Supporting young people to manage gender-related distress using third-wave cognitive behavioural theory,ideas and practice

Abstract

The Gender Identity Development Service (GIDS) supports gender diverse young people, and their families but currently does not provide weekly psychological therapy as part of its core work. In addition, local Child and Adolescent Mental Health Services (CAMHS), may feel deskilled in providing support for this population. We, a group of three Clinical Psychologists, aim to share some common themes and observations gained from our work in GIDS. We talk about how existing Cognitive Behavioural Therapy (CBT) models can be relevant and helpful for the challenges facing gender diverse young people, without pathologising, or aiming to change a young person’s gender identity. An illustrative case study is presented, based on an amalgamation of young people we have worked with highlighting how third-wave cognitive behavioural theory, ideas and practice can be used to support young people to manage gender-related distress. Further reflections on the broader socio-political context, and implications for clinical practice and future research are discussed.

Keywords

Gender Mental Health Transgender Children Adolescents Gender Diverse CBT

Introduction

GIDS

The Gender Identity Development Service (GIDS) is a national service for children, young people and their families presenting with atypical gender development. GIDS is the only NHS provision for young people seeking support around distress experienced as arising from feelings about gender. The outcomes for young people presenting to GIDS are diverse. Discussion of gender diversity, its presentation in young people, and the associated dilemmas is beyond the scope of this paper, and has been covered extensively elsewhere (e.g. Kaltiala-Heino et al., 2018).

The key aims of GIDS are to facilitate exploration of gender identity development, promote wellbeing, and ameliorate any associated behavioural, emotional and relationship difficulties that young people are experiencing (Davidson et al., 2019). GIDS provide support to gender diverse young people experiencing gender-related distress using a multi-disciplinary approach and integrating psychological theory and models. Currently, the provision of weekly psychological therapy is not a core part of the GIDS model. When needs requiring weekly therapeutic input are identified, efforts are made to identify local services to carry out this work.

The socio-political context around gender care is presently uncertain. Access to physical interventions for gender has evolved several times since its initial use around 30 years ago (Delemarre-Van De Waal and Cohen-Kettenis, 2006). The number of young people being referred to GIDS for gender-related care continues to increase (Kaltiala et al., 2020), with young people facing increasingly longer waits to be seen. Following the recent judicial ruling and appeal (Court of Appeal, 2021, High Court of Justice, 2020), further precautionary measures have been put in place, potentially limiting gender diverse young people’s access to physical interventions. Legal recognition of gender diverse identities, and debates around access to gender services, have become a political battleground, receiving significant media attention.

Both clinical experience, and research literature demonstrate that gender diverse young people often experience bullying connected to their gender expression (Gower et al., 2018). In addition, the number of transphobic hate crimes in the UK continue to rise each year (BBC, 2019; BBC, 2020). Thus many young people find themselves navigating a world where heteronormativity is policed.

In this context, it appears even more important that young people access therapeutic support to help them manage and reduce their gender-related distress whilst they wait to be seen by gender services, and make decisions about physical interventions. In addition, gender diverse young people may continue to experience gender-related distress after accessing physical interventions (Van de Grift et al., 2017), therefore even those who have accessed interventions could benefit from therapeutic support.

We are a group of three Clinical Psychologists who have all been working with this population for a number of years. Working closely with colleagues from local CAMHS services, we have recognised that clinicians can feel deskilled in providing support to this population (Canvin et al., 2021). Research literature suggests that mental health professionals working with gender diverse individuals may worry about ‘getting it wrong’, for example saying the wrong thing about gender to clients or colleagues (e.g. Canvin, 2020; Salpietro et al., 2019). Given the current socio-political context around gender care for young people, and the long waiting times for support from our service (Gender Identity Development Service, 2021), we can understand why CAMHS clinicians may worry about ‘getting it wrong’.

In this paper we present an illustrative case study which has been anonymised by amalgamating work we have done with a number of young people in our service using a CBT approach. We will use this illustrative case study to share some of the common themes and observations gained from our work in GIDS, and talk about how existing CBT models can be relevant and helpful for the difficulties and challenges facing gender diverse young people.

A note on ethics

The history of pathologisation of transgender identities (Sennott, 2010) introduces a tension around setting out a therapeutic model for working within this population. This is brought into focus by the current debates around conversion therapy and medical interventions for gender diverse young people (Turban, et al., 2020; D’Angelo, et al. 2021).There are fundamental ethical differences between therapeutic work which pathologises and aims to change a person’s gender identity, and therapeutic work which aims to help people manage and potentially reduce distress about gender.

