Towards a trans inclusive practice: thinking difference differently

Abstract

Within the UK a polarised and politicised discourse exists that attempts to pitch transgender identities in opposition to discourses on sexual orientations. This suggests that interventions assisting clients in their understanding of one, would be detrimental on exploration of the other i.e., to be affirming of gender identity is to cause conversion of sexuality and vice versa. This paper attempts to address some of the problems with this oppositional critique and solve some of the practical problems that the theorist and/or clinician may encounter while attempting to help their clients within the realm of psychological therapies. It does so through Deleuzian ontologies of difference, coupled with Bhaskarian critical realism. We aim to present a (re)consideration of the biopsychosocial model of Health. The recent publication of the International Classification of Diseases 11^th Edition and its reclassification of trans aetiology as a Disorder of Sexual Development has presented a conceptual shift from gender dysphoria towards a gender incongruence model (WHO 2022). The aim of this article therefore is to develop practice by enhancing the conceptual toolbox of the clinician and therapist working with Gender Sex and Relationship Diversities (GSRD). Thereby enabling them to better approach a wider diversity of clients safely.

LAY SUMMARY

This paper explores current conversations and ideas around the phenomenon of trans gender identities and minority orientations. It aims to present an ethical model which can inform the clinical practice of therapists and is underpinned by a critical realist interpretation of biological, psychological and sociological aspects of the mind and body. Overall, the paper acts as a call to action against conversion practices which aim to position trans experience and sexual attraction in opposition to each other.

Keywords:

• GSRD
• sex
• sexuality
• trans
• gender
• identity

Working with gender and sexuality

The term “Gender, Sex, and Relationship Diversities,” or GSRD as described by Davies and Barker (2015), is becoming increasingly popular in the field as being a more inclusive descriptor of a range of identities, not just those based on sexual orientation or gender identity (Barker, 2019). Our discussion is focused primarily on sexuality and gender and yet remains applicable when considering the broader scope of GSRD clients. Indeed, most recently there are suggestions that GSRD therapy is an emerging modality in and of itself (Davies, 2022). Whilst we are not aiming to explore this modality specifically within this article, issues around what may comprise “competence” in working with diverse communities is not lost on us, and our aim is that this article contributes positively to these discussions.

When working with LGBTQIA+, and indeed GSRD client’s, practitioners cannot ignore the ongoing socio-political conversation happening in wider society (Stock 2021, Joyce 2021, Faye 2022, Serano, 2022). These conversations come into the therapy room as they invariably impact on how clients experience themselves and therapeutic work in general. Practitioners approaching a session with a person expressing trans experience should be aware of the negative impact some of these discourses may have on their clients. For example, some elements of the mainstream media and political discourse pitch gender identities and sexual orientation in mutually exclusive opposition to one another. Recent discussion around the provisions within a UK ban of so-called “conversion therapies” being a case in point, as is the ongoing political posturing over the provisions of the 2010 equalities act (Gov.uk 2021, Legislation.Gov, UK 2022, Madirgal-Borloz, 2023). We feel it is important to address some of the myths and misnomers around these positions and present a grounded conceptual framing that can be applied by practitioners to prevent this supposed conflict from occurring.

Doing ontology: the human being

An oft discussed core element of the counselling and/or therapeutic relationship is the practitioner’s ability to be “non-judgemental” (Koh, 1999, Winslade, 2013). However, there will always be a certain level of judgementality embedded within any clinical practice. Critical Realism (CR) gives us a framing by which we can consider a process known as Judgemental rationality (JR): that which gives the practitioner an ability to make decisions and impose what we might call “possibilities and limits” upon a particular set of situational contexts and/or a particular set of discursive practices while constructing a formulation of the client’s concerns (Bhaskar, 2008, 2010). Whilst the language of formulation might not speak to all counsellors, the fact that we use theory to conceptualise a client’s concern means that we do exercise a degree of judgement whether we recognise this or not (Van Rijn, 2015: NICE, 2018).

But the application of judgemental rationality comes with something of a snag, namely “what makes a given judgment rational?” Our view is that judgemental rationality is contingent upon the practitioner’s prior knowledge, professional training, and academic/clinical sphere of operations. In other words, we often “fall to the level of our training rather than rise to the level of our aspirations” (Feloni, 2017). As a result, the knowledge base of the therapist is going to be both an enabler and, in some cases, a disenabler of progress within the given field of therapy. Pluralistic approaches to therapy may be particularly useful here since they recognise that different clients need different things at different times, and in so doing link to considerations of ethical practitioner commitment and competence (Cooper & McLeod, 2010; Gabriel, 2016).

Therefore, we believe that JR when applied to the field of ontology, (the study of “Being” and/or “what is’ in the philosophical sense) offers solutions that can aid our thinking when one considers the question of “being trans/nonbinary” verses “being gay/lesbian/bisexual” in line with justification and evidence bases.

