • Purpose / when: before accepting gender-related cases, and whenever the law changes.
  • Steps: (1) United States: on 31 March 2026 the US Supreme Court ruled 8–1 in Chiles v. Salazar that Colorado's conversion-therapy law, as applied to a counsellor's talk therapy, regulates speech based on viewpoint; it reversed the lower courts, which had not applied sufficiently rigorous First Amendment scrutiny, and sent the case back (SCOTUSblog; NPR). Its effect on other states' laws is [uncertain]. Colorado has since responded with HB26-1322, barring licensed therapists from imposing a predetermined outcome on a minor patient's sexual orientation or gender identity [source: CLEAR] [uncertain: status may have changed]; how individual state laws treat "exploratory" therapy is [uncertain]. (2) United Kingdom: the MoU is a professional, not statutory, instrument [source: MoU v2]; check your regulator for current statutory proposals [uncertain]. (3) Elsewhere: the UN Independent Expert records that Malta's law excludes services supporting exploration from its ban [source: A/HRC/44/53, para. 76(b)]; for other countries, verify current law from official sources before relying on it [uncertain]. (4) Seek legal advice from your professional body or insurer when unsure [synthesis].
  • Example language (illustrative), to a client: "The law in this area has been changing. What doesn't change is how I work: I won't try to change who you are, in any direction."
  • Watch for: relying on secondary summaries; assuming a ruling in one place applies in another. Working: your practice stays within current law and your body's code [synthesis].

4.17 Referral and liaison with specialist services

  • Purpose / when: the client needs specialist gender services, medical care, eating-disorder or neurodevelopmental assessment, or crisis care.
  • Steps: (1) Identify services commissioned or licensed in your area and their criteria. (2) Explain referral options neutrally, including waiting times; BASW notes long waiting lists after the closure of the Tavistock children's gender identity service in March 2024 [source: BASW]. (3) Liaise, with consent, on risk and co-occurring needs. (4) Continue supportive therapy while the client waits. (5) Never refer to a practitioner or programme offering change efforts [synthesis].
  • Example language (illustrative): "Here are the options available, what each one does and how long it may take. I'll keep seeing you while you wait."
  • Watch for: the client's distress rising during long waits; referral being experienced as rejection. Working: the client has a clear plan and continued support [synthesis].

4.18 Supervision, self-scrutiny and bias checking

  • Purpose / when: throughout, and especially when you feel strongly about a case or about the debate.
  • Steps: (1) Bring all gender-questioning cases to supervision. (2) Before sessions, ask: what outcome am I hoping for, and how might that show in my questions? (3) Review session notes for leading questions. (4) Seek consultation from a colleague with a different view where it would help you test your neutrality. (5) Keep up to date with your professional body's statements [synthesis].
  • Example language (illustrative), in supervision: "I notice I'm relieved when this young person sounds less sure. I want to check that isn't shaping what I ask."
  • Watch for: defensiveness; practising in fear. A survey of Therapy First member therapists reports anxiety about working in a hostile professional environment and strategies to avoid conversion-therapy allegations [source: PubMed abstract, 2024] [uncertain: citation details not verified]. Working: you can name your pulls and your clients experience you as open [synthesis].

4.19 Documentation and record-keeping

  • Purpose / when: every session; records may be read by clients, parents, regulators or courts.
  • Steps: (1) Record the client's stated goals in their words and any changes to them. (2) Record your stated frame (no predetermined outcome) and consent and assent. (3) Record risk assessments and safeguarding decisions with reasons. (4) Describe the client's identity in the terms they use. (5) Avoid speculative causal formulations about identity in the record [synthesis].
  • Example language (illustrative), note entry: "Client describes themselves as questioning; goal is to reduce anxiety and think through telling family. Frame re-explained; client agrees."
  • Watch for: notes that read as building a case for one outcome. Working: a reader could see that the client led the work [synthesis].

4.20 Repairing a rupture where the client felt steered

  • Purpose / when: a client says, or shows, that they experienced you as pushing them towards or away from an identity.
  • Steps: (1) Invite the feedback and thank them for it. (2) Acknowledge your part without defensiveness. (3) Explore what felt steering. (4) Re-state the frame and agree what to do differently. (5) Check at later sessions [synthesis]. Ashley (2023) identifies the therapeutic alliance as one of the ethical lenses at stake in this area [source: Ashley 2023].
  • Example language (illustrative): "You're right that my question pointed one way. That wasn't fair to you. Can you tell me what it felt like?"
  • Watch for: the client withdrawing quietly rather than objecting. Working: the client raises disagreements more readily [synthesis].

