“Ethical Care in Secret”: Qualitative Data from an International Survey of Exploratory Therapists Working with Gender-Questioning Clients

Abstract This is a mixed methods international survey of therapists (n = 89) belonging to Therapy First, an organization supporting the use of exploratory therapy, rather than gender affirmative therapy, with gender-questioning clients. The method used was an electronic questionnaire, producing a 33% response rate from members. Responses were analyzed using thematic analysis. This article reports qualitative responses relating to therapists’ experiences of anxiety in working in a hostile professional environment, and their adoption of strategies to minimize risk of allegations of conversion therapy. Therapist strategies included refining existing marketing approaches to serve preferred client groups, and reliance on proven therapy models.

The debate about gender identity (GI), conversion therapy (CT), gender affirmative therapy (GAT), and exploratory therapy (ET), also known as psychotherapy for gender issues, continues to be strongly contested from all sides.It shows little sign of resolution, recalling some of the fury associated with the earlier debate about the similarly contested concepts of recovered memory and false memory of the 1990s.At that time, there was similar concern about the potential damage caused to clients and their families by therapists working with challenging client material, intense media debate, threats of legal intervention, and a close scrutiny of allegedly problematic approaches such as recovered memory therapy (Jenkins, 2002).Given the current controversy over gender therapy, this article discusses qualitative data, taken from an international online survey of nonaffirmative therapists working with gender-questioning clients, to explore how this group manages the challenges of practice in this contested field.

Rationale for Undertaking This Research
The existing literature suggests that therapy for gender issues is deeply conflicted over the appropriate therapeutic response toward gender-questioning clients.Nonrandom research surveys in the United States and United Kingdom have failed to establish a compelling argument for the widespread prevalence of CT by therapists (Government Equalities Office, 2018;James et al., 2016;Jenkins & Esses, 2021;Ozanne Foundation, 2021;Sex Matters, 2021;Turban et al., 2019;Turban et al., 2020).This is distinct from evidence for the existence of nonaffirmative responses within therapy, which is paired with often illegal conversion practices within faith settings.There is a consensus across professional therapy associations in favor of a legal ban on CT, with limited tolerance of exploratory therapy for gender issues.There is also a broad endorsement for gender affirmative therapy as the preferred stance to be adopted by therapists, although this lacks a firm evidence base and rests largely on approval at the policy level within the major professional associations.
Research in the United Kingdom suggests that there is a small minority of therapists who continue to practice according to their established modality and who are unconvinced of the need either for GAT, or the need for a legal ban on CT (Mollitt, 2022(Mollitt, , p. 1024)).The existence of groups such as Therapy First in the United Kingdom and United States suggests that there is a similar minority of therapists in the United States, although its exact size is hard to estimate without further data.
Given the stance of professional associations favoring GAT and the increasing push toward legal bans on CT, defined in broad rather than narrow terms, it would be reasonable to assume that this minority of therapists is practicing within a challenging, if not hostile, environment.A charge of practicing CT, that is, by our definition, nonaffirmative therapy, could lead to a criminal prosecution and potential loss of a license to practice in some legal jurisdictions or to a serious professional complaint and expulsion from a professional membership organization in other nonregulated jurisdictions.Either way, this would probably entail a loss of professional career and associated status and income, which might well be anxiety provoking for many therapists thus affected.Beyond the actual risk of licensure challenge or professional complaint, the current situation may well also be considered to have a "chilling effect" on the work of exploratory therapists, where the risk of exposure by clients, colleagues, or political lobby groups may also be an additional source of perceived hazard.Our research is therefore designed to tease out some of the experience of nonaffirmative therapists working in this uncertain and challenging environment.

Literature Review
Several concepts first need to be defined before exploring the relevant literature.The concept of GI is right at the core of this debate.Gender identity has been defined as "the private experience of gender role, and gender role is the public manifestation of gender identity" (Money, 1994, p. 164-5).Gender dysphoria is further defined as "the incongruence between gender identity and the sex assigned at birth" according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (Coleman, et al., 2022, p. S59).Approaches that refute the existence of a GI are often described in broad terms as being gender critical (Stock, 2021).
The two main, often directly counterposed, therapeutic approaches in relation to GI are, on the one hand, gender affirmative models and, on the other, gender-exploratory approaches."Gender affirmation refers to the process of recognising or affirming TGD (i.e.Transgender and Gender Diverse) people in their gender identity-whether socially, medically, legally or behaviourally, or some combination of these" (Coleman, et al., 2022, p. S13).In contrast, "Gender-exploratory therapy does not aim for any fixed outcome in regard to how one experiences or expresses their gender … it seeks to understand and ameliorate gender-related distress noninvasively, whilst respecting the individual's freedom to express themselves freely and authentically" (Therapy First (formerly Gender Exploratory Therapy Association) (GETA), 2023, p. 7).
Conversion therapy provides another key reference point within this polarized debate.It has been defined as "an umbrella term for a therapeutic approach, or any model or individual viewpoint that demonstrates an assumption that any sexual orientation or gender identity is inherently preferable to any other, and which attempts to bring about a change of sexual orientation or gender identity, or seeks to suppress an individual's expression of sexual orientation or gender identity on that basis" (BACP, 2022, p. 2).Each of the definitions provided above is clearly open to challenge and critique.