Identity, assemblages, and the idea of difference

Giles Deleuze was a mid-twentieth century continental philosopher. A full exposition of Deleuze’s work is beyond our scope here, but in brief his important contribution to our argument is that he considered the human body an assemblage. Not in the purposive predestined way of a machine that “should” produce “a given outcome,” but rather in the context of how each system interacts with another. Deleuze further suggested that it is our (interpretive) inductive reasoning that suggests a “proper” outcome, or purpose for this assemblage.

For example, consider the context of teleological reproductive drives, the idea of which underpin heteronormativity (the common-sense view of people being assumed to be straight) as a universally natural concept (Deleuze 1994, Deleuze, 1980). In other words, the assumed natural state of affairs for humans is to experience heterosexual attraction because of a presumed reproductive imperative. The assumptions at work here are that one is “supposed to be, because one is fundamentally designed to”.

Deleuze recognized that as human beings we are always doing a process of becoming in which we have a shifting awareness of our “selves” and our surroundings (Deleuze 1990). Bhaskar similarly produced a means by which we might recognize that “knowledge” (which is the process of collective and or individual becoming) emerges over time (Bhaskar, 2008). The outcome of the combined thinking of these two authors can be summarized via the proposition that the “idea of the natural” and “the natural” itself are two independent entities, each of which will influence the lives of human beings (Ellis & Reilly-Dixon, 2023). Thus, what we know, and crucially what we do not know, are equally causative in creating whatever concept ultimately emerges from a narrative exploration. A classic example of which would be the either/or (binary) dichotomy of heterosexual and homosexual, that was criticised by Foucault as a speciation in his conversation with Noam Chomsky in 1971 about “human nature”. Wherein, the latter is merely the conceptual mirror of the former and, as some conservative authors may suggest, a lesser “unnatural” one to boot (Foucault, 1971). It is this idea of “lesser and/or unnaturalness” that the authors wish to critique.

When considering “difference” in the common vernacular, we tend to think of it as difference between “things,” between objects, concepts, categories, and therefore between known identities (Deleuze 1994). In considering difference before “thing” one can perhaps begin to see a distinction between that which is categorised, (the thing) and the mechanism of categorisation (the naming of the thing). So, Deleuze suggested that difference exists before identity (categorisation) and that as a result, our conceptual categorisations of that difference, (ontologies) howsoever they (and it) might be expressed—could be subject to change. Note here that Deleuze is not just talking about belief, rather he is suggesting that material reality can be independent of our beliefs about it. Something that both Roy Bhaskar and Karl Popper recognised with their concepts of emergence and falsifiability (Bhaskar, 2008, Popper 2010).

Deleuze realised that when we consider the identification and categorising of human “Being” and human “Doing” we have something of a chicken and egg problem, i.e., the doing could define the being, or the being creates reason for the doing. For example, take a question from one of our recent lectures on inclusive therapy with trans people. A delegate asked, “what is being affirmed in [gender] affirmative therapy?” We would suggest that what is being affirmed in material terms is the principle of variance (biodiversity) and the mechanism of self-report (of difference) that may give rise to a sense of one’s embodied self. Ergo, it is not about identities in as much as it is about enabling the creation of them through justificatory means of evidence: permissions and possibility. So, the therapist creates a space which allows for this exploration and does not see being trans as oppositional, wrong or false.

To simplify this, consider visiting the optician and taking an eye test. One cannot show the optician one’s eyesight directly, but merely explain it in relation to different lenses that the optician applies. The optician on the other hand must believe the patient and does so on the basis of their understanding of the mechanics of the eye itself, and related function. So, in this case the principle of self-report of difference relates to “eyesight” and the justifications for intervention (from the view of the optician) is contingent on the evidence base, ergo the physiology of the eye.

Therefore, the oppositional argument, that suggests affirmation of a trans gender experience would be an affirmation of an untruth, must itself be based in an idea of the natural that is synonymous with a particular conceptualisation of the “physiology of the body”. We will unpack these ideas below.

The biopsychosocial assemblage

Consider the human body and the world in which it exists. We might describe this as having Four broad layers to it: Bio-physiological—Anatomical—Psychological—Social (Sapolsky, 2018; Engle, 1979). Most of our lives are lived within the social experiential and interactive communications realm; how we act, what we do or say, and how we think in conjunction with others. Recognition is a large part of this process, as are various forms of language (Deleuze 1990, 2015). Words are linguistic tools to enable us to make sense of the world. Descriptors: denoting signifier and signified, that operationalise the “internal comparative category” that is “things that are similar to or different from some other thing.” Thus we, all of us, navigate the terrain of our lives via a process of conception (of meaning) through perception (of the familiar or unfamiliar), which together constitute the reasoning about the observed world, including other people.