Within this paper we use the term ‘gender-related distress’ as opposed to the more commonly used gender dysphoria. Our reason for doing so is that we want to be clear what our work focuses on. In the DSM 5 (American Psychiatric Association, 2013), Gender Dysphoria in Adolescents and Adults is defined as having both ‘A marked incongruence between one’s experienced/expressed gender and assigned gender’ and ‘clinically significant distress or impairment in social, occupational or other important areas of functioning’. (American Psychiatric Association, 2013, p 452). Our work focuses only on the second of these criteria; we do not believe it is ethical for therapeutic work to focus on changing someone’s experienced/expressed gender but do believe that it is ethically necessary for anyone working in this field to be aiming to reduce distress.

Gender-related distress is experienced in many different ways including a felt sense of dissonance between body and identity and distress related to minority stress (Cooper et al., 2020). It is important to note that not all gender-diverse people experience gender-related distress (Olson et al., 2016), so gender-related distress should not be assumed to be a necessary consequence of identifying as transgender.

There have been previous attempts to set-out therapeutic models for working with gender diverse young people. Broadly, existing therapeutic approaches fall into two groups, therapies which can be described as “explorative” and therapies which can be described as “affirmative”. “Explorative” therapies (e.g. Evans & Evans, 2021) are approaches which seek to bring a curiosity to the meaning of identifying as transgender for a particular client, facilitating the possibility of a shift in identity. “Affirmative” therapies (e.g. Austin et al., 2018; Joseph et al. 2020) primarily seek to support gender diverse young people manage experiences of discrimination and minority stress, implicitly accepting that some forms of gender-related distress are not amenable to therapeutic support. Our approach aims to find a third position between these two ideas; accepting and affirming our clients’ self-reported gender identity whilst seeking to bring a broader curiosity to understanding and managing gender-related distress.

Why CBT?

CBT has the largest evidence-base for the treatment of a range of difficulties in children and young people (Rapley and Loades, 2019). CBT aims to facilitate exploration of internal and external experiences, in order to improve understanding of and alleviate distress, by helping people to develop adaptive strategies (Fenn & Byrne, 2013). Given this, it seems that CBT could effectively be used to help gender diverse young people manage the gender-related distress that they experience. However, research examining the efficacy of CBT interventions for gender diverse young people is scant. A recent review of evidence-based treatment for social anxiety in gender diverse young people (Busa et al., 2018) indicates that CBT could be useful for this population, with ‘appropriate adaptations’, though the authors do not state what these adaptations might consist of. Research to date has not examined how a CBT model could be applied to support the understanding and management of gender-related distress in young people.

When using CBT approaches, we tend to work using an integrative, third-wave approach, incorporating elements of more traditional CBT with techniques from third-wave approaches such as Compassion Focused Therapy (CFT), Dialectical Behavioural Therapy (DBT), and Acceptance and Commitment Therapy (ACT). A description of the CBT model, techniques and approaches are beyond the scope of this paper. In line with CBT work targeting other difficulties young people face, we utilise different therapeutic techniques based on a shared formulation, and make adaptations based on the young person’s developmental level. We propose that an integrative model of CBT, including third-wave approaches, could be particularly useful in work with this population, in that the aim of these approaches is to help people develop a different relationship to their experiences (Hayes and Hofmann, 2017). Third-wave CBT models have been shown to be helpful in other areas where people are experiencing distress in relation to something which is not amenable, possible or ethical to change, and integrative CBT approaches are widely used in health psychology. For example, ACT has been used to support young people with cancer (Clarke et al., 2021), CBT has been shown to be beneficial for supporting children with a range of health conditions (Moore et al., 2019), and CFT has been shown to be efficacious in reducing distress in people with chronic illness (Carvalho et al., 2021). Moreover, it has been suggested that CBT approaches can be beneficial in empowering people in coping with marginalisation and oppression based on their racial and/or ethnic identity, immigration status, socioeconomic status, disability, sexual orientation, gender identity, gender expression, religious identity, language (Dale & Saunders, 2018). As such, in this paper we present examples of work completed with gender diverse young people using an integrative CBT approach to support them to understand and manage gender-related distress, in order to outline the potential usefulness of this approach for this population.

Setting up the therapy

As with all therapeutic interventions, it is vital that therapy is in line with a young person’s hopes and wishes for change, and that client and therapist are working towards the same goals. The current political climate in the UK is increasingly volatile for gender diverse young people. Therefore, it is understandable that young people may find it difficult to trust medical professionals, particularly those offering to help manage their experiences of gender-related distress through therapy.

