What Therapists Get Wrong with Adolescent Gender Dysphoria

My thoughts after nearly a decade in the field

Stacey Warnix

There are just over 4,000 of you who read this monthly newsletter because you want thoughtful and nuanced reflections about caring for gender-questioning adolescents.

I will continue making this writing available for free, and paying subscribers really help me to do this -- as of now, only 2.6% of you are paying supporters. If you can, join the paid tier to support my work here. If you can’t, then please like, share, and comment.

---

At its core, psychotherapy is a relationship between two people, organized around discovery and meaningful change. The relational dynamics in the room, of both therapist and client, when discussed openly in session, create opportunities for greater awareness of the inner drivers that shape emotion, behavior, and relationships. As Jonathan Shedler writes, “The essence of psychodynamic therapy is exploring those aspects of self that are not fully known, especially as they are manifested and potentially influenced in the therapy relationship.” Through this process of reflection and emotional understanding with a trusted Other, therapy helps individuals see themselves more accurately, access their authentic emotions, and make choices that improve their lives and relationships.

Yet in contemporary clinical culture—especially in work with adolescents exploring gender identity—psychotherapy’s curious and relational ethos has been subsumed by an ever-widening polarity. On one side, many “gender-affirming” therapists limit their role to validating a declared identity and facilitating transition in whatever form the client desires. On the other, some therapists who push back against the affirmation model interpret the proliferation of diverse gender identities as a sign of mental illness run rampant, at times echoing the paternalistic tone of psychiatry in decades past. This clinical divide unfortunately runs parallel to a societal one, reflecting broader social binaries.

The challenge for any clinician working in this contentious field is to remain vigilant against ideological capture and to stay firmly grounded in the principles that form the foundation of good therapy. Initial impressions about what gender distress represents, or what direction therapy should take, should remain tentative until there is enough time and trust to form a shared understanding of the client’s emotional and relational world. Unfortunately, this kind of process is still hard to come by, especially when therapists identify with an ideological position instead of maintaining their professional stance of curiosity and restraint.

Today’s essay examines how therapists swept up in these political currents can lose the basic frame essential to effective work with clients. Drawing from nearly a decade of work with gender-distressed adolescents and their families—and from my own experience making some of these mistakes myself—I describe the most common ways therapists may unintentionally stray from the purpose of our craft, and how to restore the depth and integrity of psychotherapy when working with gender-questioning or trans-identified young people.

1. Starting With a Conclusion

We can’t possibly know what role gender plays in a young person’s life without first lingering in significant uncertainty. We must ask questions, explore the context, and allow meaning to emerge slowly. When clinicians approach therapy with a new client, if they rush to define the problem or prescribe solutions, they may end up alienating the young person or colluding with their client’s maladaptive framework. The therapist is also likely to be completely wrong in his or her formulation.

Instead, understanding a young person’s relationship to gender identity is like peering through a foggy window. Only with time, patience, and gradual clarity does an accurate picture emerge into view.

2. Losing the Symbolic Dimension

A growing literalism has taken hold of the field. Some therapists treat gender identity declarations as potentially fixed and essential aspects of a person. In cases like this, they attempt to blindly affirm or carefully assess their way to a conclusion about the person’s core identity: is this client trans or not? On the other hand, some therapists approach a person’s identity claims as simply irrational misunderstandings of reality. Here, all that remains is argument, debate, and rationality.

In both cases, the therapist has failed to recognize that claims about gender incongruence hold symbolic meaning. They offer a rich metaphor that requires the clinician to hold gender claims lightly and to read between the lines. Therapy must remain curious and open to the emotions, desires, needs, and conflicts being expressed through gender. Attempts to take this distress literally—and either immediately medicalize it or debate its premise—are misguided. It is only when we recognize body–mind conflicts as symbolic that we open the possibility for meaningful understanding.

3. Pathologizing the Identity

Reacting to the push to normalize transgender identities, some clinicians now argue that transgender identification should be classified as a psychiatric disorder. Many of these therapists acknowledge that gender distress is culturally mediated, yet they still locate the pathology within the individual. This formulation collapses important layers of complexity and misunderstands the nature of the phenomenon.

I regard the adoption of a transgender identity as a strategy—a culturally salient schema, a kind of ready-made psychological template that promises relief, belonging, and coherence amid inner turmoil. Like any strategy, it can be adaptive or maladaptive; it can resolve distress, run its course, or fall short of what was hoped for. For some adults who understand its trade-offs, the trans strategy may indeed provide genuine relief and a lasting sense of stability. To deny this, or pretend it never happens, is dishonest—or a reflection of the algorithmic silos that shape what we see (and what we never see).

