Flourishing amid uncertainty

Youth gender dysphoria is complex, and it calls for a psychological response that is cautious, curious and patient

Photo by Jordan Whitt on Unsplash

Rachel Hannam

The old expression “throwing the baby out with the bathwater” refers to accidentally discarding something valuable while trying to get rid of something unwanted.

It is a useful metaphor for the current debate surrounding gender care.

Most clinicians would agree that we needed to challenge and discard the old “bathwater” of pathologising homosexuality, enforcing rigid gender roles, disparaging gender nonconformity, and assuming that clinicians always know best. These were genuine advances that needed to be made.

The problem is that, in our determination to remove those outdated assumptions, we also discarded some of the things we still needed. In rejecting stigma, we rejected diagnostic curiosity. In rejecting paternalism and conservatism, we rejected thoughtful clinical judgement. In rejecting “gatekeeping”, we rejected careful assessment. In rejecting certainty about gender, we abandoned our tolerance for uncertainty itself.

History reminds us that some of medicine’s greatest mistakes were made by compassionate professionals genuinely attempting to relieve suffering. Conversion therapy, lobotomies, and thalidomide were not born from cruelty. They emerged from a genuine desire to help, coupled with misplaced certainty about what would fix it and a failure to adequately weigh long-term risks against immediate hopes or ideas of the time.

Good intentions have never been enough.

The debate over gender medicine is therefore not simply about transgender identities, healthcare, or politics. At its heart, it is a debate about how we understand and grapple with human suffering.

For much of modern history, psychology and medicine have wrestled with a difficult question: when should distress be accepted, explored, and understood, and when should it be treated with interventions? Increasingly, I believe we have lost our capacity to hold that tension.

I believe the future of psychology and good psychotherapy depends less on discovering new treatments and more on recovering an older wisdom: that human discomfort and struggles are often complex, meaningful, and resistant to quick solutions.

On complexity

Modern medicine excels at solving complicated problems like fixing a broken leg or removing an appendix. The challenge is recognising when a problem is complex rather than merely complicated. It is also a challenge to determine when something is truly a problem at all—not all discomfort is a problem—and psychology has long known about optimal discomfort and its importance for learning and growth (Vygotsky, 1978). And yes, sometimes young people have gender dysphoria and find it deeply distressing. But in these cases, the distinction between complicated and complex matters.

Complicated problems can be broken down into discrete parts, analysed, and solved through technical expertise. Complex problems involve multiple interacting factors, uncertainty, and outcomes that cannot be predicted with confidence. Some of these factors are likely to be philosophical, moral and ethical, rather than just physical or technical.

Many of the disputes surrounding youth gender care stem from disagreement about what kind of problem gender dysphoria actually is.

The rhetoric I often encounter is that “trans people have always existed”. I see the issue differently. As a psychologist, I find the definition of “trans” very broad and too imprecise to be useful. I know the term “trans” is intended to be broad and imprecise, and reflects a “lived experience”, but I also know it is a modern construct that hasn’t always existed. However, the experience of diverse gender expression and ambivalence (or dislike of one’s body or role in society) has always existed.

I have spoken with enough older lesbian, gay, bisexual, and gender-nonconforming individuals to know that many wrestled for years with discomfort about their bodies, their sexuality, or the cultural expectations of their sex. Looking back, many describe these experiences not as problems with simple solutions, but as part of the complexity of becoming fully human.

The question is not whether (that which we now label) gender dysphoria exists. The question is: What kind of problem do we understand gender dysphoria to be?

In recent years, gender dysphoria in young people has increasingly been treated as though it were a complicated problem with a straightforward solution: discuss the distress, give it a name, affirm the identity, get schools and families on board, modify the body, and the patient feels better.

Yet gender-related distress appears to be a profoundly complex phenomenon involving developmental, psychological, familial, socio-cultural, neurodevelopmental, and biological factors that interact in multi-directional ways we do not fully understand.

As Meadows (2008) argues, simplifying a complicated problem can be very helpful. Simplifying a complex problem can be very dangerous.

Gender distress is experienced by an individual, but its causes are contextual, layered and complex. When complex human problems are reduced to a single explanation and set of interventions, we risk mistaking simplification for understanding. Human struggles are not always problems to be fixed. Sometimes they are realities to be understood, explored, and accepted.

Sometimes we need to say to a young person: “I really understand that you wish you had been born female, but you were born male.” Or vice versa. Then we explore what that means.

A medical lens

The gender medicine debate reflects a broader cultural shift.

Modern society has become increasingly uncomfortable with ordinary human suffering and inclined to medicalise it. Experiences once understood as part of personality differences, developmental struggles, or the ordinary challenges of growing up, are now routinely viewed through a diagnostic lens. Our profession of psychology has become exceptionally skilled at naming suffering and less patient with understanding it. In our desire to help, we often teach people that ordinary struggles are symptoms to be treated rather than experiences to be navigated.