Given this context, it is important to have open and honest conversations with young people about the ethical positioning of CBT in relation to gender-related distress, and the ways in which therapy could help them, without invalidating their gender identity. We have found it important to both hear and validate a young person’s gender experiences, prior to commencing any therapeutic work around managing distress. We have found metaphors from ACT to be particularly helpful in scaffolding these conversations. For example, using the ‘Passengers on the Bus’ metaphor (Luoma & Hayes, 2009) to think about how a young person could live a life in line with their values, at the same time as having difficult thoughts and feelings in relation to their gender. Similarly, the ‘Quicksand’ metaphor (Harris, 2011) can be helpful in thinking about the impact of fighting against thoughts, feelings, and material realities (e.g. waiting times) in potentially perpetuating and magnifying experiences of distress. In addition, it can be helpful to think together about the role of self-compassion versus self-criticism when experiencing distress. These conversations can help to reframe therapy as providing young people with the skills to manage and potentially reduce distress around gender, rather than attempting to change or ‘fix’ someone’s gender identity. It is likely these skills will prove helpful throughout their gender journey, and life beyond.

Illustrative case study

The following illustrative Case Study combines the features of different pieces of therapeutic work undertaken by the authors with a number of young people, in order to protect the anonymity of individuals, and to illustrate a range of CBT approaches. The average number of sessions we have offered young people is 16, and we have tended to offer these at either weekly or fortnightly intervals depending on the preferences of the young people.

Alex

Alex is 16 years old, White British and was assigned female at birth. Alex asked us to use this name and he/him pronouns. Alex lives with his older sister (aged 18) and his parents. Alex’s mother has significant health problems having been diagnosed with cancer a few years ago, and this has meant that Alex has taken on somewhat of a caring role for her. Alex’s father works full time, and Alex told us that he has a somewhat distant relationship with his father.

Alex spoke about ‘not having given gender much thought in primary school’. He recalled how, in primary school, boys and girls would often all play together and there were minimal differences physically. Alex’s parents described that from a very young age, they had thought of Alex as being ‘boyish’, and that he had ‘always been a tomboy’.

Alex said that gender first came to the foreground when he began his period at 9 years old (many young people at gender services begin puberty younger than average; Kaltiala-Heino et al., 2015). This was very distressing for Alex as it happened before he had been told about periods and the school did not have provisions (such as sanitary bins) to support him with this. Alex described how this experience left him with a ‘confused’ and ‘uncomfortable’ feeling in relation to his body.

Alex found the transition to secondary school difficult. He was separated from his (mostly male) friendship group as friendship groups split along gender lines. He felt pressure to present in more stereotypically feminine ways in order to fit in. Alex said that the ‘confused’ and ‘uncomfortable’ feeling grew into ‘everything feeling weird and not right’.

Alex came across a YouTube video on transgender identities in Year 8. He found similarities between his story and those of trans people online. Alex said that after this, his distressing feelings about his body had continued to increase and after one night where he described feeling very suicidal, he spoke to his family about his feelings about gender. After speaking to his family, Alex cut his hair short, which made him feel happy and ‘more himself’. He also began to wear a binder. At the start of Year 10, Alex ‘came out as a boy’ and reported feeling a sense of relief, but he continued to feel ‘weird and not right’.

Alex started college during his assessment at GIDS, which seemed to significantly increase his anxiety. This anxiety appeared to be mostly focused on how he was perceived by others in relation to his gender. It transpired that Alex had decided to attend college ‘in stealth’, such that he kept his birth assigned gender hidden from his peers, and there was an idea that being in stealth at college had increased worry about being ‘found out’, and therefore increased the distress he experienced around his body.

Gender-related-distress

Alex described experiencing distress focussing around his chest, voice and period which he labelled as ‘dysphoria’. He used very tight binders to change the shape of his chest, on a daily basis. He also experienced low mood and anxiety, and often felt overwhelmed by feelings of distress about his body. He sometimes spoke of wanting to “slice his chest off ”, or cutting his chest so that doctors “finish the job”.

Common themes and therapeutic techniques

Next we will describe some of the common themes we have noticed when working with gender diverse young people. Due to the paucity of research in this area, some of the common themes we identify are based on our observations as clinicians working with many gender diverse young people. These observations require empirical validation so they are here necessarily tentative and open to refutation. We go onto describe how CBT techniques helped Alex manage some of these factors.