Conversion Therapy
Conversion therapy is therefore defined as any model of therapy "which attempts to bring about a change of sexual orientation or gender identity, or seeks to suppress an individual's expression of sexual orientation or gender identity" (BACP, 2022, p. 2).The term conversion therapy rests on an implicitly religious metaphor; that is, converting a person from one faith to another, by a range of means including missionary work, persuasion, threat, torture, or execution.Therapy, by definition, is based on a voluntary rather than a coercive professional relationship and requires fully informed client consent.Nonconsensual CT therefore presents as a contradiction in terms.It has been replaced in some discussions by the more qualified term conversion practices (Ozanne Foundation, 2021, p. 2).
The concept of CT has a perhaps intentional association with the earlier practice of aversion therapy.It was designed to reduce or eliminate same-sex sexual attraction by homosexuals and lesbians.This practice was carried out within the National Health Service (NHS) and, to a lesser extent within private practice, in the UK during the 1960s and early 1970s, mainly using aversive behavioral therapy (electric shock or nausea-inducing apomorphine).This atypical therapy is described in a small survey (n = 31) of patients and close relatives (Smith, et al., 2004).Use of gay aversion therapy for homosexuality, together with a more limited use of psychoanalysis for a similar purpose, was intended to change specific, targeted aspects of clients' sexual behavior such as attraction and arousal.Gay aversion therapy, however, was never accepted as being part of mainstream therapeutic practice within the NHS (Smith, et al., 2004, p. 431).This approach was based on restricted, patriarchal models of ethics, consent, and efficacy, as framed in turn by the relatively conservative legal and social mores of the time.
The same limitations would apply to later attempts to refine aversion therapy under the therapeutic label of reparative therapy in the United States (Panozzo, 2013).Panozzo has succinctly defined reparative therapy as "a treatment intervention associated with a loosely defined, unstandardized, unvalidated, but, most important, religiously motivated treatment designed to decrease or eliminate same-sex sexual behavior … for persons with ego-dystonic same-sex impulses" (Panozzo, 2016, p. 765).It is worth noting here that gay aversion therapy and reparative therapy share a similar narrow, very specific, allegedly therapeutic focus, which is based on a fatally compromised application of concepts of ethics, consent, and efficacy.
The concept of CT has been radically expanded from the earlier much more specific construction of gay aversion therapy to include attempts to change or even suppress GI.Conversion therapy in relation to GI is now being paired with similar past historical attempts to change or suppress sexual orientation.However, sexual orientation and GI are not by any means equivalent or complementary concepts.Sexual orientation is a behavioral concept, linked as it is to observable behaviors such as attraction, arousal, and sexual contact.By Money's definition, GI is an internal experience reliant on concepts such as sex, gender, and gender role.Money's definition points toward a conception of GI as being both presocial and immanent (i.e.present and discoverable).This sits outside the positivist philosophy usually applying to science, medicine, and law, and presents serious difficulties in terms of achieving a precise definition for legal or other purposes.
The concept of GI essentially presents as part of a complex belief system and ideology, requiring extensive and continuous social validation to ensure its very survival.Gender identity as a concept lacks independent criteria and a means of objective verification.It is fully dependent on a process of individual self-declaration and social acceptance by relevant peer groups and communities for its continuing validation.

Legal Context of Gender Therapy in the United States
In terms of US law on CT, this varies from state to state.There are now 28 US states with total or partial legal bans on CT for minors, excluding practices carried out by religious providers (Movement Advancement Project, 2023).There is currently a key case on the legal status of gender-affirming health care for minors, which has been decided at the appeal court level, and which may now be referred to the US Supreme Court (L. W., et al. v. Skrmetti, et al. & Jane Doe 1, et al. v. Thornbury, et al., 2023).

Legal Context of Gender Therapy in the United Kingdom
Within the UK, a proposed ban on CT in Scotland has been paused for further consultation.Within England and Wales, active government support for a legal ban has waned since the consultation started in 2021.As a result, there are currently several proposals for private members' bills on CT currently before Parliament.At the level of policy as distinct from law, the Memorandum of Understanding (MOU) on CT has been signed by 32 organizations, including the NHS and all the major professional therapy associations (BACP, 2022).The MOU calls for a legal ban on CT.
However, the United Kingdom Council for Psychotherapy (UKCP) has recently broken ranks to issue a statement to its 11,000 members, clarifying that "exploratory therapy should not in any circumstances be confused with conversion therapy" (UKCP, 2023).This is an important development, which acknowledges that there is strong legal protection for therapists' rights to hold and express gender critical views.The UKCP's position therefore sits uneasily with the MOU's current dominance over professional therapy practice and with pending legislation designed to ban CT (Forstater v. CGD, 2021).

Research into Current Practice in the UK with Clients with Gender Identity Issues
The focus on potential legal bans on CT and the ongoing debate over GAT versus ET raises questions about the impact of these developments on current practice in the United States and United Kingdom.Some pointers in this direction can be found in the research carried out by Mollitt (2022) into contemporary practice in the UK.This is a mixed methods survey (n = 576) covering a wide range of therapists in the UK.While the analysis is restricted by the author's overreliance on transphobia as an explanatory concept, there are some useful findings.A small minority of therapists (5%) took the view that a client's wish to change GI was an indication of mental illness, and a similar percentage did not support the Memorandum of Understanding in campaigning for a legal ban on CT.This figure increased to 9% of therapists on the issue of opposing an affirmative stance with clients identifying as trans.Out of all participants, 8% expressed the view that a ban on CT would limit their ability to work with clients identifying as trans (Mollitt, 2022(Mollitt, , p. 1020)).
The research identifies a perception that nonaffirmative approaches, which would include any approach that is not gender affirming, are experienced by some therapists as going against the consensus promoted by their professional associations.Thus, a nonaffirmative practice entails their perceiving a risk of legal consequences or of a complaint."The data shows that the perception that this way of working is under attack by the MOU is bolstered by personal, perhaps unconscious or unwitting anti-trans views.The data highlights that the risk of litigation by ʻaccidentallyʼ conducting CT is felt to be a very real fear" (Mollitt, 2022(Mollitt, , p. 1025)).Mollitt suggests that these therapists' views are "anti-trans," rather than acknowledging that they may be based on careful thought, nuanced opinion, or a commitment to professional ethics and to established therapy modalities, as alternative, equally viable explanations.

Refining the Concept of Gender Affirmative Therapy
Gender affirmative therapy as a model of practice has largely developed in the United States, as an adjunct to gender-affirming health care.Gender affirmative as a term is a misnomer, as neither therapy nor health care are intended to affirm a client's existing sex or gender.Affirmative therapy is intended to socially validate and reinforce the client's existing sense of GI; that is, a phenomenological experience of gender incongruence with their natal sex.This internal experiencing is unlikely to be known to others, unless revealed or communicated to others such as a therapist.The preferred therapist response according to this school is to affirm the client's GI, via selective use of pronouns, plus acknowledgment and validation of the client's internal experience.Hence, the more accurate term to use for describing the therapist's response is that of GI affirmative therapy, rather than GAT.
Ashley, a trans activist and nontherapist, has cogently defined what is described as trans-affirmative therapy: Gender-affirmative approaches follow clients' lead when it comes to gender, emphasizing the importance of respecting clients' desires regarding social gender affirmation, which includes gender identity, gender expression, name, and pronouns; supporting clients' free, self-directed gender exploration; and scaffolding their decision-making surrounding transition-related medical interventions.(Ashley, 2023, p. 472) Gender affirmative therapy has been extensively supported by numerous US professional associations (ACA, 2010;AAP, 2018;APA, 2015;APA, 2021;Coleman et al., 2022).