The gender medicine debate therefore exposes a larger question: have we become too quick to medicalise human discomfort and avoid the complex struggles of the human experience?

Psychologist Nick Haslam’s (2016) concept creep thesis argues that concepts such as trauma, abuse, harm, and mental disorder have gradually expanded to encompass an ever-wider range of human experiences. This expansion has undoubtedly increased awareness of genuine suffering. But it has also reduced our tolerance for normal human adversity.

When every struggle becomes a disorder, the space for personal growth, adaptation, and resilience begins to shrink. This concept creep coincides with the current cultural exaltation of minority status and oppression. Such confluence of sociocultural factors in therapeutic culture has revealed important issues, but it has concealed others and created blind spots in our practice.

Curiosity disappears

The consequences of medicalisation trends often become visible in the therapy room. Increasingly, clients arrive with diagnostic labels already attached to their experiences. This is not just in the gender space but also with neurodiversity where clients come in saying: “I think I have ADHD/Autism/Dissociative Identity Disorder”. Sometimes these labels are helpful or appropriate. They can provide relief, validation, or a framework for understanding distress. However, they can also create significant therapeutic blind spots.

The clinician’s task is not to reject a person’s understanding of themselves, but neither is it to endorse it. The most valuable question in therapy is not, “What do you believe?” but rather, “How did you come to believe that?” The task of therapy is not to affirm a story at face value. It is to understand how that story was written.

The danger is what clinicians sometimes call diagnostic foreclosure. Once a label becomes an answer, curiosity disappears. We stop asking “Why?” because we believe we have already established “What”. Once a diagnosis is attached, everything can start looking like evidence for it—classic confirmation bias. Labels that initially illuminate complexity can gradually collapse it.

Respecting complexity matters because when diverse experiences are grouped together in a single category, we lose sight of the individual. The more significant the intervention being considered, the greater our obligation to understand the unique story that precedes it. Labels can bring clarity, but should never become substitutes for understanding.

Psychology loses its way when understanding is replaced with validation. When therapy becomes a process of confirming conclusions rather than investigating them, opportunities are lost. The goal is not to challenge people for the sake of challenging them. The goal is to ensure that important questions have not gone unasked.

I believe that what psychology as a discipline needs now is not more rhetoric, nor more sympathy.

Psychology needs more curiosity.

Missing the individual

One of the mistakes in this field has been to treat gender dysphoria as a single phenomenon with a single explanation (or no explanation). The most natural question for psychologists and doctors alike should be: “What might be driving this client’s rejection, dislike, repulsion or distress related to their body?”

The question is not whether dysphoria is real. Of course, it is. People have disliked their bodies in various ways for many years, e.g., due to their weight (eating disorders), or their perception of their nose being too big (body dysmorphia). The important questions are: “Have we been too quick to assume that everyone is experiencing the same thing? And what contributes to the experience in the first place?”

In practice, we have grouped together very different people under the same umbrella, despite profound differences in histories, motivations, developmental pathways, and experiences. A girl whose hatred of her body is linked to trauma, bullying, or sexualisation may be experiencing something very different from an autistic or gender-nonconforming boy who believes life would be easier as a girl. Both may differ significantly from an adult male who has spent years entertaining erotically-charged fantasies about becoming a woman.

There are many roads that lead to gender dysphoria; there is danger in assuming they begin in the same place.

Perhaps the most important unresolved question in gender care is whether distress arises because the body is wrong, or because the person’s relationship to their body has become troubled.

These are not merely semantic differences. They represent fundamentally different formulations of the problem and lead to very different therapeutic responses.

Many clinicians I know privately acknowledge this dilemma, one that has little to do with politics. We are told that gender diversity is a natural and healthy variation of human experience, yet gender dysphoria is simultaneously conceptualised as a medical condition requiring irreversible interventions.

We tell young people that bodies do not determine their gender, yet body modification is often presented as a primary pathway to resolving distress.

These inherent contradictions are difficult to ignore.

If gender identity is independent of the body, why does treatment so often focus on changing the body? If gender diversity is a normal variation, why is it approached through a medical framework?

These are legitimate clinical questions. Asking them should not be considered controversial, nor should challenging logically inconsistent answers be dismissed as transphobic.

A profession that questions itself

Good clinical care requires the ability to hold compassion and critical thinking at the same time. These qualities are not opponents. They are partners.

The question is not whether a particular approach is right or wrong. The question is whether we remain free to examine its assumptions, limitations, and outcomes. When certain questions become difficult to ask, the quality of our clinical thinking suffers.

This is particularly important in areas involving significant uncertainty and potentially irreversible interventions. Scientific progress has never depended upon unquestioned consensus. It depends upon the freedom to examine, challenge, refine, and sometimes abandon prevailing ideas when the evidence warrants it.