Safety-seeking behaviours

We have identified several factors which may be described as safety-seeking behaviours: actions aimed at reducing immediate distress about gender, and have the unintended consequence of maintaining or intensifying distress over time. Many of the safety-seeking behaviours we highlight here have the aim of reducing ambiguity in gender presentation to avoid judgement from others or themselves.

It is important to note that gender diverse young people may have good reason to feel like they need to reduce ambiguity in their presentation to keep themselves safe. In a 2018 study, 58% of young gender diverse people reported experiencing bullying from peers in relation to their gender expression in the last month (Gower et al., 2018). For this reason, prior to thinking about developing different relationships with these safety behaviours, it is important that there is consideration as to whether work is needed with networks to ensure that young people are indeed in a safe and supportive environment.

Binding

Chest binding is the use of an item of clothing or bandages to hide the appearance of breasts. Binding is associated with a range of negative physical health outcomes, however, it has also been described as having a felt sense of mental health benefit for transmasculine people (Peitzmeier et al., 2017).

A common pitfall we have seen around binding is that over time it can intensify self-focus on the chest through the sensation and restriction of the binder. Some young people then bind more frequently or with tighter binders with the aim of reducing distress, creating a vicious cycle. The health impacts of binding and the way that binding restricts some activity can also mean that young people can come to feel distressed both about having a chest and about feeling that they have to wear a binder in order to manage.

Alex spoke about his negative feelings towards his chest, and the lengths he would go to in order to hide his body. When at school or outside the house, he would wear a binder extremely tightly, which he said felt very uncomfortable. Unfortunately, the tightness and frequency of his binding resulted in Alex developing physical health problems, having to attend A&E, and missing school. When at home, he would wear a pillow underneath his t-shirt, and in the garden he would wear a life-jacket. This made it hard for him to exercise and look after his body, which was one of his values (Harris, 2011).

In sessions, we spoke about the things wearing a binder/life jacket opens up and closes down for him. We thought about whether there might be times where not wearing a binder might open up other possibilities for him, in line with his values. Alex noticed that on a day where he was feeling a bit better in himself, he was able to go for a run wearing a swimming costume and a hoodie, which made him feel good. He said he would struggle to do this on a day where he was feeling particularly low.

We also spoke about the role of self-focus on his feelings of distress about his body. Alex said he recognised that using a pillow and lifejacket at home might mean he focused even more on the parts of his body he doesn’t like. However, he spoke about how he was proud of the image he has worked hard on to create, and doesn’t want anyone to see him as “less of a boy”, if they saw him without the pillow/lifejacket. Although Alex didn’t change his decision about binding, using a lifejacket, or pillow, he was more able to weigh up the costs and benefits in each situation, and have a better understanding of the choices he was making.

Mirror checking and making critical comparisons

Likely in part due to the difficult reality of living in a society where experiences of transphobia are common, and being at a normal developmental stage where peer acceptance and conformity are considered important, many young people we see present with significant anxiety about ‘passing’ as cisgender. One of the ways that young people try to manage anxiety around this is by spending a significant amount of time focussing on their body attempting to hide any indicator of their birth assigned sex (e.g. adjusting clothing, holding their body in particular ways, binding). Young people also speak of looking in the mirror frequently, for reassurance that they are passing. As in CBT models for body dysmorphic disorder (Veale, 2004), mirror checking can serve to increase the critical attention young people bring to their body increasing distress over time. Perhaps as a result, some young people report feeling distressed about parts of their body that are not commonly perceived as gendered (e.g. feeling that they have a feminine/masculine eye shape).

Some young people also report making frequent critical comparisons between their own body and that of cisgender peers in person or on social media. Young people have described this as a way of seeking reassurance that they are passing. As with mirror checking, this has the unintended consequence of increasing critical focus on the body. Research has previously highlighted that making more frequent social comparisons is associated with poorer body image in adolescents (Jones, 2001).

In talking about Alex’s experience of “dysphoria” we noticed together that this feeling fluctuated in intensity and was a label Alex used for a whole range of different complex emotions. We noticed that “dysphoria” was more around when things were feeling difficult in other ways (e.g. such as when Alex broke up with his boyfriend). Alex said that when “dysphoria” was around he would begin to get lots of self-critical thoughts which focused on comparing his body to a biological male.