Limitations of the Concept of Exploratory Therapy
Exploratory therapy is referred to as a useful therapeutic response to gender-questioning clients (Ayad & O'Malley, 2023;D' Angelo, Syrulnik, Ayad, et al., 2021;Marchiano, 2017;Patterson, 2018, Withers, 2020).In some very specific instances, exploratory therapy is acceptable to supporters of a CT ban, but only in relation to clients who are unhappy or in distress about their GI (MOU, 2022).Nevertheless, it is rejected by other critics as being akin to CT (Ashley, 2023).Exploratory therapy is hard to define as a distinct modality, unless it is specifically badged as an adaptation of an existing model of therapy (Spiliadis, 2019).

Methodology
This research used a mixed methods approach to methodology; that is, employing both quantitative and qualitative approaches.Ethical review was provided by the Institutional Review Board for New York University (NYU), locator # FY2023-7784.The questionnaire (see Appendix A) was designed to be an international survey crossing national boundaries, so that data handling and data protection issues were required to be fully compliant with relevant US law and the General Data Protection Regulation (GDPR) applicable in the European Union (EU) and UK.The co-researchers were also required to follow the research ethics practice applicable to membership of New York University and of the British Association for Counselling and Psychotherapy (BACP, 2019).Permission was obtained to email an invitation to an electronic survey to the members of Therapy First (TF), formerly known as the Gender Exploratory Therapy Association (GETA) (n = 266) between August 15 and September 20, 2023, from the organization.
A series of four emails was sent to the membership of TF (see Appendix B).Members were also notified of the survey by four TF-only social media posts (see Appendix C).Finally, the availability of the survey was announced at webinars held by TF during the data-gathering period (see Appendix D).All notices directed members to the consent page (see Appendix E) from which they could either access the survey to show their consent or be taken to a separate page advising them of their specific rights under the GDPR (see Appendix F) and to access the survey.The survey included both quantitative and qualitative questions, and produced 89 responses; that is, a response rate of 33%.
As detailed in the questionnaire (see Appendix A), quantitative prompts were also provided to study participants in addition to the qualitative prompts, which form the basis for this writing.
The quantitative prompts were included to allow the researchers to explore associations related to providing ET to persons with gender nonconforming concerns.Among the associations explored quantitatively was one related to participant beliefs around providing sexual orientation change efforts (SOCE)-SOCE is frequently misconstrued as being related to gender orientation change efforts (GICE).The participants were overwhelmingly opposed to SOCE.Other associations explored were participant fears related to loss of income, loss of reputation, and financial harm if the participant was brought up on charges of performing "conversion therapy" by a licensing or professional board.Quantitative data obtained from the survey is analyzed and discussed in a separate article by these authors.
The participants lived in several countries, primarily English-speaking ones.These include, in order of their frequency, the United States, the United Kingdom, Australia, and Canada, as well as other nations.Nearly two thirds held master's degrees, 23 held doctoral degrees, and several held bachelor's degrees or no degree at all.Approximately half had seen 1 to 5 gender nonconforming patients in the past two years with a gradual reduction in therapist frequency represented until only 9 related having seen 21 or more such patients in the past two years.

Qualitative Analysis
Qualitative analysis was carried out using thematic analysis, based on a deductive approach, as "an accessible and theoretically-flexible approach to analysing qualitative data" (Braun & Clarke, 2006, p. 2).As both researchers are active participants within current debates about exploratory therapy within the field of psychotherapy, the orientation to data analysis was selected as being deductive (i.e., top down), rather than inductive or bottom-up orientation.According to Braun and Clarke, "ʻTheoretical' thematic analysis would tend to be driven by the researcher's theoretical or analytic interest in the area and is thus more explicitly analyst-driven" (Braun & Clarke, 2006, p. 12).Narrative responses to survey questions were coded and grouped into themes and subthemes, which were illustrated by selected examples, case histories and diagrams.Responses are reproduced without editing in terms of spelling, grammar, and phrasing, to minimize the risk of imposing unintended meanings on the material.

Case Examples
By way of introduction to the numerous topics considered, we offer these case examples of challenges these therapists related to ground readers in the material.

