Out On The Couch

Affirmation, Exploration, and Informed Consent

Posted: 7-18-23 | The Affirmative Couch

A nonbinary Asian person sits on a sofa engaging in mental health care therapy. The clinician' s back is to the camera while offering affirmative therapy enriched with exploration and informed consent.

Gender Dysphoria disproportionately affects transgender and nonbinary (TGNB)  communities, and can impact mental health in many ways. For many TGNB individuals, affirmative therapists offer a space—perhaps the first space—to pursue therapy that accepts them for who they are. One of the key elements of affirmative therapy is combining affirmation with exploration, but always in the context of informed consent.

Why Affirmative Therapy?

At The Affirmative Couch, we believe that Affirmative Psychotherapy is valuable in particular for members of sexuality-, gender-, and relationship-expansive communities. Affirmative psychotherapists have experience, training, and expertise in working with sexuality-, gender-, and relationship-expansive communities.

Affirmation in Affirmative Therapy

Affirmation does not mean simply agreeing with everything a client says or suggests—the work of therapy often requires psychotherapists to compassionately confront things that the client would rather not. In this case, affirmation most specifically means that the identity, presentation, and lived experience of the client is affirmed as real and valid, even if they are marginalized by society.

For TGNB clients, their therapists may have had no training in how to work with trans communities—in many cases, they may have received training that pathologized trans identities. An affirmative therapist offers a space to quite simply exist as a trans person seeking therapy without the validity of transness becoming part of the therapeutic process.

Exploration in Affirmative Therapy

TGNB individuals have a wide range of experiences. Gender identity and expression may be fluid, or may have been fluid in the past as the client came to understand their identity. In other cases, they might have understood their gender identity from a very young age and felt very little if any fluidity. 

No matter what the individual experience of gender, Affirmative Psychotherapy invites exploration when it is therapeutically relevant. Cultural myths and rhetorics surrounding gender often tend to focus on very narrow ideals of gender—ideals that are constraining and difficult to grapple with for many if not most cis and trans people. Exploring the cultural ideas about gender that have impacted a client can help them to understand their own gender and how it intersects with all aspects of their health care. 

Exploration of gender with the intention to find out “why” someone is trans is antithetical to affirmative therapy. Affirmative therapists do not ask their clients to defend their identities by exploration of reasons. Exploration of gender is about gaining deeper understanding and insight to deepen the relationship the client has with themselves and others. 

Informed Consent in Affirmative Therapy

Affirmative therapy is about both affirmation of identity and exploration of identity. Exploration and affirmation of meaning, motivations, experiences, and emotions (just to name a few potential opportunities for exploration) to deepen understanding is part of being as informed as possible. Exploring complex and sometimes contradictory aspects of identity while affirming the client’s experience is an important aspect of affirmative therapy. 

An affirmative therapist does not pursue a potentially uncomfortable exploration of gender dysphoria with their client without the client’s explicit informed consent for such a conversation. (For a more detailed discussion of consent, you may want to check out this post about consent and kink-aware therapy.) This honors the client’s autonomy and helps establish safety. Using the letter required by many insurance companies and surgeons as ammunition to force the conversation is akin to coercion. 

Clinical Examples

An example of embarking on exploration while holding affirmation and informed consent might look like a part of this conversation:

“I am not here to evaluate your gender, such as whether you are truly trans. I believe you are who you say you are and no one else can decide that for you. What I am interested in discussing is your decision-making process, your understanding of risks and benefits, factors related to mental health and well-being, and any plans you have for support. I am hoping that this can be a collaborative discussion and that I can ask questions and provide information that will be helpful to you in your process (Chang et al, 2019).”

Most informed consent with TGNB clients focuses solely on its role in medical transition due to transnormativity, when its role is in all healthcare – including psychotherapy. Transition may include social, medical or legal transition. Affirmative therapists should be facilitating a discussion of the risks and benefits of these decisions with clients in a way that prioritizes the client’s autonomy and decision-making authority, including making “mistakes.” 

Affirmative therapy also recognizes that personal identity (including but not limited to gender identity) changes over time, and that those changes are not necessarily a sign that previous understandings of self were wrong. Normalizing the fluidity of gender, sexuality, and identity is central to affirmative therapy. Similarly, informed consent for medication transition includes a discussion of risks and benefits of the medical procedure sought after by the client. 

However, focusing too much on risk can be akin to “scaring the person into not transitioning”; focusing too much on benefits can be akin to “pressuring someone into transitioning.” An affirmative therapist attempts to find the balance in order to help the client make an informed decision. Additionally, the affirmative therapist helps the client hold any ambivalence that the client feels about any decision (including a decision of non-action).  

Learn More from our Courses

The text Gender-Affirming Medical and Surgical Treatment for Therapists presented by Cadyn Cathers, PsyD, Up to 10 CEs available is printed below a photo of a person in a white doctor's coat holding a heart with the transgender pride flag colors on it.



Chang S. C. Singh A. A. & dickey lore m. (2018). A Clinician’s Guide to Gender-Affirming Care :  Working with Transgender and Gender-Nonconforming Clients : A Comprehensive Resource for Mental Health Professionals, Educators & Students, p.143. Context Press.

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