We spoke together about the ways that Alex tried to manage the feeling of “dysphoria”. Alex spoke of trying to gain reassurance that he was passing as male by self-checking, involving making lots of comparisons between his own body and that of biological males. Alex said that when “dysphoria” was around he would spend lots of time on social media looking at male bodies which he recognised as unhelpful.

We noticed together that Alex’s strategies to manage “dysphoria” whilst aimed at reducing distress had the unintended consequence of serving to heighten his focus on the parts of his body that he disliked. This meant that over time experiences of “dysphoria” were maintained and increased. A compassionate approach was used to help Alex develop a way of bringing a kinder and less critical attention to his own body.

Avoidance

Avoidance comes in different shapes and sizes for this population. For some young people, avoidance can mean retreating from a social world to avoid the real or imagined judgements of their peers. Some young people speak about avoiding social situations as an escape from the possibility of someone misgendering them or recognising them as transgender. Avoidance of social situations has the impact both of increasing anxiety about re-entering a social world (Heimberg, 2002) but also can lead to young people becoming withdrawn and depressed through lack of pleasurable experiences (Veale et al., 2008).

Due to the distress of some young people in recognising the sexed parts of their bodies, some young people may also go to great lengths to avoid experiencing their body. Sometimes this can show itself in young people avoiding looking at themselves in the mirror, showering in the dark or avoiding changing their clothes. This can also show itself in young people avoiding physical activities which involve a sensory experience of their body (such as washing, exercise or, for adolescents, masturbation). This kind of avoidance both means that anxiety is increased when they do inevitably experience their body, but also means that their experience of their body becomes more difficult; if you avoid sensory experiences of your body, it becomes very unlikely that you will ever have a pleasurable experience of your body. We have also seen that over time for some young people the avoidance of experiencing their body can lead to a sense of detachment from the physicality of their body.

Alex spoke about how when the “dysphoria” was particularly bad he began avoiding any reflective surface and showering in the dark. He spoke about one time where he had accidentally seen himself in the school bathroom mirror and experienced a panic attack. We recognised together that whilst avoidance prevented him from feeling anxious in the moment, it increased his fear around recognising his body in the longer term.

Behavioural strategies that were used included exposure to avoided places/situations (e.g. going to the college café, asking a question in class), and dropping safety seeking behaviours (e.g. walking around college with headphones on, not looking at people when speaking).

Alongside behavioural strategies, Alex was introduced to different strategies to help manage the thoughts that were increasing and maintaining anxiety, such as present moment awareness training, thought diaries to help him to notice self-criticism, development of self-compassionate responses, and thought defusion exercises (Harris, 2011).

Tolerating uncertainty and distress

Tolerating uncertainty

Contextually, the UK is currently an uncertain, even hostile, place for gender diverse young people. It makes sense that amongst this background, gender diverse young people would find this uncertainty profoundly troubling, and fundamentally invalidating of who they are, and therefore want to seek greater certainty.

There are also individual psychological reasons why we might expect young gender diverse people to experience more difficulties in tolerating uncertainty. Research has highlighted a link between early adverse childhood experiences (ACEs) and more difficulties in tolerating uncertainty (Sternheim et al., 2017) and gender diverse young people are significantly more likely to experience ACEs, with one survey noting that 48% of gender diverse young people had experienced four or more ACEs, compared against 14% of the general population (Craig et al., 2018). Gender diverse young people are also significantly more likely to experience autism spectrum condition (Glidden et al., 2016) which itself has also been linked to intolerance of uncertainty (South & Rodgers, 2017).

Intolerance of uncertainty has been shown to predict a range of mental health difficulties, including depression and anxiety (Jensen et al., 2016). Some young people speak of experiencing distress which they were unable to understand or conceptualise. For other young people, the perceived uncertainty around social interactions, ‘passing’, and feeling accepted by peers can be highly distressing.

Alex talked about feeling highly anxious about speaking in class, or saying anything when in a group of peers because he was unsure how the interaction would go, whether his comments would be welcomed and appreciated, and whether what he said might impact how well he ‘passed.’ Alex recognised that these worries were in part related to an intolerance of the uncertainty of the outcome of these interactions, and he was able to reflect that by avoiding speaking out he was not only missing out on social interactions and building social relationships, but also avoiding uncertain situations. Behavioural strategies were used to increase Alex’s tolerance of uncertainty by gradually exposing himself to uncertain situations (e.g. answering a question in class, giving an opinion in his friendship group), and analysing the outcomes, which frequently were not as bad as he had anticipated.