Case Example of Anxieties Related to Work with Gender Variant Clients
The following case example illustrates some of the complexity involved in working with gender-questioning clients, and the resultant anxiety this may entail for some therapists.
A 19 y/o client away from home at college who I saw for approximately six months was psychologically unstable and dropped out of care about two years ago.He was getting hormone blockers and cross-sex hormones from a physician near his college, would not give me an ROI [release of information] to consult with that physician or with his family-and his mother had contacted me by email but I did not respond to her because the client would not give an ROI.This was at a time when I was just beginning to see the larger landscape of "gender" in mental health.I had worked with several clients over the years who were gender-diverse/non-conforming, medically transitioned, only socially transitioned, sometimes socially transitioned, partially medically transitioned and detransitioned (before that was a word) but none were focused on "gender" issues when they presented for care.This client was something new and I worried at every step that I might do something to upset this person.While it wasn't a direct, frequent worry, I increasingly felt like this person was being handled and led by his internet and trans friends and not able to focus on intrapsychic work and that my efforts to keep that focus were understood as me not affirming him (though at that time I didn't even know that "affirmative model" was a "thing").I worried enough that I suggested he find a therapist who specialized in gender identity issues because I did not (and I told him this from day one of his telling me he was "trans"), but he insisted, for a while, that he stay with me.As I said, eventually he dropped out.However, three months ago, I got a letter from [Social Security Disability] because he was applying for disability benefits and obviously had listed me as one of his providers.I always resist such inquiries, ignore them until/unless I'm notified at least twice, because my practice is that I do not share information about a person's care with anyone unless forced because it interferes with the therapeutic relationship.When I do respond, I never send records I only offer a very brief, specific but somewhat generic, meaning no personal, treatment summary.In this client's case, the request came using the client's male birth-name, not the name he used when he was in care, and I worried that whatever I said could be used against me if the client didn't like what I offered.I'm always uncomfortable with such requests-and that may be my personality-but was more worried with this request.I did send in what I thought was accurate but depersonalized enough, and I hope the client gets the help they need.But in the current climate, this was/is unsettling.
Logically, I don't think I am at any risk what-so-ever.Really.But emotionally it was difficult interacting with this client on many levels, including the feeling that with the help of a posse he might come after me for not caring for him enough or "affirmatively." I have an older male client with whom I have worked for many years on and off who has "gender issues." I am not worried at all in this case about license complaints.
The therapist identified several concerns, including the client's preferred focus on gender issues, for which the therapist felt ill-equipped to respond to effectively, and the client's involvement of a third-party agency, which required potential infringements of client confidentiality.There appeared to be a tension between the in-session work and the potential 'tug' for the client of unknown external influences from peer groups and from social media.The therapist also described what seems to be a lack of familiarity with the wider context of gender politics at this time, in terms of sharply demarcated therapeutic models such as gender-affirming care as distinct from exploratory therapy.The involvement of a third-party agency may also have heightened the therapist's concerns about this contributing to a potential complaint, particularly where the client name recorded may not have corresponded with the client's own preferred name.There appeared to be difficulties within the therapeutic alliance that complicated the negotiation of a workable solution.The therapist's concerns shifted and changed over time and are contrasted with a lack of concern in relation to a more established pattern of therapeutic work with an older client with gender issues.As might be expected, the therapist's emotional responses contained both client-specific and more general aspects, and fluctuated and changed over time, illustrating a degree of nuance, ambiguity, and fluctuation, rather than a fixed and unchanging level of anxiety with regard to this issue.

Case Example of Experiencing a Complaint
Eleven cases of being put on report in some way to an overseeing body were shared by the subjects.Below is an example.
In grad school in 2022, I was reported by classmates because I had shared with them some articles about topics e.g.European countries pulling back on gender care for youth due to the harms they were seeing.I was accused of being transphobic, that I had caused them harm and they felt unsafe as "trans allies." I was subjected to a disciplinary meeting and was initially told I had to follow a ""remediation plan" that included reading 3 papers on LGBTQ care (affirmation), and then to write a 3 page reflection paper on this, as well as meet with a professor once/month for an hour until I graduated, for supervision.I managed to defend myself and one of the professors on the committee has had me in class and as an advisee and gave me the benefit of the doubt, so the plan was canceled.However, this remains in my files at the university.I now work with teens in private practice, as a resident in counseling, and am working with a client whose parents find me through GETA.I feel like I am dancing on a very thin tightrope, so I have to be very careful, but I have been upfront with the client and his parents that I practice exploratory therapy when it comes to gender dysphoria.I have not informed my supervisor or the owner of the practice of my views or approach, as I fear I will not be able to practice what I consider evidence-based, ethical therapy with these clients.
This would seem to be an example of a complaint or disciplinary process initiated by fellow students, in their espoused role as trans allies, on the grounds of the participant having referred to evidence that some European countries were following a different policy toward gender-affirming care, as compared with some states in the United States.It is revealing that, rather than potentially opening up a discussion on research evidence and policy change, this was seen to require a disciplinary response toward the participant.The sanction was perhaps mild; that is, to carry out further reading of papers sympathetic to gender-affirming care and to write a reflective piece on this issue.However, the fact that the professor detailed to carry out additional supervision as part of the sanction but decided not to fulfill this latter part of the sanction suggests that there was some flexibility within the disciplinary process.It perhaps also carries a hint that the process here is one of appearing to carry out sanctions, at least in part, but without more senior staff necessarily agreeing with the probity of the disciplinary process, or even with its outcomes on this issue.
If anything, the message received by the therapist from this experience of complaint is the need to be as clear as possible to clients and parents on the exploratory nature of his therapeutic work with them, but not to risk such openness with professional colleagues or supervisors, given the potential risk of further sanctions.The metaphor employed here-namely, "I feel like I am dancing on a very thin tightrope"-aptly conveys a combination of threat of serious damage, calculated risk, and a degree of professional grace, which this therapist seems to have applied in pursuit of a chosen therapeutic stance on this issue.

Qualitative Data Broad Themes
Data from the survey was grouped into four broad themes, which are discussed in more detail below.They were therapist responses to the environment for therapeutic practice, therapist concerns regarding complaints and overall practice environment, therapist strategies for practicing exploratory therapy in an adverse environment, and therapists' motivation to provide therapy for gender nonconforming clients.

Therapist Responses to the Environment for Therapeutic Practice
This section outlines responses to Q.17 and Q.18, regarding a complaint made by a client, or their collateral and to Q.19 and Q.20, regarding experience of a third-party complaint made by a person never associated with a patient/client.Responses were grouped into three themes: experience of a neutral environment for exploratory therapy, experience of a hostile environment, and experience of a complaint to an overseeing body (see Figure 1).Data collected for this section relates to the number of relevant statements made on these themes and not to the number of participants making the statements.Participants indicating a neutral environment, for example, were unlikely to make more than one statement about this.Others had far more to say.
Slightly over half of the responses referred to experiencing a hostile environment for therapeutic practice.One third of responses referred to experience of a complaint.The term complaint is used here in a broad sense, in that referrals to a licensure board or professional association would not necessarily be investigated as a formal complaint and might be dismissed.Data indicated that 11 out of 89 participants (12%) had been the subject of a formal complaint, either made directly by a client or colleague or by a third party not directly involved in the therapy.The following section includes a range of statements made by participants in relation to their working environment and experience of complaint.

Experience of a Neutral Environment for Practicing Exploratory Therapy
"The gender ideology is quite strong in my state REDACTED but i see others have successfully navigated this and are still out (e.g.: REDACTED).I am in the process of being more outspoken." "I practice in a rural area that is not litigious and most parents are worried about or not supportive of the new stated gender ID. "

Experience of a Hostile Environment for Practicing Exploratory Therapy
"My clinic is one of the most well known day treatment/intensive outpatient programs in the REDACTED [my] metro area.Despite that reputation, I do believe we could be shut-down if I were to openly espouse the practice guidelines suggested by GETA/GENSPECT.The McCarthyism-like dynamics surrounding this topic are real!To a large degree, I have to remain silent and I struggle with that every day." REDACTED "[In the place where I live], three clinicians who have been open and public about their work have had their license(s) threatened by complaints and two are currently under investigation.""I attended a CEU workshop where a representative from the SPLC [Southern Poverty Law Center] spoke.He said that they were continually "hunting" for clinicians who do not affirm LGBT + in order to bring lawsuits against them with the goal of stripping them of the clinician's license."