4.21 Consulting with a colleague drawn to the exploratory approach

  • Purpose / when: a colleague or trainee asks your view on exploratory therapy or wants to adopt it.
  • Steps: (1) Ask what they mean by it and what draws them (4.1). (2) Discuss the shared ground: open exploration and holistic assessment are endorsed across the cited statements [source: MoU v2; A/HRC/44/53, para. 70]. (3) Discuss the line the bodies draw: any predetermined outcome, or treating the identity as pathology to be resolved, falls within their definitions of conversion practice [source: MoU v2; APA 2021]; note critics' view that the approach does so in practice and proponents' denial [source: Ashley 2023; Garcia-Ryan]. (4) Point them to their regulator's guidance and to supervision [synthesis].
  • Example language (illustrative): "Curiosity is part of good therapy. The question is whether the curiosity is open, or whether it's aimed at a result. How would your clients know which it is?"
  • Watch for: the conversation becoming a debate about youth medicine rather than about therapeutic stance. Working: the colleague can describe how they keep outcomes open [synthesis].

5. Handling problems

The problems below are the psychotherapist's own synthesis [synthesis]; a source is named where one states the point.

  • The client is stuck between two camps. A client has absorbed opposite messages online, at school, at home and from earlier therapists and cannot think for themselves. Response: slow down; name the polarisation; separate the client's own experience from the arguments; work on one concrete concern at a time (sleep, a conversation with a parent). [synthesis]
  • "Resistance" that is mistrust of therapy. A client harmed by earlier change-directed work, or a client who expects you to affirm or to challenge on cue, holds back. Response: treat wariness as reasonable, not as resistance; increase transparency (4.4), offer control over pace and topics, and invite feedback each session (4.20). [synthesis]
  • A parent demands an outcome. Response: restate the frame (4.11); decline any change goal, which the bodies regard as unethical and potentially harmful [source: MoU v2; APA 2021]; offer the parent their own support; if the young person is at risk, act on safeguarding (4.14). [synthesis]
  • A young person withdraws assent. Response: pause, explore why with the young person alone, and do not continue under pressure from adults (4.5). [synthesis]
  • Overwhelm and crisis. Disclosure, family rejection, online hostility or long waits for specialist services can precipitate crisis. Response: move to risk assessment and safety planning (4.6); give 988 (US) or Samaritans 116 123 (UK and Ireland); use your service's crisis pathway; follow safe-messaging principles. [synthesis]
  • Co-occurring problems dominate. Severe depression, an eating difficulty, trauma symptoms or neurodevelopmental needs take most of the session. Response: treat or refer for them on their own merits (4.10); for eating difficulties route to medical and specialist services, with the National Alliance for Eating Disorders for support; never make treatment conditional on a change in identity. [synthesis]
  • Non-adherence to the frame by others. A school, faith leader or other professional pursues a change goal alongside your work. Response: with consent, liaise; if a minor is at risk use safeguarding routes; for a professional use the duties in 4.15. [synthesis]
  • The therapist feels unsafe to practise. Fear of complaints from either direction can make a therapist defensive or avoidant; a survey of Therapy First members reports such anxiety [source: PubMed abstract, 2024; uncertain: citation details]. Response: clear documentation (4.19), supervision (4.18), advice from your professional body or insurer, and practice that follows the no-predetermined-outcome principle [source: MoU v2]. [synthesis]
  • The client asks for your personal view on youth medical care. Response: say that this is a contested area, outline what the cited bodies say and where they disagree (4.13), and return to what the client wants for themselves; avoid offering medical opinions outside your competence and never advise on starting, stopping or changing medicines. [synthesis]
  • Rupture after a misjudged question. Response: repair openly (4.20); Ashley (2023) treats the alliance as an ethical, not only technical, matter [source: Ashley 2023]. [synthesis]
  • Legal uncertainty. The law changed in the US in 2026 [source: CLEAR on Chiles v. Salazar] and may change elsewhere. Response: verify current law from official sources before acting on any summary, including this one (4.16). [synthesis]
  • The therapist's own beliefs are strongly engaged. Response: supervision, consultation with colleagues who hold different views, and, where neutrality cannot be maintained, a well-managed transfer to another clinician who will keep outcomes open. [synthesis]

Sources

Web sources:

Works cited:

  • Blosnich, J. R., Henderson, E. R., Coulter, R. W. S., Goldbach, J. T. and Meyer, I. H. (2020). Sexual Orientation Change Efforts, Adverse Childhood Experiences, and Suicide Ideation and Attempt Among Sexual Minority Adults. American Journal of Public Health [uncertain: volume and pages not verified].
  • Cass, H. (2024). Independent Review of Gender Identity Services for Children and Young People: Final Report. NHS England [uncertain: report text not verified; content cited from BASW and NHS Wales summaries].
  • APA (2021). Resolution on Gender Identity Change Efforts; Resolution on Sexual Orientation Change Efforts [titles as given in the APA press release; texts not verified].
  • Sullins, D. P. (2022). Reanalysis of Blosnich et al. 2020 [uncertain: not verified].
  • IRCT / Independent Forensic Expert Group (2020). Statement on conversion therapy [uncertain: not verified; cited in A/HRC/44/53].
  • Vieten, C. et al. (2013). Spiritual and religious competencies for psychologists [uncertain: not verified].
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