Tolerating distress

As noted many young people accessing our service are more likely to have experienced early developmental or relational trauma (Kozlowska et al., 2021). This in turn can lead to young people experiencing more difficulties in tolerating distress (Vujanovic et al., 2011).

There are specific ways in which distress tolerance skills are of increased importance for gender diverse people in the UK. Those that wish to go forwards with physical interventions (e.g. cross-sex hormones, surgery) often find themselves having to wait years before they can access these interventions. In addition, other young people may wish to find ways to manage their distress without physical interventions.

Alex began to recognise his own level of emotional arousal using the ‘fizz scale’ (Ayres & Vivyan, 2019), and the connectedness between his thoughts, feelings, behaviours and physical sensations (Greenberger & Padesky, 1995).

Alex particularly enjoyed the metaphor of the ‘quicksand’ ( Harris, 2011 ) to reflect on how by not accepting and struggling against difficult feelings, this often makes the situation feel much worse. Alex noticed that when difficult feelings were around, he might immediately become angry, or lash out at others. However he noticed that this immediate reaction to fight the situation made him feel worse, and it wasn’t in line with his value of being a good person to others. Alex had spent time considering his values, and the therapist used the ‘choice point’ ( Harris, 2011 ) exercise to help Alex identify times when he could act more in line with his values when he was starting to feel distressed.

When Alex noticed that difficult feelings were around, he found that using third-wave (e.g. DBT) techniques helped him to tolerate his distress, and often helped him feel better, such as immersing his face in cold water, distracting himself, talking to others, and speaking to himself compassionately. We reflected that sitting with and managing his distress in this way, rather than lashing out at others, was more in line with his values.

Examples of therapeutic techniques

Table 1 compiles a range of third-wave CBT techniques which have been adapted to support young people to manage gender-related distress, and examples of potential outcomes of these interventions, based on our experiences working with a number of different young people.

Table 1.

Examples of CBT techniques and potential outcomes.