Experience of Complaint for Practicing Exploratory Therapy
"Treating a declared FtM 15 y.Parents (Ps) asked family to use her birth name and pronouns.An aunt used her preferred name and pronouns deceptively.Ps cut off contact with aunt.Aunt complained to my professional body that I had told the Ps to do this and that I must be practising conversion therapy." "Two individual activists (not former-patients) have filed formal complaints against my license when I was living in [US state].Both have been dismissed.My online presence has made me a target of certain radical activist trans groups." "A few local practitioners complained to the licensing board about my refusal to offer affirmation therapy.They claimed I am transphobic, homophobic, and racist."

Discussion of Therapist Responses to the Environment for Therapeutic Practice
A minority of participants indicated that the environment for practicing exploratory therapy was neutral.Responses which appeared to be from the United States seemed to depend on which state the therapy was taking place-some states have passed legislation outlawing CT.One related the neutrality coming from their rural setting.For others, their experience was of working in an intimidating and hostile environment, where colleagues could be openly critical.The perceived risk of hostile comments made online or of trans activists policing therapists was a significant factor affecting their therapeutic practice.One said it was "a minefield of well-intentioned hysteria that I constantly have to tip-toe threw."Experience of hostile actions against therapists included withdrawal of an offer to share office space from a colleague, awareness of complaints made against colleagues, critical social media postings, no longer receiving invitations to participate in a valued professional activity, and threats of being reported for raising concerns about GAT.
Actual reported experience of a complaint was rare among this sample.A pervasively hostile environment at professional, collegial, and practice level was more common.

Therapist Concerns Regarding Complaints and Overall Practice Environment
Several questions in the survey asked participants about their emotional responses to the issues involved such as Q.11, a challenge to their licensure or professional membership for allegedly practicing CT, Q.12; the thoughts, experiences, and information underlying these anxieties; and Q.15 the anticipated degree of emotional distress which might follow suspension.
The responses included 42 statements that had a reference to the therapist's affect or emotions, using terms such as worry, concern, and fear.Participants expressed concern about being the subject of a complaint, but also of being subject to hostile action by colleagues or trans activists.Others expressed concern about the effect of current policies promoting GAT on clients generally, or about the perceived constraints experienced regarding their practice.Others voiced concerns about more general aspects such as the current situation within their professional association, or the lack of therapists prepared to work with clients on gender.A smaller group expressed a relative lack of anxiety about these issues.This appeared to be based on a degree of confidence in their own ability to deal effectively with the likelihood of challenge or complaint, via careful risk management.
Figure 2 presents the main groupings of the themes identified in the narrative responses.Statements were grouped according to themes, so that one participant, for example, might express concerns about several distinct issues, plus a lack of concern about a specific issue.Each statement expressing concern was logged and categorized within a broader theme.Some participants expressed several concerns, or a lack of concern about specific issues.Thus, this method categorizes a range of emotional themes made within a participant statement, rather than simply linking one emotional theme solely to each participant.This results in a slight degree of overcounting, given that a small number of participants made multiple statements regarding anxiety, while most participants expressed anxiety or its absence regarding a single issue.Almost half of the statements made by participants referenced anxiety about being the subject of a complaint, or of being subject to hostile action by colleagues, clients, or trans activists.A small number of participants had previously been the subject of a complaint.However, more responses referred to what was perceived as hostile action by colleagues, clients, or trans activists.

Anxiety Regarding Complaint
very concerned about legal liability would have been a major loss if the complaint had led to loss of registration.This was the most distressing experience of my 50 year career.social workers are more likely to understand gender dysphoria through a political lens as opposed to a person-in-environment, developmental lens.My awareness of this is what keeps me a little anxious -a part of me is not confident the [ASWB] would have my back if accusations were to be made.

Anxiety Regarding Hostile Action
"I worry that I will be 'canceled' and given poor reviews on Google and social media." "I constantly worry that if I even ask a client (or colleague in consult) … I will be labeled and attacked for being a bigoted ʻtransphobeʼ" "I'm also concerned about influence of social media where people who don't even know my work directly might accuse me of this based on who I follow on Twitter if they were to look me up there."

Anxiety Regarding Adverse Effects on Clients and on Own Practice
"I am deeply concerned about complicated and often traumatised young people and neurodiverse adults being channelled into medicalised treatments unnecessarily." "I feel genuinely afraid to ask any of the normal questions I would ask when someone reveals a new area of confusion or distress.I actively avoid these conversations and/or refer clients out which feels like such bad therapy."

Wider Concerns
"Once I found out what was happening in 'gender-affirming care, ' I just felt that I wouldn't be able to sleep at night if I didn't do something about it, even if in some small way." "Just reading about the level of politics in this mental health issue worries me."

No Anxiety
"I'm not much a 'worrier, ' in general, however, and once I make a well thought-out decision-such as deciding to do this work-I accept that there may be certain consequences." "I used to be more worried about a risk to my license but in consulting with REDACTED [another professional], and doing my own research, it seems very a very difficult accusation to prove."

Discussion of Therapist Concerns Regarding Complaints and Overall Practice Environment
The anxiety appears to be an occupational hazard, which accompanies deciding to work with this client group in a hostile professional and therapeutic environment.However, for a minority of participants, anxiety has been resolved via a framing of their therapeutic approach as valid and necessary.Overall, anxiety does not appear to be leading at this point toward professional flight from the field.Paradoxically, professional and personal anxiety may also be a motivating factor to continue therapeutic work in this area.To clarify, participants' anxiety about the limited provision of exploratory therapy for gender-questioning clients may contribute to their expressed rationale for commitment to working with these issues, despite some adverse aspects.

