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Affirming Sexual Orientation and Gender Identity

It's normal in adolescence to question sexual orientation and gender identity.

As a kid, I had no interest in sports. The baseball and football gear my parents bought me lay unused on my closet floor. Instead, I spent my days reading. And when I ran out of library books, I read the Funk & Wagnall’s encyclopedia in the hallway closet—the 1960s version of surfing the internet.

I went to a small Catholic high school, where jocks and cheerleaders dominated. As a male, I was expected to be athletic. But I was scrawny, clumsy, and generally uninterested in organized physical activity. The bullies called me all sorts of names—“sissy,” “woos,” and “fag.” But the worst of all was “woman.”

In adolescence, it’s impossible not to internalize the labels and epithets that are tossed at you by peers and elders. And there was a time, in my early teenage years, when I wondered if I really was developing into a woman. These worries persisted, despite the fact that my penis and testicles were growing, my voice was deepening, and I now had to shave the hair off my face once a week. Gradually my gender identity issues dissipated as I befriended other teens—male and female—who, like me, were more interested in academics than athletics, and who showed me that I was a valid person as I was.

Noted psychologist Sandra Bem pointed out decades ago that it’s healthy to have a mix of masculine and feminine traits, whether you’re a man or a woman. Any remaining doubts I may have had about my gender identity were dispelled by reading Bem. Yet for others, questions about sexual orientation and gender identity persist well into adulthood.

I’ve just finished reading the 2017 Handbook of Sexual Orientation and Gender Diversity in Counseling and Psychotherapy published by the American Psychological Association. I’m a cognitive psychologist interested in human thought processes, not a therapist, but I do try to read widely in the field. However, what I read in the Handbook troubles me.

The Handbook takes an “affirmative therapy” approach. As I understand it, this means helping clients accept themselves as they are without feeling the need to conform to societal stereotypes. In other words, affirmative therapy is the opposite of “conversion therapy,” which seeks to help the client conform to the expectations of society. In this sense, I applaud affirmative therapy. After all, we can’t all be jocks and cheerleaders.

The chapters on sexual orientation made perfect sense to me. So what if you’re a man who’s sexually attracted to other men? There’s nothing unnatural about a same-sex orientation. We see it playing an important role in many cultures throughout history. In a liberal society, consenting adults should feel free to follow their sexual inclinations and grant others that same privilege.

In reading the Handbook , though, I was disturbed by the discussion of gender identity. It’s not that I object to the open discussion of these issues. Quite to the contrary, I know this is important because I too struggled with gender identity questions in my youth. Instead, what I find problematic is the standard approach nowadays to resolving these issues.

As I describe in the post " When Sex and Gender Don't Match ," psychologists use the term “sex” to refer to male or female attributes of the body, and they use the term “gender” to refer to the psychological experience of feeling masculine or feminine. For the vast majority of people, biological sex and psychological gender more or less line up.

The term “gender dysphoria” refers to the distress that occurs when a person’s physical sex doesn’t match perceived gender. A girl may be more interested in rough-and-tumble sports or building things. A young man may find he’s excited more by fashion than football. These are just simple examples and not intended to portray the rich and varied range of the transsexual experience.

As I read the chapters on affirmative theory in gender dysphoria, I had great expectations. I would want to help clients embrace whatever gender identities they may have. And I’d tell them, as Sandra Bem reminded us half a century ago, that a mixture of masculine and feminine traits results in a healthy, well-rounded individual.

But this is not the standard practice, as I soon found out. Instead, clients reporting gender dysphoria are quickly shunted into hormone therapy as a preliminary to sex reassignment surgery. In other words, if physical sex and psychological gender don’t match, we change the sex to match the gender.

I see nothing affirmative about hormone therapy and sex reassignment surgery. Rather, it’s conversion therapy at its most insidious. It seeks to change the appearance of the human body so that the way you act won’t offend anyone’s gender stereotypes.

In most cases, cutting healthy tissue from the body would not be considered a reasonable course of action. Hormone therapy and sex reassignment surgery make irreversible physical changes and leave most patients sterile. Furthermore, there are no clinical studies showing the long-term efficacy of these procedures.

Changing physical sex to match experienced gender amplifies the existing sex and gender stereotypes in our culture. If you like doing “guy” things, you should look like a guy. If you like doing “girl” things, you should look like a girl. This seems to be the underlying rationale.

Reconstructive surgery can make miraculous changes in the life of a person who suffers from congenital deformity or accidental disfigurement. But when people undergo medical procedures to change the apparent sex of their bodies, they can forsake the richness of their personal identities in exchange for cardboard cutouts of their true gender and sexuality.

Indeed, as the transgender literature rightly points out, people expressing gender identities outside the masculine-feminine binary have played important roles in various cultures throughout history. In a liberal society, we need to recognize these people who don’t fit into cookie-cutter gender identities as expressing valid aspects of the human experience. Rather than discriminating against those who buck the stereotypes, we need to welcome them for the diversity with which they enrich our society.

For some, sex reassignment surgery may be the best course of action. We as a society need to respect the choices that mature adults make about their bodies, even if we don’t agree with those decisions. However, I am concerned that too many impressionable young people are being seduced into the medical option as a quick fix to gender dysphoria before they’ve had the opportunity to fully explore their sexuality and gender identity.

Psychotherapy is designed to help people achieve a deeper understanding of themselves as complex persons. But the current standard approach to gender dysphoria emphasizes superficiality over profundity and appearance over awareness. Medical and mental health care providers working with these populations need to seriously reconsider whether they’re truly acting in their clients’ best interests.


Bem, S. L. (1993). The lenses of gender: Transforming the debate on sexual inequality. New Haven, CT: Yale University Press.

DeBord, K. A., Fisher, A. R., Bieschke, K, J., & Perez, R. M. (2017). Handbook of sexual orientation and gender diversity in counseling and psychotherapy. Washington, DC: American Psychological Association.