Technique	Example	Outcome
Passengers on the bus Metaphor (Luoma & Hayes, 2009)	“Suppose there is a bus and you’re the driver. On this bus we’ve got a bunch of passengers. The passengers are thoughts, feelings, bodily states, memories, and other aspects of experience…”. In this metaphor the driver responds to the passengers by trying to struggle against them, or giving in to them. The third option is to acknowledge them, and continue to head in the direction of your values. The therapist asked Alex what parts of the metaphor connected with him, and introduced the idea of living life in line with your values, at the same time as having passengers on the bus.	Alex related the Passengers on the bus metaphor to his experience of not coming out at school, because he experienced thoughts which focused on all the potential negative outcomes. He expressed that going forwards, he would choose to live life more in line with his values. The therapist and Alex continued to use the metaphor to frame conversations about ways he could live in line with his values, at the same time as having difficult thoughts and feelings connected to gender.
Quicksand Metaphor (Harris, 2011)	“…If you should ever fall into quicksand, struggling is the worst thing you can possibly do. What you’re supposed to do is lie back, spread your arms, and lie as still as possible, floating on the surface…”. The therapist asked Alex which parts of the metaphor connected with him, and introduced him to the idea of sitting with difficult emotions, rather than struggling against them.	Alex made sense of the Quicksand metaphor as “if you sit with the emotion and let them be, you will have a better outcome”. He noticed that when he cries, he lets the emotion out and feels better. Over the course of therapy, Alex’s thinking around the metaphor developed, particularly as he practiced mindfulness techniques to observe and move towards difficult emotions connected to his gender.
Compassionate thought record (Vivyan, 2010)	Alex was asked to note down negative thoughts he experienced over the week, and complete a compassionate thought record sheet, which prompted him to think about what he would say to a friend going through the same situation, or what a caring friend would say to him.	Alex wrote about a situation where he was walking down the street with thoughts such as “people must be thinking ‘is that a boy or a girl?’” and “why do I have this body?”. Alex was able to come up with more self-compassionate thoughts such as “no one actually cares what you look like” and “even if you don’t 100% pass, it doesn’t make you less of a guy” which he said helped the negative thoughts and emotions feel more manageable. He was able to bring these kinds of thoughts to mind when he noticed himself having self-critical thoughts in later situations.
Behavioural Experiment (Bennet-Levy et al., 2004)	Alex completed a behavioural experiment around walking alone through the school corridors, whilst dropping his safety behaviours (without fiddling with things in his pockets, looking down at the ground, or hiding behind friends). Alex expected that groups of people will be staring at him, whispering “is that a boy or a girl?”, and laughing.	Alex noticed that “No one laughed at me, stared, pointed or judged”. And “No one actually cares what you look like”. As therapy continued, Alex practiced walking alone through the corridors “acting confident”, with his head held up. He noticed that acting confident led to him feeling confident, and by the end of therapy, he was regularly walking down the corridor alone, without having to think about it.
Attention training technique (Wells, 2011)	Alex described in his formulation that when he is feeling anxious in social situations, he notices everything his body is doing, and worries that people will see he is sweating, and that people will see he is trans. The therapist introduced him to the role of self-focused attention in amplifying anxiety, and they practiced attention training exercises in session. In these exercises, Alex was asked to listen to a soundscape, and switch his attention between particular sounds, for 5 minutes. In another exercise, Alex was asked to focus on different images in a video, and switch between images amongst distractor objects.	Alex practiced the attention training exercises between sessions, when in a non-anxious state. He also practiced listening to sounds, or noticing objects of a certain colour when in anxiety provoking situations (e.g. walking to the shop). Alex found that this helped shift his attention away from him from his thoughts, focus less on his body, and reduce his anxiety if he was starting to feel panicky.
Thought defusion exercise (Leaves on a stream, Harris, 2009)	Alex struggled with difficult thoughts, particularly if he caught a glimpse of the shape of his body, such as “why was I born into this body when this isn’t me at all?” and “all my guy friends have male bodies, I feel different to them”, which led him to feel sad and upset. The therapist introduced him to the Leaves on a Stream exercise to help him have some distance from these thoughts when they were feeling particularly overwhelming. In this exercise, Alex was asked to imagine a stream with leaves floating along the surface of the water. He was then asked to put each thought or feeling which entered his mind onto a leaf, and watch it float by.	Alex said that he found the exercise helpful, saying that he could see his thoughts on leaves running down the stream. He practiced the exercise both between sessions and in future sessions. He found it to be a helpful technique in managing his thoughts when they were particularly distressing. He continued to use “Leaves on a Stream” as a technique for letting difficult thoughts and emotions pass during difficult situations.
The Fizz Scale (Ayres & Vivyan, 2019)	The therapist introduced Alex to the ‘Fizz Scale’ using an analogy of a fizzy drink to describe different levels of emotional arousal like a ‘fizz’. Alex used this scale to talk about experiences in his body and in his mind at different levels of arousal.	Alex described feeling constantly at a 3/10 on the ‘fizz scale’, feeling angry and uncomfortable, with difficult thoughts running through his head. He noticed that he quickly jumps from 3/10 to 10/10 in a difficult situation. This analogy allowed Alex to begin to notice his own level of emotional arousal in different situations, and notice thoughts which cause the fizz to increase. This insight allowed him to think about ways of managing his thoughts, feelings and physical sensations in difficult situations.
5 Aspects CBT Formulation (Greenberger & Padesky, 1995)	The therapist introduced Alex to the 5 aspect CBT model, describing the connections between thoughts, feelings, behaviours and physical sensations. Alex completed the formulation around an incident at school where another pupil asked him “are you a boy or a girl?”	Alex recognised that he was not particularly annoyed at the pupil who said the comment, but the incident activated difficult thoughts, feelings and memories he had about himself, which caused his anger to escalate right up to 10/10, and he yelled at the pupil in class. The therapist and Alex spoke about how it is not ok that he had to cope with comments like that, however he would still like to be able to have a bit more control over his emotions and behaviours.
Choice Point (Harris, 2017)	The therapist introduced Alex to the ‘Choice Point’ exercise to think about which actions would move Alex towards, or away from his values in a difficult situation. Alex used the example of a pupil asking him “are you a boy or a girl?” in class.	Alex thought about his value of getting along with people, and being open. He felt that raising his voice, shouting at the pupil, and storming off were ‘away moves’ – actions which moved him away from living in line with his values. He felt that explaining in a calm voice why that was an inappropriate question to ask in class, and noticing his angry feelings but not reacting to them were ‘towards moves’ – actions which moved him towards living in line with his value of getting along with people and being open. Alex was able to hold these towards and away moves in mind in future difficult situations, and make choices which were more in line with his values.

Discussion

Outcomes

The case study we present above is illustrative, in that it consisted of an amalgamation of work we have completed with several young people in our service, in order to both protect the young people’s anonymity and to provide a broad sense of the ways in which CBT approaches can be helpfully used with this population. As such, it is beyond the scope of this paper to show quantitative outcome data to demonstrate the efficacy of the CBT approach we have used, and this is an area for future research. However, we present some reflections based on the experiences of the young people we have worked with, whilst acknowledging that our conclusions are anecdotal and may be subject to reporter bias.