Therapist Strategies for Practicing Exploratory Therapy in an Adverse Environment
This section explores narrative responses to Q.22 and Q.23, which asked about steps taken by participants to defend themselves against a challenge or complaint.The comments are generally of two types: strategies specifically geared to deal with the risk, or an orthodox response relying on the security of a chosen therapy model.
Strategies included the use of deflected or targeted marketing.Deflected marketing responses could entail changes to website material or to the wording used in describing the therapy on offer to deflect or deter enquiries from potential clients who may be seeking GAT.Targeted marketing might include an explicit orientation focused on potential clients potentially seeking ET.Tailored responses also included purposeful selection of clients offering more risk, such as minors, or avoiding that same group for other therapists.
Contracting describes the process of negotiating the context, form, content, and focus of therapy.This could be carried out at the stage of the client completing referral documentation, either online, in the first contact session, or in the verbal, face-to-face process of clarifying what is involved in therapy directly with the client.In the context of the survey, contracting seemed to involve careful attention by therapists to issues such as informed consent, communication with parents for therapy with minors, use of personal pronouns, and the overall purpose and limitations of exploratory therapy for gender issues.
A smaller number of tailored responses made explicit reference to the law.Contracting with clients can include a range of different aspects, including administrative (payment details), professional (tasks and goals), psychological (relational aspects), and, where appropriate, organizational protocols (safeguarding, data protection) (Jenkins, 2006).Contracting can also carry a legal element, which confirms the status of the document as a legally binding and enforceable agreement between consenting parties.
The middle group of orthodox responses referenced a reliance on the therapist's espoused practice model as providing the most effective defense against challenge or complaint.
The remaining group of responses included those opting for less frequently cited strategies such as enhancing personal security, or presenting a niche response.In the latter case, the participants seemed to be repositioning themselves within the wider sphere of the market for therapy; for example, by use of professional networking as a primary means of obtaining client referrals.A niche response could also involve a significant change in professional role, possibly entailing a less restrictive degree of professional regulation.

Strategies for Practicing Exploratory Therapy in an Adverse Environment
Figure 3 is based on responses, rather than participants.Some participants reported using multiple strategies to defend against the risk of challenge or complaint.The following are examples of narrative responses.

Tailored Responses: Deflected/Targeted Marketing
"On website and in consultation with parents and clients I say that I do not practice conversion therapy nor do I practice affirmative care therapy but rather I practice exploratory therapy as I would with any other condition I'm presented with." "I refuse to use any affirmation phrasing on my website and in my documentation."

Tailored Responses: Client Selection
"I specialize in working with youth and families, I have pivoted to working with all self-referral adults as to bypass any possible assumption that could be places upon me for 'conversion therapy.'" "I only consider working with Detrans/desisting persons as they are especially vulnerable." "Not seeing certain patients (e.g., those under 18)."

Tailored Responses: Contracting
"I am extremely careful in my use of spoken language in sessions and in writing.I specifically refer to gender dysphoria and standard evidence based ways of approaching therapy overall." "Inform that I do not work using the affirmation model and say my role is to explore thoughts, feelings etc. to better understand the young person, that I have a professional responsibility to ensure informed consent is provided for any interventions, that I don't know what the end outcome will be and it is not for me to tell what to do, this is a big decision and important that time taken to understand this."

Tailored Responses: Legal Defenses
"With potential families I have stated that I follow the guidelines of the law, that I do not practice conversion therapy, and that I am not trying to push for a certain outcome." "I've consulted frequently with REDACTED [someone] who is a REDACTED lawyer with a focus on REDACTED [issues in this area] to help me understand how to protect myself and my patients."

Orthodox Response: Reliance on Standard Therapeutic Method
"I've really done nothing other than practice the way I always have."

Minority/Niche Responses: Professional Networking
"Public membership in GETA, conversations about the topic with fellow clinicians, information on my website that openly discusses the topics, my plans to write and speak publicly about my views on this issue."

Minority/Niche Responses: Personal Security
"Mainly from activists online and their outrage.I'm worried in that sense but in my daily life I have no interactions with activists and stay below the radar online.I'm not on any social media.At all."

Minority/Niche Responses: Change of Professional Role
"I am so concerned with the ideological demands on licensed professionals that I have decided not to pursue licensure and to instead work as a coach."

Discussion of Therapist Strategies for Practicing Therapy in an Adverse Environment
A substantial number of therapists (n = 10) responded that they no longer worked with clients younger than 18 years old, suggesting a degree of partial flight from a sector of the field, rather than from the field of gender therapy as such.Another participant referred to a preference for working with detransitioners, as an especially vulnerable client group.
A smaller number of participants made specific reference to the law, either in detailing the relevant law relating to CT at a state or national level, or in terms of using a lawyer to check relevant informed consent documentation, or as a source of legal advice if facing potential challenge or complaint.
A smaller number of participants used less common strategies, such as increasing their personal security, by avoiding any presence on social media.Others used professional networking within specialist referral networks to offer a niche therapeutic service for clients with gender issues.Several participants had rebranded their professional role from therapist to that of coach, apparently to operate more autonomously and with less restrictive control from the relevant regulatory bodies.

Therapists' Motivation to Provide Therapy for Gender Nonconforming Clients
This section explores responses made to Q.24 (i.e., motivation to provide therapy for gender nonconforming clients), plus material provided in response to other questions where relevant (see Figure 4).The survey produced a wide range of material in response (n = 100), covering factors such as the participant's primary commitment to their therapeutic role, personal and biographical factors, perspectives on the social harms associated with gender therapy, a preference for ET rather than GAT, compassion reasons, and ethical values.Some participants discussed their motivation in terms of a combination of factors, with a small number providing complex, detailed outlines of their motivation for this area of practice, given the challenges and anxieties outlined earlier.
The largest group of responses (45%) referred to the therapist's primary commitment to their therapeutic role as the main motivating factor for working with this client group.Therapeutic role is understood here in broad terms, and could include possession of relevant specialist training, .awareness of the high level of client need, and relative lack of services available, plus a sense of professional obligation to work in this field despite its comparatively high risk of adverse complaint or challenge.
Therapeutic role links to the related issue of therapist support for the use of ET with this client group.This stance of opposition to GAT was expressed by a minority of responses (12%).A roughly similar proportion of responses (14%) expressed a social perspective on current debates on gender health care, emphasizing the harms produced by what some described as a social contagion regarding GI.Personal and biographical factors featured in the responses of a similar minority (16%), where participants disclosed their own transgender, lesbian, or feminist positions as providing a strong foundation to their motivation to work in this field.For smaller groups of responses, motivation was linked to feelings of compassion for this particular client group (8%), or was based on their espoused ethical values (5%).The following are statements made by participants in relation to their motivation for working with gender nonconforming clients.

