Define Affirming: A Call for Clarification
November 4th, 2023 | Kindred Voices
Camie Nitzel, PhD LP, Licensed Psychologist and Founder of Kindred Psychology, responds to Nebraska’s new regulations regarding gender affirming care for minors. You can read the full letter below, sent on November 1, 2023 to Dr. Tim Tesmer, the Chief Medical Officer of Nebraska DHHS. Dr. Tesmer is responsible for creating and regulating these new procedures. A Public Hearing about these regulations took place at the Lancaster County Event Center on Tuesday, November 28 2023, from 7:00am-7:00pm.
Dear Dr. Tesmer:
I am writing to seek clarification about specific language included in the revised Emergency Regulations specific to LB574. I write to you as a practicing Licensed Psychologist, Clinical Supervisor, and Founder of Kindred Psychology. We specialize in serving members of the LGBTQ+ community, including a substantial number of gender diverse, nonbinary, and transgender youth and their families. As a psychology practitioner, supervisor, and scholar, it is imperative that I understand both the letter and spirit of your statement.
The initial Emergency Regulations (10/1/2023) were intended to guide implementation of LB574, which empowered you as Chief Medical Officer of the Division of Public Health for Nebraska Department of Health and Human Services, to “specify the number of gender-identity-focused therapeutic hours required” for transgender and gender diverse youth to be eligible for medical intervention.
In addition to specifying the required number of hours (40), the Emergency Regulations (10/1/2023) further required that “the therapeutic hours must be clinically neutral and not in a gender affirming or conversion context”. This statement seemed to conceptually position Gender Affirmative Therapy and Conversion Therapy at opposite and extreme ends of an imagined spectrum, prohibiting both. Practicing in a “neutral” capacity was presented as the desired approach somewhere in the middle.
Two weeks later, the Emergency Regulations (10/16/2023) were expanded, now including a reference to the clinical framework for the 40 mandated therapeutic hours. The revised regulations direct therapists to be “clinically objective and non-biased” and “not merely affirm the patient’s beliefs.”
I require clarification on the aforementioned language. It is unclear to me whether the expanded regulations are prohibiting the use of the empirically-supported Gender Affirmative Model of therapy, or whether the regulations are using “affirming” as an adjective, thereby prohibiting therapists from speaking and behaving in a generally culturally-competent, affirming manner.
To guide the clarification process, I wish to provide some background as a Licensed Psychologist with extensive training and experience in Gender Affirmative Therapy. It is my hope that outlining the principles and practices that comprise Gender Affirmative Therapy will dispel any lingering myths and underscore the necessity of immediately amending the Emergency Regulations.
Gender Affirmative Therapy
The American Psychological Association (APA) recommends the empirically supported Gender Affirmative Model (Keo-Meier & Ehrensaft, 2018; described below) as the best practice for assessment and treatment of gender diverse youth and their families. As such, this is the model I have used, and have trained other clinicians to use. The Nebraska Psychological Association (NPA) has also trained Nebraska psychologists in this model of care by selecting “Transgender Psychological Evaluations and Gender-Affirming Care” as the theme for the Spring 2023 Conference.
Evaluation and Treatment Planning
Gender Affirmative Therapy provides a therapeutic relationship for clients to explore the complexity of their identities with a knowledgeable, highly trained provider. In practice, Gender Affirmative Therapy begins with a parent or guardian seeking out and consenting to mental health services. We begin with a thorough developmental assessment that is multi-modal (screening tools, questionnaires) and multi-informant (parents, youth, siblings, teachers) in nature. Further, the developmental assessment also considers the following:
- DSM-5-TR criteria for mental health disorders (i.e., neurodevelopmental such as autism spectrum disorder, eating, mood and anxiety disorders, current or past experiences of trauma, suicidality or self-harm behaviors, thought or personality disorders, substance use, etc.)
- Personal and family strengths
- Physical health, co-occurring medical conditions
- Psychosocial functioning, behavior, job/school performance
- Peer relationships and interpersonal functioning
- Experiences of minority stress
- Religious, spiritual, and cultural values
- Family attunement, including the ways the youth’s gender expression is understood and accepted among other family members.
This evaluation process guides the development of the clinical conceptualization and treatment plan, which provide the roadmap for therapy. Any behavioral health needs identified in the assessment are incorporated into a treatment plan.
Individual and Family Therapy
Gender Affirmative Therapy also addresses any symptoms of gender dysphoria the youth is experiencing, and may include important therapeutic processes such as psychoeducation about gender and sexuality, body care and awareness, facilitating physically healthy behaviors, teaching coping skills, deepening self-understanding, facilitating assertiveness and self-advocacy, envisioning self in the future, restructuring family communication, encouraging family support, improving home-school cooperation, cultivating supportive community relationships.
In therapy, gender diverse youth explore their own questions about themselves, according to their individual needs and stage of development. The therapist’s role in this process involves helping youth find language for their internal experiences related to gender identity. We spend time navigating the complexity of intersection between sexual orientation, sexual attraction, relationship affiliation, and feelings around gender. Some youth request assistance with social transition and coming out to friends and family.
Sometimes gender-affirming therapists help pre-pubescent youth adjust to their rapidly changing bodies, or cope with physical changes that are causing unanticipated distress. For those youth who are experiencing specific anatomic or genital dysphoria, we provide therapeutic interventions for dysphoria management.
