Since the official depathologisation of trans identities in the latest version of the International Classification of Diseases (ICD-11) (Castro-Peraza et al., 2018; 2019), little is known regarding the impact of the historical change on psychotherapeutic and counselling practice. In various public services worldwide, participation of mental health care providers (MHPs) has already been lessened or suspended, since their involvement in healthcare provision is not considered obligatory anymore (Gómez-Gil et al., 2020; Spanos et al., 2020).

This rearrangement cannot be directly attributed to the only completely effective in early 2022 ICD revision (Gaebel et al., 2020). Instead, it involves a general tendency towards citizen participation and self-determination in mental healthcare of gender diverse people (Ortega Arjonilla et al., 2018). It cannot be easily documented, either, since services of the kind are not offered by single entities but by several institutions of different calibre, including Gender Units of University Hospitals, primary health centres, private practice, LGBTQI organisations, and others. Moreover, MHPs perform a variety of tasks depending on their abilities and context. Psychotherapy and counselling are different procedures themselves, entailing different sets of methods, usually for different purposes. Here they are examined jointly, along with psychological assessment, as mental health services (Wylie et al., 2016).

Before the ICD revision and despite its own predicaments (see Suess, 2020, for a criticism), dominant biomedical, psychological and legal discourses had been promoting a Western, dichotomous, normative model of understanding gender (Fausto-Sterling, 2000; Johnson, 2016; Spade, 2006). This model, replete with universalist assumptions, has been grounded upon the entitlement of those discourses to granting legitimacy to certain prototypical identities, and to imposing and institutionalising normative positions as natural, through laws, tax rules, or values such as monogamy (Athanasiou and Butler, 2013; Iantaffi and Bockting, 2011; Sennott, 2010). Gender role expectations have constituted a quantitatively measurable artefact (López-Sáez and García Dauder, 2020) with painful implications for people who do not fall within this traditional gender dichotomy (Doan, 2010). Therefore, psychological practice has contributed to the erasure of alternative testimonies, narratives, and modes of conceiving sex and gender (Bauer et al, 2009; Occhino and Skewes, 2020).

Transgender and gender non-conforming people¹ are notably more likely to seek mental health services for gender issues than the rest of the LGTBQI community is for issues related to sexual orientation and sexual identity (Hendricks and Testa, 2012; Israel et al., 2008). They are also more likely to find those services unhelpful or ignorant of their particular needs (Benson, 2013; Suess, 2020). Psychotherapy’s ineffectiveness and subjects’ dissatisfaction have often been reported both in literature and throughout empirical studies (Bockting et al., 2004; Raj, 2002). This negative relation has led to a history of mutual suspicion, where subjects have had to assume the training role, due to a generalised lack of specific training on LGBTQI issues in mental health providers’ curricula (Carroll and Gilroy, 2002; Chavez Korell and Lorah, 2007; Gherovici, 2017).

In psychotherapy and counselling with TGNC people, Patrick Grzanka and Joseph Miles (2016) document three main models: the conversion model (or pathologisation), the gatekeeping model (or incorporation), and the affirmative model (affirmation). Each model supposes a different approach to the therapeutic relation. It is significant to observe how this threefold division has configured the therapeutic space during the last two decades, and how shifts in psychological practice have affected power relations between MHPs and gender diverse clients. Additionally, such division is neither merely chronological, nor a simple mimicking of ICD revisionist culture: the three models may even coexist over time, creating a complex landscape of practices. There is, however, a linear evolution in terms of renouncing institutional violence, the affirmative model being the most inclined towards reading gender dysphoria as societal prejudice instead of an individual issue (Tosh, 2016).

I purport to use the aforementioned division to examine the universalist presumptions behind TGNC experiences that have perpetuated this culture of suspicion. Although I endorse their call for epistemic break from positivist and post-positivist paradigms (Tosh, 2016, p. 376), I depart from their invitation to actualise psychological work by forcing it out of the therapy room (Tosh, 2016, p. 386), proposing a novel, critical examination of the therapeutic relation instead. My aims are to explore how specific dynamics between TGNC people and psychologists are affected by dominant psychological discourses that have promoted universal, standardised ideals of transgender identity; and subsequently, to contemplate the changes brought by the recent ICD revision.

In order to examine the discursive and contextual aspects of subjective formation that cannot be revealed through standard psychological and taxonomical technologies, I appeal to studies that address the therapeutic alliance. Grzanka and Miles believe that Science and Technology theorists have not sufficiently stipulated gender identity issues in psychotherapy, leaving knowledge production in the field to be assumed almost entirely by psychologists (Grzanka and Miles, 2016, p. 372). I use the situated knowledge acquired through feminist and critical STS (Campbell, 2009; Latham, 2016), to understand alliance itself as a technology of narrating, exploring and configuring gender. Gender identity emerges in therapy through practises and narratives of diverse value, depending on each particular cultural and professional context.