Many of the young people we have worked with using CBT approaches have felt they have benefited from the intervention. They have been able to learn strategies to manage anxiety and gender-related distress, and in many cases, we have seen subsequent reductions in both. This has often meant that young people report feeling more able to engage in their interests, education, and social relationships. We have also observed that these interventions have enabled young people to think more flexibly about the benefits and risks of interventions, such as binding.

We have found that collaboratively developing a formulation around distress related to gender can, for some people, help reduce this distress. A formulation can help in developing joint understanding, and identifying potential maintaining factors. There is an important difference between using formulation to understand and guide interventions to help reduce a young person’s gender-related distress, and formulating their gender identity as a target for intervention. As we have described, CBT for gender-related distress does not aim to change the gender someone identifies as.

Implications for clinicians

Clinicians working with gender diverse young people might consider a CBT approach, similar to that described above. We have described how several common CBT techniques could be adapted for use with this population, and we encourage clinicians to think creatively about how they could use their therapeutic skills to help young people manage their gender-related distress. There are likely to be many more tools from CBT which could also be adopted, such as using diaries to support young people to notice what brings on distress related to gender, and the ways they manage it.

Alex spoke of initially being sceptical about the benefits of a therapeutic approach, as he felt only physical interventions would help to reduce his distress. Other young people may feel similarly, feel unmotivated to engage, or feel that by suggesting CBT, their gender identity is not being validated. It is important to talk with young people about these concerns, sharing that CBT for gender-related distress does not seek to invalidate a person’s gender identity, but aims to help them manage or reduce the distress they experience. It is sometimes helpful to compare this work to that of Clinical Health Psychology, where CBT interventions are routinely used to help people manage distress related to physical health conditions, without invalidating or challenging the experiences of their condition.

This being said, how can we make sure that young people who connect with these ideas are able to access a therapeutic space to manage their gender-related distress? Are there times when a specialist gender service would be best placed to be offering in-depth therapeutic work? Would families perceive a specialist gender clinic to have the expertise needed for this work? Or would additional difficulties arise due to the gender service’s role in decision making around physical interventions? May there be other times when this work could be effectively done locally, with clinicians who know the young person well, in a more timely manner? As gender-related care for young people in the UK continues to be reviewed and restructured, we hope that pathways for young people to access therapeutic approaches for gender-related distress become clearer.

Broader reflections

It is important to bear in mind the challenging social reality described in the introduction, as many gender diverse young people experience bullying, discrimination and transphobic hate crimes (e.g. Gower et al., 2018). This social context could also contribute to young people’s gender-related distress. It could also be argued that the current socio-political climate around gender has contributed to an environment where distress about gender is intensified. We would hypothesise that young people be less distressed about gender in a society which was more open, diverse and accepting of gender diversity (Wren et al., 2019).

In the current context, it is important to use an individualised approach for each young person. Clinicians could explore with a young person which safety-seeking practices feel necessary for them to feel safe from bullying or violence, and which practices they may be able to relate to more flexibly.

Future research

As with any therapeutic innovations, it is important to evaluate the effectiveness of CBT approaches for gender-related distress, using outcome measures and structured research studies. It would be equally important to report and evaluate the CBT approaches already being used by clinicians to support young people with gender-related distress, to inform a practice-based evidence approach. Further research could also explore appropriate outcome measures for evaluating CBT for gender-related distress. Evaluating this approach raises questions about how or if gender-related distress could be objectively measured, and change demonstrated, or whether more general measures of distress are appropriate. Finally, further research could also qualitatively explore gender diverse young people's experiences of CBT for gender-related distress, to better understand which aspects of the therapy were most or least helpful, and what they would like to be included in a therapeutic approach for gender-related distress.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

Informed consent

As mentioned, the illustrative case study was formed of an amalgamation of different stories from young people, along with representative fictionalized details to ensure anonymity. Where more detailed parts of stories or experiences in therapy were used, we gained written consent for publication from young people which was also discussed with parents.

Young people were informed that we wanted to write an anonymized version of their story and experience of therapeutic support in our team. They were given opportunities to ask questions and we made clear that they could decline their consent and this would not affect the care they received in our team. All young people were 16 and older at the time of writing.

ORCID iD

Lauren Canvin

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