A mature profession is not one that never makes mistakes. Every profession and professional makes mistakes. The mark of maturity is the willingness to identify blind spots, revisit assumptions, and tolerate disagreement in the service of better care. Psychology and medicine should be confident enough to examine themselves without fear.

What therapy can offer

If gender-related distress is often complex, then our response should reflect that complexity. Given the increasing visibility of (and lawsuits involving) detransitioners, we should be far more cautious than we have been. Medical intervention has increasingly become a substitute for the deeper exploration that identity struggles often require.

Importantly, affirmation and exploration should not be treated as opposites. The deepest form of affirmation is taking a young person’s experience seriously enough to explore it fully. Genuine curiosity communicates respect. It says, “Your experience matters enough that I want to understand it in all its complexity”, knowing that this takes time.

Therapy can provide an opportunity to slow everything down, not just for the sake of it, but because exploration, understanding, and personal growth, especially growing into our adult identities, should take time. Time allows clinicians and families to explore the onset and development of gender-related distress, examine social influences such as peer groups and online communities, and consider the broader identity formation processes. It creates space to assess for autism, trauma, anxiety, depression, obsessive-compulsive disorder, eating disorders, and other psychological concerns that have historically contributed to distress.

Therapy also allows clinicians to work collaboratively with parents rather than excluding them from the process. The gathering of information from different perspectives has been a typical component of therapy, not an anomaly. The therapeutic process encourages humility about self-diagnosis and resists the temptation to collapse complexity into a single explanatory framework.

At its best, therapy provides an opportunity for people to build tolerance for uncertainty, ambiguity, and emotional discomfort. It cultivates self-compassion, resilience, and reflective capacity.

Therapists should continually ask: “What is going on here?” And then follow with a second question that is equally important: “What else might be going on here?”

Rather than assuming the body is the problem, therapy can help people cultivate hope for a more peaceful relationship with the body they already have.

Your body is not a mistake

Psychology has traditionally helped people cultivate self-acceptance. We should not abandon that principle. Across virtually every area of mental healthcare, the goals of self-understanding, self-compassion, and resilience remain foundational therapeutic aims. It is deeply embedded in Acceptance and Commitment (ACT), compassion-focused and psychodynamic therapies.

As therapists in this space, we must be careful not to collude with self-rejection. The deepest forms of therapy help people reconcile with themselves rather than divide themselves against themselves. Self-love does not mean complacency. It means learning to treat yourself as a person to be understood rather than a problem to be fixed.

A healthy society should teach young men and women that they do not need to modify their bodies in order to be worthy of love, belonging, or dignity. Young people deserve to hear that their bodies are not mistakes and that they are already their “true selves”, even if it makes them feel uncomfortable at times. During adolescence and early adulthood, identity is often fluid, dynamic, and evolving. Under the age of 30, a changing sense of self is a sign of healthy development rather than pathology.

A culture that genuinely celebrates diversity should also be capable of communicating a simple message: it is possible to learn to feel at home in your body. Supporting clients to inhabit their bodies with acceptance remains one of our most important therapeutic tasks as psychologists.

Before we ask whether a body should be changed, we should first ask whether the person has been given every reasonable opportunity, over time, to learn to love and accept themselves as they are.

The baby we need to keep

A psychologist’s role is not simply to make suffering disappear. It is to help people find meaning, dignity, resilience, and growth within it. The capacity to sit with discomfort and suffering is becoming a neglected clinical skill in an age increasingly focused on immediate relief.

There is something profoundly healing about discovering that you do not need to become someone else to be worthy. Human flourishing begins with the radical idea that you are worthy of care before you change anything about yourself.

That principle sits at the heart of psychology’s traditional commitment to self-understanding, self-acceptance, and human development. It is the foundation beneath curiosity, reflective capacity, resilience, and the ability to tolerate uncertainty.

The debate over gender medicine is often presented as a conflict between affirmation and exploration, or between validation and caution. It is neither. The real challenge is whether we can preserve the ethical foundations of clinical care while responding to genuine distress.

In our effort to remove the bathwater of stigma, discrimination, rigid gender roles, and outdated assumptions, we have discarded some of the very things that make good therapy possible: curiosity, careful assessment, developmental understanding, tolerance for uncertainty, and respect for complexity.

Those are not obstacles to compassionate care. They are compassionate care.

And that is the baby we need to keep.

Dr Rachel Hannam has been a practising psychologist since 2002. She works in private practice in Brisbane, Australia.

List of references

Haslam, N. (2016). Concept creep: Psychology’s expanding concepts of harm and pathology. Psychological Inquiry, 27(1), 1–17. https://doi.org/10.1080/1047840X.2016.1082418

Meadows, D. H. (2008). Thinking in Systems: A Primer. Chelsea Green Publishing.

Vygotsky, L. S. (1978). Mind in Society: The Development of Higher Psychological Processes. Harvard University Press.