Throughout the text, I do not consider psychotherapeutic accompaniment incompatible with gender self-determination. Even though the notion of gender configuration implies a dyadic process, where the psychotherapist or counsellor reflects certain aspects of the person’s gender identity back to them, that does not a priori constitute monitoring. Accompaniment of TGNC people may not concern their gender identity, but rather issues of exclusion, discrimination, stigma and well-being (Benson, 2013; McBee, 2013). Accordingly, under no circumstance should psychotherapy itself be understood as a forceful practise of aversion or of “curing” trans people, unless when explicitly referring to conversion therapies.

Transgender identities and experiences are utterly disparate, bringing to the surface not only the discordance between gender identity and sex assigned at birth, but more importantly, what gender identity is about: social group membership, felt contentment with one’s own self-presentation, felt pressure for conformity, and attitudes towards other gendered groups (Egan and Perry, 2001; Wood and Eagly, 2015). TGNC people in Western societies have long been obliged to comply with several psychiatric, medical and legal criteria of gender in order to be recognised as such and be relatively integrated into society (Billings and Urban, 1982; Hines, 2013; Johnson, 2016). Passing, the “ability” to socially hide trans status (Garfinkel, 1967/1991), has been a key element in this system of compliance.

As a standpoint of societal power distance, passing creates a double paradox, since it signals that both by passing as non-transgender (from now on, cisgender) and by failing to do so, TGNC individuals are flawed (Spade, 2006). In case they pass as members of dominant gender groups (men or women), apart from the high levels of self-policing they need to submit themselves to, they are frequently met with distrust and hostility. Society might react by believing TGNC people have misleading behaviours or are even lying about themselves. In case they fail to pass, they seem to be “doing gender” in an unsuccessful way. In both cases, they are being thought of us deceivers. Thomas Billard (2019) has called this framework “the deception frame”.

Under these circumstances, it would seem fundamental to examine whether a person followed gender norms correctly, by dressing, talking, moving and behaving in a standardised, stereotypic mode. Therefore, gender evaluation was a task many MHPs would implement (Serano, 2016). Sandy Stone (1987/1991) was one of the first theorists to elaborate on how TGNC people who wished to receive hormonal treatment or to undergo “sex reassignment surgery” would study referential texts, get informed by other testimonies and follow professional guidelines in order to perfectly match established transition criteria. Gender evaluation was an obstacle to overcome, a challenging but inevitable play one had to assume, if they wanted to accomplish bodily modification.

Professionals’ “determining gender” has been in constant dialogue with subjects’ “doing gender”. Determining gender is a term that signals how our gender identity is authenticated or assigned by others, through our expressions, presentations and behaviours (Westbrook and Schilt, 2014). Psychological practise has played a major role in configuring this external representation, with direct effects to TGNC people’s self-perception (Tate, 2014). MHPs would reflect their “standards of gender” and would validate a certain narrative that “did gender” via pre-approved standards. Gender evaluation was attached to a gatekeeping role that wished to ensure identity stability through time and erase the fear of regret of surgical interventions. In this asymmetrical dynamic, therapists desired to hear that the lust for change came from desperation and dissatisfaction (Latham, 2016; Spade, 2006). Even until our days, verbal scales of masculinity and femininity might still avow for such kind of performances (López-Sáez and García Dauder, 2020).

In another important account, Douglas Mason-Schrock (1996) informs of the narrative constitution of the “true self” within transgender support groups. At least until the 1990s, personal stories of members would be submitted to intragroup revisions in order to conform to a standard ideal of transsexuality. In fear of losing recognition, groups would be tactfully blind to internal contradictions of new members’ narratives, and would instil the storylines they would find more appealing. Members would be guided towards essentialist narratives (for instance, memories of cross-dressing in childhood), because socially constructed transsexuality would be subject to contempt.

This wrong body narrative implicitly validated the existence of a right body experience, and ascribed gender dysphoria exclusively to transsexual people (Halberstam, 1998; Hausman, 1995). Initially popularised during the 1960s, it was revolutionary in terms of dismissing a traumatic tradition of conversion therapies. Nonetheless, in the 1990s it was beginning to seem insufficient, since an increasing amount of TGNC people would claim their independency from the strict criteria of the biomedical and psychiatric system and would define themselves as trans even without any need of bodily intervention. Activist groups, radical thinking on gender, and distrust on health professionals’ motives, initiated a process of gradual alienation from the narratives Mason-Schrock and Stone describe. The shift, however, seemed like a threat to those people who depended on the system’s confirmation in order to fully transition, and that mounted to a series of conflicts inside the transgender community (Johnson, 2016; Missé, 2018).