Primary Commitment to Therapeutic Role
"I'm motivated by the need to treat all my clients who are suffering from anxiety, depression, trauma, Etc." "I have not been a therapist who has focused on LGBQ population.I have however been involved with providing therapy for children and their families throughout my career.I believe this is about protecting children." "I'm interested in working with detransitioners because I focus on trauma informed care and recognize the trauma this population has endured." "I am motivated to provide the highest level of mental health care and support for any person seeking treatment, including but not limited to those listed above." "My specialty is autism and I see many of my patients suffer and fall into the gender blaming trap.This has forced me to have to look at gender dysphoria treatment."

Client's Need for Psychotherapy
"I consider Gender affirmation therapy to be more akin to conversion therapy.I subscribe to the view that explorartory therapy is what we considered the norm for a therapeutic approach up to very recently." "The knowledge that if I don't take this client, it's most likely that someone 'gender-affirming' will, and the treatment they provided will create suffering for the client, his/her family, and untold others."

Social Harm Perspective
"We are in the midst of a mass psychogenic craze which will cause untold wreckage in many lives." "I am a transman with 20 years of lived experience.What we are witnessing right now is nothing short of a contagion.It is absurd and I am annoyed by the lunacy which medical personnel largely supports and condones."

Personal and Biographical Factors
"As a lesbian, I am quite alarmed by what's happening to kids, particularly gay and lesbian kids, in the context of trans ideology and techno medicine." "I have had personal experience as a gender non-conforming young person who was harmed by gender affirming healthcare."

Compassionate Reasons
"I care.People are being harmed and they don't know it."

Ethical Values
"I believe that it is ethically wrong to forgo good client care in an attempt to follow the status quo, and that mental health professionals and others in the caring fields have an obligation to push back against harmful ideologies, no matter what the cost to our professional reputation is."

Case Examples of Therapist Motivations
The following is a selection of five longer responses to the question of motivation for working with gender nonconforming clients, which perhaps gives a better sense of the complex, multiple factors influencing therapists' rationale for wanting to work with this client group.Rather than providing a single-dimensional response to the survey question, these participants offer more of a wider and often deeply personal sense of how they explain their own reasons for working with complex client issues, in an often challenging and hostile environment.
I'm interested in working with detransitioners because I focus on trauma informed care and recognize the trauma this population has endured.My work as a sociologist focused on sex and gender, including a post-doc on Gender Identity Disorder and the politics and social processes that led to its inclusion in the DSM [Diagnostic and Statistical Manual of Mental Disorders].As a lesbian, I am quite alarmed by what's happening to kids, particularly gay and lesbian kids, in the context of trans ideology and techno medicine.I am currently most open to working with adult de-transitioners (in this area of practice); my broader practice specializes in people harmed by partners and family members with Cluster B personality patterns).I have had, in recent years, trans identified adults on my case load, but we have focused on issues other than their trans identities, in most cases.
I find the entire subject fascinating and I also feel an ethical duty to provide open, curious therapy for young people especially.I feel they are deeply misinformed and easily suggestible and don't have the capacity to consider long-term consequences to medical interventions.I've also noticed that a lot of other issues-anxiety, pubertal changes, depression-are getting lumped under gender dysphoria.And as a person I've always struggled with sexism, misogyny, as well as my internal sense of being quite masculine in certain ways and getting a lot of grief for that even though I look outwardly very feminine and pretty.This mis-match has always been a struggle!I also grew up in a medical family with a father who was a general surgeon and a mother who was a registered nurse so I have deep familiarity with the medical profession and doctors with integrity and how very, very serious any kind of surgery to alter the anatomy is.Most people don't have this exposure to the surgical field and are really unaware of how serious any kind of surgery is.
I am a transman with 20 years of lived experience.What we are witnessing right now is nothing short of a contagion.It is absurd and I am annoyed by the lunacy which medical personnel largely supports and condones.I am also offended by the attitudes of young, gender-confused individuals who think gender is fluid.True dysphoria is not a choice or a "preference."Often, I hear clients saying they have a "preference" to be the opposite gender or they believe they ARE the other gender or non-binary (which is ridiculous).They say these things when they've had no surgery and taken zero hormones.This is not how gender dysphoria works.I feel a duty to help others so they can avoid regret.I particularly empathize with the parents.
I think we are living through a medical scandal that has damaged people in serious ways.I would like to offer a non-medicalized approach to people who struggle with gender dysphoria or who are gender non-conforming.I would like to help people accept their bodies as they are and know that there is not anything wrong with them if they are gender non-conforming.I would also like to help people relieve distress they feel by making internal rather than external changes.I think people who experience distress about their gender deserve better than "affirming care."They should have quality psychotherapy.
Many things-foremost among them: The knowledge that if I don't take this client, it's most likely that someone "gender-affirming" will, and the treatment they provided will create suffering for the client, his/her family, and untold others.It's also important to me to be part of the larger effort to educate people about the realities of "gender-affirming care" and to do my part to protect vulnerable individuals.Lastly, I'm a feminist, and putting those values to work in the service of women and girls matters to me.

Discussion of Case Examples
The selected case examples illustrate a complex interweaving of the themes discussed above; namely, a primary commitment to therapeutic role, the client's need for ET rather than GAT, a wider sense of the social harms associated with gender health care, the key role of personal and biographical factors, together with compassionate reasons for working with this client group, and the importance of working in an ethical manner.If anything, the notion of a primary commitment to the therapeutic role is perhaps underillustrated here within this selection, given the urgency and passion with which participants outline their motivation.Many of the responses making up the dominant group (i.e., a primary commitment to therapeutic role) are framed in a slightly more cognitive manner using terms such as interested, believe, motivated, see, and recognize.Responses in this group of selected case studies include more reference to affect and emotion, using terms such as alarmed, annoyed, offended, empathize, or reference to experiencing behavioral conflict such as struggle.

