The gender-affirmative life span approach: A developmental model for clinical work with transgender and gender-diverse children, adolescents, and adults.

Abstract

The gender-affirmative life span approach (GALA) is an innovative therapeutic framework for promoting the mental health of transgender and gender-diverse (TGD) clients of all ages. Based in interdisciplinary philosophical foundations, GALA proposes that TGD clients can be supported in psychotherapy through (a) developing gender literacy, (b) building resiliency, (c) moving beyond the binary, (d) exploring pleasure-oriented sexuality, and (e) making connections to medical interventions. Psychotherapy incorporating these 5 core components is developmentally tailored for children, adolescents, young adults, or older adults. Developing gender literacy is the process of understanding how sex assigned at birth, gender identity, gender expression, and sexual orientation are distinct but interconnected concepts, as well as learning to identify oppressive practices in TGD people's lives. Building resiliency involves learning how to overcome adversity and effectively cope with challenging situations in life. Resiliency-building also involves having social support networks to share these difficulties and gain support. Gender and sexual binaries pathologize nonconformity and limit the full range of healthy gender and sexual expression. Moving beyond the binary to a spectrum approach allows for the inclusion and affirmation of all gender identities and expressions. Unfortunately, research and practice have largely focused on negative sexual outcomes for TGD people. Thus, age-appropriate psychotherapy aimed at developing sex-positive pleasure and satisfaction is critical. Lastly, gender-competent mental health practitioners need to have knowledge about, and skills to refer for, medical interventions, when appropriate. Clinical Impact StatementQuestion: As transgender and gender-diverse (TGD) people's needs have increasingly been included in healthcare practices, and as more TGD people affirm their identities at younger ages, it is clear that a new model of gender-affirmative mental health care is needed. Findings: The genderaffirmative life span approach (GALA) is an innovative therapeutic framework for promoting the mental health of TGD people across the life span, with broad implications for gender and sexual health. Meaning: GALA proposes that TGD people can be supported in psychotherapy through (a) developing gender literacy, (b) building resiliency, (c) moving beyond the binary, (d) exploring pleasure-based sexuality, and (e) making connections to medical interventions. Next Steps: We invite psychotherapists to adopt GALA when working with TGD clients of all ages.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

“…HCPs should employ interventions tailor-made to the individual needs of the child that are designed to 1) foster protective social and emotional coping skills to promote resilience in the face of potential negative reactions to the child’s gender identity, expressions, or both (Craig & Austin, 2016 ; Malpas et al., 2018 ; Spencer, Berg et al., 2021 ); 2) collaboratively problem-solve social challenges to reduce gender minority stress (Barrow & Apostle, 2018 ; Tishelman & Neumann-Mascis, 2018 ); 3) strengthen environmental supports for the child and/or members of the immediate and extended family (Kaufman & Tishelman, 2018 ); and 4) provide the child an opportunity to further understand their internal gender experiences (APA, 2015 ; Barrow& Apostle, 2018; Ehrensaft, 2018 ; Malpas et al., 2018 ; McLaughlin & Sharp, 2018 ). It is helpful for HCPs to develop a relationship with a gender diverse child and family that can endure over time as needed.…”

“…It is helpful for HCPs to develop a relationship with a gender diverse child and family that can endure over time as needed. This enables the child/family to establish a long-term trusting relationship throughout childhood whereby the HCP can offer support and guidance as a child matures and as potentially different challenges or needs emerge for the child/family (Spencer, Berg et al., 2021 ; Murchison et al., 2016 ). In addition to the above and within the limits of available resources, when a child is neurodivergent, an HCP who has the skill set to address both neurodevelopmental differences and gender is most appropriate (Strang et al., 2021 ).…”

“…It is neither possible nor is it the role of the HCP to predict with certainty the child’s ultimate gender identity; instead, the HCP’s task is to provide a safe space for the child’s identity to develop and evolve over time without attempts to prioritize any particular developmental trajectory with regard to gender (APA, 2015 ; Spivey & Edwards-Leeper, 2019 ). Gender diverse children and early adolescents have different needs and experiences than older adolescents, socially and physiologically, and those differences should be reflected in the individualized approach HCPs provide to each child/family (Keo-Meir & Ehrensaft, 2018 ; Spencer, Berg et al., 2021 ).…”

“…Parents/caregivers and their children should also have the opportunity to develop knowledge about gender development and gender literacy through age-appropriate psychoeducation (Berg & Edwards-Leeper, 2018 ; Rider, Vencill et al., 2019 ; Spencer, Berg et al., 2021 ). Gender literacy involves understanding the distinctions between sex designated at birth, gender identity, and gender expression, including the ways in which these three factors uniquely come together for a child (Berg & Edwards-Leeper, 2018 ; Rider, Vencill et al., 2019 ; Spencer, Berg et al., 2021 ). As a child gains gender literacy, they begin to understand their body parts do not necessarily define their gender identity and/or their gender expression (Berg & Edwards-Leeper, 2018 ; Rider, Vencill et al., 2019 ; Spencer, Berg et al., 2021 ).…”

Beyond diagnosis: Prepubescent gender expansive children on the margins of clinical measures

“…It speaks to the importance of clinicians paying attention not only to what a child believes about gender but also to a child's level of flexibility (or rigidity) in their perspective on gender. Observing children's responses through this lens gives the clinician insight into the extent to which interventions related to gender literacy as described in the Gender Affirmative Lifespan Approach (Berg et al, 2017; Rider et al, 2019; Spencer et al, 2021) may be crucial for a given child.…”