The trans sceptical argument is no exception. It is built on two central premises; firstly, that sex is immutable, biological, and binary, which we might call a binary mutually exclusive model (BME) and secondly that transition as a process is purely psychosocial. Linguistically the trans sceptical position alternately makes use of both social construction (of gender) and an isomorphic collapse of sex and gender, dependent on which author you read (Stock, 2019, Soh, 2018, Taylor, 2020). This allows them to present some equivocation between what is meant by the term “trans gender,” dependent on context. However, park this for now and let us examine the first premise of immutable binary sex. We need to ask two questions.

1. Is this true?

2. How would we know this?

Firstly, no one is denying the material, biological and empirical reality of reproductive sex. That is the easy part. However, a person’s sex is composed of multiple variables. Hormones (progesterone, testosterone, oestrogen) and their relevant receptors in the tissues. Chromosomal genetic material, reproductive organs, genitalia, and secondary sexual characteristics. Each of which influences the other across the bio-physiological and anatomical levels. For sex (or any system) to be binary there must be two, and only two outcomes from it. Most people who subscribe to the binary idea point to the anatomical level of penis/vulva as definitive here. And yet—those structures are effects of some or all the other variables, and since not every penis or vulva are identical then variance (as difference) exists here too. What about chromosomes, XX/XY? This again is not definitive since there are people who have variations in this area, and more over the possible variations within the chromosomal systems do not exhibit definitive linear correlation relationships with any given endocrinological or anatomical outcomes (Ainsworth, 2015, Serano, 2022). So, given all the above, is sex a binary?

Empirically speaking? No. Our materially sexed bodies are the result of a multivariate process that form an overlapping bimodal distribution coalescing about two averages. A distribution which, by its very existence, denotes variance. No singular metric, whether anatomical or bio-physiological is universally definitive, or devoid of inductive, and/or linguistic propositional logics. Thus, from a scientific point of view, sex would be more accurately described as a Multi Variate Process (MVP). While a given person’s sex may be perceived as a singular “thing” it is in actuality an accumulation of numerous processes.

But what about the idea that the materiality of sex is immutable, in contrast to merely the “concept” of it? Here we can examine the evidence of trans therapies. On taking Hormone Replacement Therapy (HRT) a trans person’s endocrine system would be able to respond. In the case of a trans women receptors for oestrogen already existed in the tissue target cells and her body was able to change, e.g. fat redistribution, breast growth, muscle mass, gonadal atrophy. In the case of a trans man, the same is true in respect of testosterone, e.g. increased muscle mass, voice changes, facial hair growth and clitoral growth. Were the materiality of sex an immutable binary, receptors for “cross sex” HRT would not be present and/or the changes described would therefore not be possible. This leads to two central outcomes. Firstly, plasticity of the human endocrine system is key to the biological materiality of transitional health care. Secondly, the recognition of the effects of variances within the singular human assemblage is that which also underpins the rational for transitional HRT itself. It is no surprise therefore that some authors attempt to exclude the endocrine aspect from the discussion, preferring instead to focus on either chromosomes, or the anatomical. Both of which are, paradoxically, effects of the MVP, and thus subject to cytoplasmic cellular and/or endocrinologically driven bio- physiological plasticity and variance (Stock, 2019, Richardson, 2015).

So—this leads us to the second (trans sceptic) premise “That transition as a process is purely psychosocial.” Clearly this is wholly dependent on the truth claim inherent in the first premise (that sex is immutable, biological, and binary). Systemic recognition of trans people and their healthcare needs includes a psychosocial component for sure, as does sexuality, but it also includes bio-physiological and anatomical components. Therefore, contrary to the assertions of some authors, trans experiences and identities are not limited to merely superficially performative gender nonconformity but are inclusive of material variations in living systems of difference (Butler, 1990, Hines, 2007, Pearce, 2018 Vincent, 2020, Serano, 2022).

We have deliberately avoided use of the terms “trans gender” and/or “trans sexual” until this point. Because the obvious question to ask is “what exactly is being transitioned.” If one accepts that gender and sex are distinct then one could theoretically be trans gender in some sense without transitioning sex. And more over how (and if) sex could be transitioned is pertinent here. If one limits definitions of sex to the anatomical realm, then this would universalise genital surgical intervention as the moment of transition, thereby removing bodily autonomy for trans people. This would also lead one to the conceptualisations of pre surgical trans people as remaining unchanged in terms of sex with the result that they become thought of as such—with all the associated sociological presumptions (males in women’s spaces, trans identified males, danger to women, deviant sexual predators etc).

However, if one includes endocrinology in the discussion, then the moment of bio-physiological transition becomes harder to define, whilst also introducing the important idea that the material “reasons” for transition may not be limited to isomorphically defined concepts of deterministic male or female psychosexual drivers qua sexuality, as some more conservative theorists have suggested (Blanchard, 1985, Soh, 2018, Greer 2015). But transitional journeys are nevertheless expressed in ways that are contingent to the knowledge base of the transitionee, their agency and autonomy (words are after all an imperfect tool).