Discussion
The qualitative data produce a picture of a community of practitioners that clearly feels itself to be under pressure.This pressure is not overwhelming, but is tangible, in that many therapists perceive themselves to be working in a hostile environment, where the threat of potential complaint, understood here in broad terms, is an occupational hazard, and for many, a source of anxiety.While a minority have been subject to a formal challenge or complaint, the anxiety surrounding the potential for such action affects wider numbers, as part of a "rippling out" process.Yet anxiety can have different effects, in disabling some, or in motivating others.The widespread anxiety reported does not seem to have undermined their willingness to continue working in the field and may constitute in part a motivating factor to do so.
A large proportion reported working in a hostile environment, largely due to the critical attitudes of professional colleagues.Most were in private practice, which begs the question of how this might be related to environmental pressures; that is, as cause or effect.It may be that working in private practice reflects the changing arc of their career, with a late stage shift out of wage employment into private practice as more senior practitioners.Alternatively, it may represent a tactical move to the relative autonomy offered by private practice.
The data suggest that therapists are adapting traditional and well-established strategies to minimize the degree of risk of complaint or challenge and to increase the positive outcomes of working with gender issues.Therapists in any form of practice, particularly private practice, are likely to use careful marketing and client selection to achieve these goals.However, it seems that therapists are using deflected and targeted marketing in very specific ways, allied to careful contracting, to avoid what are perceived to be higher-risk groups of clients and to work more with preferred client groups, including, but not restricted to, detransitioners.
The background debate on alleged CT and attendant legislation or professional sanctions has been charged with producing unintended chilling effects on therapists, including that of professional flight from the field of gender therapy.The limited evidence from this survey supports this to a limited degree.
Overall, the picture presented by the data seems to indicate a process of normalization of gender therapy for this group of practitioners.This is an important observation, given that the rise of gender therapy in the past decade is founded on the twin premises of trans fragility and trans exceptionalism).Trans fragility derives from a claimed heightened vulnerability to suicide.Trans exceptionalism posits that work with this client group demands significant changes to therapeutic practice, via the adoption of managed speech, disclosure of pronouns, reduced attention to safeguarding risks, and the adoption of an advocacy or trans ally role by the therapist.Normalization therefore implies a clear rejection of these two linked rationales for providing GAT (i.e., trans fragility and trans exceptionalism).
Normalization seems to be evident among this group of therapists in several ways.First, therapists have largely responded to the uncertainties of working with gender issues by adapting already existing strategies for finding the appropriate type of clients, through deflected and targeted marketing, careful client selection, and contracting, backed up to some degree by legal advice, as discussed above.Second, beyond these measures, many therapists seem to have framed their work in this area as being consistent with existing mainstream therapeutic practice or "quality psychotherapy" as one participant termed it, rather than requiring major changes in technique or an innovative and entirely new therapy.This might explain why only a minority described their motivation in terms of providing ET, perhaps on the basis that ET is not a distinct modality as such, but rather constitutes an integral feature of most current therapeutic approaches.Third, adopting a perspective of normalization might explain why a minority of therapists seemed to see the best defense against challenge or complaint as using their established therapeutic model to good effect, rather than by making major changes to their way of working.

Limitations
The opinions of the therapists responding to this survey should not be considered a random sample nor representative of the therapeutic community.Rather, they are likely, with the 33% response rate to be representative of the therapists who are members of an association that pledges itself to assist gender variant persons to explore their gender variance with a goal of understanding underlying issues that may be contributing to their gender dysphoria.How the responses of a survey attempting to reach a representative sample of all therapists would be expressed cannot be ascertained from the responses here.We cannot even be certain of the representativeness of Therapy First therapists, though the margin of error at a 95% level of confidence is 5.44%.

Conclusion
Many therapists working with gender nonconforming clients describe experiencing anxiety and identify what they perceive to be a hostile environment for their therapeutic work.To some extent, these might appear to present unique challenges to this group of therapists.However, therapists seem to have used a process of normalization as a way of responding to these difficulties.Thus, many appear to see their continued practice in this area in terms of commitment to a therapeutic role in meeting client need.Rather than opting for major innovation, therapists' adaptation to a potentially hostile environment has involved careful changes to existing strategies for marketing, contracting, and client selection.Furthermore, therapists appear to have normalized their practice with an uncertain client group and potentially unsupportive colleagues by taking full confidence in the value and validity of their own therapeutic work.
One participant captured these challenging issues in the following quotation, providing the phrase we have used for the title to this article: "The threat hanging over every therapist's head if they don't affirm causes real damage-it makes therapists want to avoid talking about gender altogether or it makes therapists have to do ethical care in secret." do not agree with, and the nature of the dataset might offer opportunities to dox or otherwise harass survey participants.
• Confidentiality of your research records will be strictly maintained by NYU, and data from the study will only be shared beyond the PI with identifying email addresses removed from questionnaire submissions, after the PI has verified that the email addresses on submissions are verified against the current GETA list of clinician member emails.Information not containing identifiers may be used in future research, shared with other researchers, redacted to further protect your privacy, or placed in a data repository without your additional consent.• Participation in this study is voluntary.You may refuse to participate or withdraw at any time without penalty.Some questions on the survey are required but you are free to stop the survey should you wish not to complete those questions.Your decision to participate or not will not affect your relationship with GETA.• If there is anything about the study or your participation that is unclear or that you do not understand, if you have questions, or wish to report a research-related problem, you may contact Dwight Panozzo at 201-476-1816, dwight.panozzo@nyu.edu,60 Werimus Lane, Woodcliff Lake, NJ 07677.• For questions about your rights as a research participant, you may contact the University Committee on Activities Involving Human Subjects (UCAIHS), New York University, 665 Broadway, Suite 804, New York, New York, 10012, at ask.humansubjects@nyu.eduor 212-998-4808.Please reference the study # (IRB-FY2023-7784) when contacting the IRB (UCAIHS).• Those living in the UK, EU, and/or EEA should familiarize themselves with their rights under the General Data Protection Regulation (GDPR).This can be done by clicking here.Feel free to print this page for your records.

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Figure 3 .
Figure 3. Strategies for practicing psychotherapy for gender issues in an adverse environment (n = 82).

Figure 4 .
Figure 4. participant comments on motivation to work with gender nonconforming clients (n = 100).