A multidisciplinary approach to care may be warranted for youth with long-standing and highly developed clarity about their gender, coupled with heightened levels of concomitant distress. Referrals may be made for dysphoria-related physical interventions such as speech therapy (for vocal dysphoria), physical therapy (for postural pain related to binding or slouching), nutrition counseling (for intervening with disordered eating used to achieve shape goals) or hormone therapy (puberty blockers and/or cross sex hormones). These referrals occur in collaboration with parents/guardians, and within the context of the comprehensive assessment, conceptualization, and treatment planning process.
Regulations Based on Myths
To be clear, Gender Affirmative Therapy is not a coercive or manipulative set of psychological practices. This therapy does not exist for the purpose of “convincing kids they are trans” to “chain them to a lifetime reliance on pharmaceuticals,” as was asserted on the floor during the legislative session. Referrals are not made for surgical intervention for youth. Further, there is absolutely no intention or motive to “dupe parents and kids into silliness that if you (transition) you’re going to become happy” (Pillen, 5/22/2023). The purpose of Gender Affirmative Therapy is not to help all gender diverse and transgender youth to physically transition, nor does it “merely affirm the patient’s beliefs.” Rather, it is a conceptual framework to guide self-exploration and discovery around identity topics that are intensely private, nuanced and complex, personal, and currently loaded with stigma and cultural shame.
Gender Affirmative Therapy is aligned with the emergency regulation that “the therapeutic hours must include sufficient parental or legal guardian involvement to ensure adequate familial support during and post treatment.” The importance of family involvement and support is incorporated throughout Gender Affirmative Therapy by using a Multidimensional Family Approach (Malpas et al., 2018). For example, Buckloh et al. (2022) state, “working with parents and caregivers of transgender and gender diverse youth is an integral part of competent gender affirming care… Evidence-based comprehensive care is imperative, which includes involving parents and caregivers. Moreover, parental and caregiver acceptance and support are one of the most important protective factors against anxiety, depression, and suicidality. By supporting parents and caregivers along their own journey, mental health providers can improve outcomes for the whole family” (p. 325).
In sum, the conceptual framework of identity exploration, therapeutic relationship, and family attunement are core components that help youth clarify identity and determine the path forward for themselves, which may or may not involve medical intervention. Should Gender Affirmative Therapy be prohibited as a model of therapy in Nebraska, gender diverse youth will lose access to the most thorough and empirically supported treatment available to them. Thus, restricting the practice of Gender Affirmative Therapy will most certainly harm the vulnerable youth that LB574 sought to protect.
Affirming as an Adjective
I sincerely hope I am misinterpreting the earlier quoted statement and can be assured that Gender Affirmative Therapy can continue to serve as the theoretical model guiding the newly required therapy hours. If this is not the case, I am concerned about the alternative interpretation. Is the complex, multidimensional care I provide being reduced to one adjective which I may not embody? “Affirming.”
Therapy by Definition Should Be Affirming
Am I to understand that psychologists and therapists are prohibited from providing an “affirming” (adjective) context for clients? If “affirming” is understood to mean to “offer someone emotional support or encouragement; give (life) a heightened sense of value, typically through the experience of something emotionally or spiritually uplifting” (Oxford Language Dictionary, 2023), then all quality mental health clinicians may as well relinquish their licenses now.
Feeling deeply seen, heard, and affirmed for one’s unique existence is central to the therapeutic experience, no matter the presenting problem or gender identity of the client. It’s what makes the therapeutic relationship safe enough to withstand challenges to entrenched unhelpful thinking patterns (CBT), carefully worded questions when behavior is out of alignment with value systems (ACT), and to feel the security necessary to reprocess traumatic experiences (CPT).
Further, what comprises a “gender-affirming context”? Am I allowed to call youth by their chosen name and pronouns, even when I have parental acknowledgement and support for doing so? Using correct name and pronoun is a basic affirming (adjective) gesture, as well as an important component of practicing Gender Affirmative Therapy. (It’s also part of being a decent human being.)
If the artwork in my office reflects gender-diverse faces, is that overly affirming? What about the sign that says Trans Nebraskans Belong by our front door? May I no longer wear my shirt that says Protect Trans Youth? Requiring a “clinically objective and non-biased” context, void of these important signifiers of safety and belonging, is contrary to best practices for inclusion (Bass & Nagy, 2022) and impossible to standardize or achieve. Further, such restrictions would infringe upon my personal and constitutionally protected freedoms of speech and expression.
In summary, the Emergency Regulations have disrupted our clinical practice by using the word “affirming” in vague reference to the type of care we may not provide. Mental health providers were not presented with a sound definition or alternative empirically supported model to guide our daily clinical decisions. Instead, the language as it currently stands leaves mental health providers in a personal and professional quandary for how to practice both legally and ethically in the State of Nebraska. This Emergency Regulation as it is currently written forces providers working with gender diverse youth to violate Chapter 156 002.04 of the Nebraska Regulations Defining Unprofessional Conduct by Psychologists, which states, “Unprofessional conduct is conduct which fails to conform to the accepted standards for the psychology profession and which could jeopardize the health safety and welfare of the client” (p. 1).
It is my sincere hope that this letter elucidates the urgent need for further clarifying edits to the regulations so that gender diverse youth in Nebraska can continue to receive care that is in alignment with best practices of the American Psychological Association (APA) and the existing regulations governing our practice in Nebraska. If I can provide any further assistance or answer any other questions, please feel free to contact me at email@example.com. Thank you for your time in reading and providing clarification.
Camie Nitzel, PhD LP
Founder / Licensed Psychologist