At the same time, clinicians are right to be concerned about the many emergent cases in which this strategy has been adopted under duress, built on false premises, or led to long-term physical and psychological harm. In some cases, even short-term satisfaction can give way to long-term regret.

But pathologizing trans identities themselves will not protect our clients from this fate. True clinical work begins when we understand “trans” not as an essence or an illness, but as a strategy—one that can be explored, understood, and either relinquished or refined through the therapeutic process.

4. Bringing Politics Into the Session

Sociocultural and political forces are now inextricable from mainstream discussions of gender identity. And because therapists are human beings, they inevitably hold personal views about these issues. But the therapy room is not the place to advance them. Introducing political framing, specialized terminology, or debate topics—especially when initiated by the therapist—pulls the focus away from the individual and toward the culture.

The most meaningful work happens in the relational dynamic between client and therapist, and in the self-awareness that develops within that space. When political concepts replace emotional inquiry, the patient’s inner world is lost to abstraction.

If a client brings political topics into session, the task is not to join the debate but to stay with the emotions being expressed. Even the most charged ideological conviction carries a psychological meaning that can only be understood by looking beneath the content of the argument to the feeling that animates it.

5. Failing to Establish Trust

Some clinicians believe that trust will form more easily if they remove all friction at the outset of therapy. They immediately use an adolescent’s preferred name and pronouns and adopt an affirming stance without knowing the temperament, personality, or needs of the young person. While there may be individual cases where this approach is necessary, superficial affirmation alone is insufficient for genuine trust to develop.

Real trust emerges when the therapist consistently and thoughtfully attends to the interpersonal dynamics unfolding in the here and now. By showing authentic curiosity and care for the client’s inner experience, even when the conversation is uncomfortable, the young person learns that the therapist is reliable, genuine, and truthful.

Conversely, when therapists operate from a pre-formulated agenda, even an “affirming” one, they foreclose the conditions necessary for true change and collaboration. Therapists should slow the pace, hold modest expectations, and refrain from challenging, reframing, or offering advice until a basic sense of safety and mutual understanding has been established.

6. Not Accounting for Parents and Transference

Young people entering therapy often come with one of two expectations about the clinician: either the therapist will serve as an extension of the parental perspective, or as an advocate who will help “get the parents in line.” It is the clinician’s task early in treatment to discern which expectation the young client carries and to address it directly.

To build a working alliance, the therapist must respond thoughtfully to this dynamic. For younger teens, it can be grounding to know that, as a rule, parents will be involved to some degree. This structure helps reduce triangulation and allows the therapist to coach parents in improving their relationships and communication with their child. When significant tension exists between teen and parents, however, this approach can hinder rapport—at least until the therapist demonstrates themself as an independent third party.

With older adolescents, therapists should carefully consider whether maintaining regular contact with parents will help or hinder the individual work. As with much of psychotherapy, a nuanced understanding of the family dynamics should guide the therapist’s approach to parental involvement: when to invite it, when to limit it, and when to hold the adolescent’s confidence as a core commitment within the therapeutic frame.

Closing: Restoring the Therapeutic Stance

Our profession’s crisis around transgender identity is not fundamentally about gender at all. It’s about the fact that we’ve forgotten what therapy is really for. The therapist’s role is not to affirm or to correct, but to help the adolescent feel with less shame, think with more clarity, and respond with greater creativity.

To bridge this divide, clinicians must practice sitting in the tension of uncertainty. We serve our clients best when we resist being pulled into ideological frameworks and instead remain anchored in a psychological and relational stance. In doing so, we offer what social discourse cannot: a space where complexity is permitted to exist.

We resist the pressure to know by working symbolically, developmentally, and within the immediacy of the therapeutic relationship. Here is where psychotherapy regains its depth. Therapy is, after all, a disciplined practice of curiosity and containment in the midst of confusion.

For parents seeking certainty or quick solutions, this is both the challenge and the hope. There are no shortcuts, but there is guidance. If you would like my help, I offer one-on-one consultations and a private parent membership community where we explore these issues in depth. After all, you’re going through this one time with your child, but I’ve walked hundreds of parents through this process. If you need someone experienced in thinking through things with you, please reach out.