The tensions between the transsexual and the transgender model (Denny, 2004) have direct analogies with the tensions between the wrong body narrative and the narrative of gender affirmation, both of which describe forms of speaking about being trans, although these parallelisms are neither secured nor absolute. Gender affirmation (Ehrensaft, 2012; Grzanka and Miles, 2016; McBee, 2013) emerged as a counter-paradigm to strict understandings of gender norms. Instead of viewing masculinity and femininity as the only existent forms of gender legitimacy, opposite, complementary, and highly portrayed, this new model would permit divergent expressions of gender. A new path was being opened for nonconforming, nonbinary and agender people, who discovered new means of defining themselves, but would still have to fight against society’s narrow gender definitions.

The transgender model was more permissive and explorative, and gender affirmation was far more liberating than the protocols of conventional gender evaluation and personality assessment. It posed issues the normative society was unwilling to face: how were legal documents, health services and gendered spaces, supposed to adapt themselves to alternative understandings of gender categories? Once again, recognisability would bring to the surface a culture of mutual suspicion and distrust, but this time, the basic difference was that approaches to gender diversity would be more client-centred and individualised, based more on bodies and less on protocols (Bockting, 2008; Carroll and Gilroy, 2002; Raj, 2002). Trans rights bills and the inclusion of TGNC people in the public sphere still followed the binary, activating gender panics whenever boundaries seemed to be shaken (Rood et al., 2016; Westbrook and Schilt, 2014).

Online culture arrived after the 1990s as another catalyst, by breaking both with a system of well secluded expert knowledge and with an idea that there is a unique pre-established way to “make transgender identities”. Many internet users started sharing, comparing, and discussing their experiences in health care, both physical and mental. Many others solicited hormones in illegal markets, arranged transition package trips to foreign countries, or simply met with people they would find in forums and associations (Raun, 2014). This culture of globalisation and instant sharing had both advantages and disadvantages: it brought power to citizen participation while also making transgender presences more homogeneous. The drawbacks of annihilating internal contradictions and rich variance in the support groups of the early 1990s, were also noticed in the commercial ways of presenting trans lives through the internet.

On the whole, the divisions between expert and lay, legal and illegal, global and local knowledge began to blur with the shift towards the new Millennium. Only after two decades into the 21st century can they be clearly appreciated, however. Even though psychological theory and practice have adapted to new gender schemes, at times not without resistance, the evolution has only been progressive and following activist claims, not preceding them. Moreover, as shall be seen below, psychological associations have generally altered their representations and attitudes towards gender diversity with time, at least in Western contexts (see APA, 2015; BPA, 2019), whilst psychiatric organisations maintain a more cautious approach to questioning the binary. The latest version of the DSM-5 (2013) can confirm such retardation. Given the spatial and historical contingencies of gender roles, the issue of cultural adaptation of guidelines is still largely pending.

Trans identity is neither transgressive nor conservative by definition (Halberstam, 1998). Some TGNC people bodily transition to achieve passing and acceptance as members of the two dominant gender groups, while others consider their transition a political move. Similarly, psychology remains relatively divided into trans-friendly and trans-sceptical approaches, although orthodox psychoanalytic or behaviourist theories are increasingly getting marginalised. A fundamental task of critical approaches concerns detecting the positionality and situated enunciation of each study or counselling practice. Nonetheless, there are various border wars that require further conceptualisation. Lisa Burckell and Marvin Goldfried (2006) establish a spectrum of five therapeutic approximations, verging from exclusionary therapist characteristics to essential alliance facilitation traits, while Jack Drescher (2013) and Grzanka and Miles (2016) simplify them to three positions, as described earlier, leaving less intermediary space.

The therapeutic space is a private, confidential space, and as such it configures gender differently than public, quasi-public and semi-private spaces do (see Westbrook and Schilt, 2014 for an analysis of space). It is a place supposedly defiant of surveillance and intrusion, or of what Petra Doan calls the tyranny of gender (Doan, 2010), although therapeutic perspectives play a decisive role regarding this aspect (Mizock and Lundquist, 2016). The way gender is performed inside a therapeutic session is conditioned upon the dynamic between performer and receiver, but also upon the material space that surrounds them. For instance, MHPs can rely on the public/private divide in order to remain discreet about their personal emotions (Fernández Garrido, 2021). Similarly, their own gender identity negotiation can be concealed through focusing on the nonnegotiable distance between them and the clients, both metaphorically and physically.

Alliance is usually established in the beginning of the therapeutic relationship, when the demand is enunciated and initial boundary negotiation takes place. Microaggressions are subtle communicative cues that discriminate against vulnerable populations, including TGNC people, and have the capacity of damaging this alliance. Misgendering, the use of inappropriate gender pronouns when addressing a TGNC person, and deadnaming, the tendency to use a TGNC’s name assigned at birth instead of their chosen name, are major signs of lack of training on issues of gender diversity. Both micro-aggressive behaviours can be unconscious or deliberate (Clark and Loewenthal, 2015; Freeman and Stewart, 2019; Nadal et al., 2012).

These attitudes are determining of alliance even from the first session (McLemore, 2014). Alliance here is to be understood as a slightly broader notion from trans or LGBTQI allyship, since the former refers to the process of creating emotional rapport between psychotherapist and client, while the latter focuses on advocacy. In practice, TGNC clients deduce allyship through alliance. An impaired therapeutic alliance is the main reason why a person would change their psychotherapist, while alliance is particularly low in cases of involuntary referral. Moreover, a less engaged alliance may indicate a higher dependency on psychometric evaluation in order to substitute for the lack of provided information or emotional rapport (Burckell and Goldfried, 2006). That is not to say that tests are exclusively of compensatory use when the relation is deficient; they might, however, operate as mediators when clients resist disclosure.

The current study wished to critically relocate three major psychotherapeutic models for TGNC people in the universal-situated dichotomy. The main purpose was to claim that, even though depathologisation of gender diversity seems to break with standardised gender criteria, it risks over-generalisation if it ignores intersectional knowledge and cultural competence. To advocate for more authentic encounters in psychotherapeutic practice after the ICD-11 revision may seem insignificant, since psychologists’ role has been lessened. Nevertheless, it strategically calls for new practice ideals that emphasise lived experience.

Wholly, assessment and therapy with TGNC people corroborate a history of systematic pressure to follow indications, guidelines and protocols intended for binary gender norms. In a quest to diversify such procedures, however, we might witness how, the more we “undo” gender, the more we also “redo” it, paraphrasing Laurel Westbrook and Kristen Schilt (2014). This paradox needs to be addressed through constant revision of our personal biases.

Narrative shifts concerning identities are hard to delineate, since they cannot be corseted into clear chronological periods. The described models may coexist in the same context, time period, even multidisciplinary team. Transgender people wishing to pass as cisgender, or wanting to undergo bodily operations, can and do co-exist in the same cultural contexts with nonbinary people that wish to keep their bodies intact and have no need to follow gender stereotypes. The same observation is applicable to cross-cultural manifestations of transgender issues: it is hard to distinguish between universalist and local practices, in social contexts where both can be equally represented.

Instead of opting for a relativist approach, a situated one is encouraged: as if in a case study, it is important to observe the context in which each TGNC experience is developed, because sometimes, standardisation restricts MHPs in offering personalised services. Despite that, not all psychologists agree in the use of guidelines, protocols and questionnaires. Not all guidelines for psychologists over-simplify or over-generalise; meaning to have a broad coverage, several attempts are indeed respectful of particularities, intersections and exceptions.

Albeit theoretically, I have ventured a comparison between what seems to be an outmoded tradition of gender determination and its deconstruction. Similarly, I wished to highlight that Western psychology should not be understood as a robust entity. There are many intrinsic contradictions and alternative paths that need to be unravelled in the process of de-universalising the psychological views of gender. Provincialisation (Shamdasani, 2018) or localisation (Gerritse et al., 2018) can aid the process of better contextualising this culture of suspicion TGNC people and psychologists have been historically immersed into. Situated studies on the negative attitudes and reluctance of MHPs, along with suggestions for adequate training (see, for instance, López-Sáez et al., 2020, on the matter) are also highly urged.

The present analysis draws heavily on previous designs. It is far from exhaustive, since it is not interested in capturing all possible implications of how dominant discourses on gender interact with transgender identities. For a more comprehensive view of the effects of those discursive mechanisms, longitudinal, cross-sectional and cross-cultural data would be necessary, both on expert and on lay level.

Critically informing on gaps in counselling and psychotherapy is also replete with methodological issues. Studies do not reckon information on the therapeutic alliance using the same tools, nor do they value confidentiality uniformly. Each therapeutic school manages different notions and techniques; therefore the application of the models outlined above is also expected to vary accordingly. Drawing upon situated STS epistemologies, cross-cultural psychology and gender studies literature, my paper covered a limited time period after the ICD revision, which has not yet been fully integrated. Future contributions should pay attention to how knowledge on the matter is produced inside the psychotherapeutic alliance, what implications it has for TGNC people, and how it is processed by research and scholarship.