Linguistics and rational judgementality in a field of difference

Ok so what has this got to do with critical realism and therapy? Let us consider an argument we sometimes see posited in some of the oppositional discourses that we are critiquing:

A young lesbian discloses that she is feeling she needs to transition. The therapist wonders whether they should be affirming the patient’s trans status or considering this as an issue of self-acceptance of a lesbian sexuality.

At first glance, intervention directions appear mutually exclusive and presents a dilemma since one would be the conversion therapy anathema of the other. According to the trans sceptic view we have a situation akin to a differential diagnosis dilemma. However, if we look closer, this statement is positing difference between categories: “lesbian” and “trans” being the two explicit ones, but in the use of the term “lesbian” there are the unspoken concepts of “woman” and “same sex attraction” and equivocations of what a medicalised “diagnosis” is. So, what to do?

Identify and define the problem.

The reason this trans sceptic argument appears so compelling is because of an isomorphic aspect of thought and some linguistic nuances. “Lesbian” and “woman” are two sociological identities—categorical descriptors of human being and doing, that are thought so well understood that the distinction between category and categorised is collapsed. Basically, an argument might be posited is that to be a lesbian one has to be a cisgender woman. This constitutes an isomorphism between “word” (category) and thing’ (person) so that the content of the word “lesbian” is assumed to have an instantly and universally known meaning (a cisgender woman with same sex attraction). Words and meaning of course belong to the psychosocial aspect of reality, but they denote the users’ manifestations of thought, and therefore signify materiality’s, whilst remaining separate from them. In this case an individual with a particular anatomy is assumed from an extrapolation of an orientation. But if we apply JR, remaining mindful of the need to avoid isomorphisms, to Deleuze’s idea of the primacy of difference (difference exists before category) then an alternative story emerges. Within the linguistic identity/category of lesbian and woman, we can see that the term lesbian is contingent upon an a priori concept of woman (Deleuze, 1994, 1990).

So, to be a lesbian, one must be a woman, but what are the materiality’s of either lesbianism or womanhood? The answer according to Deleuze is the actualisation of difference, which we might now call “variance”, that carries within it the potential for emergent bodies and attractions that exhibit (in)congruence with the expected social norms. What we are saying is that because we can separate the process of attraction from anatomy, and word from thing, there is no reason to assume a cisgender history. Being a lesbian is not dependant on the category of cisgender women or a particular anatomical state. However, those who deny womanhood to women of trans history would by definition also deny them the identity of lesbian by denoting them as men, which is, of course, a circular proposition. (There are important recognitions of autonomy, attraction to other, and consent implicit within discursive limits of bodies. The authors are not insensitive these arguments, but do not have the scope to unpack them in this article).

The concept of primary difference (variance) within an MVP model of sex opens the possibility that identification and categorisation (knowledge) are not a pre-requisite for actual existence - this means that sexuality (attraction) does not necessarily have to pre-exist a trans identity. Moreover, the point at which we discover either as an individual is not the point at which they “come into being” but merely the point at which our knowledge of them emerges. (Much like when you discover you have reversed into a bollard in the car park—it existed before you hit it—you merely became aware of it at that moment). This distinction is important when considering the arguments of Rapid Onset Gender Dysphoria (ROGD) by authors such as Debra Soh and Lisa Littman (Soh, 2018, Littman, 2018). The assertion that a given realisation is a surprise or makes one uncomfortable, (in this case trans gender sense of self concept in young people) does not automatically mean it did not pre-exist that moment of realisation and/or discovery, whether by self or other. Despite the notion of ROGD being discredited (Ashley, 2020) the concept persists through a similarly seductive habit of mind and language regarding evidence bases that is implicit in our given examples. ROGD is based on the erroneous view that one can be “convinced to be trans” through “social contagion”. Instead of seeing the process of transition as resulting from an emergent recognition of a pre-existing underlaying material non pathological difference, a difference that is then contextualised through available societal knowledge composed of permissions and possibilities, the trans sceptic view suggests that transition is merely a harmful affirmation of a psycho-social pathology. Similar arguments have been, and are being, used to deny the teaching of the existence of LGB relationships to young people (Ellis & Reilly-Dixon, 2023).

A clarifying point

Note what we are not saying here is that a woman with a trans history was literally always “a woman” pre transition. To do so would be to essentialise a conceptual narrative as a material actuality. What we are saying is that the human body is capable of existing in such a way that one may have a (hitherto unknown) bio-physiological predisposition to transition—which then may or may not be actualised given the extant temporal and psychosocial milieu in which one finds oneself (extant knowledge, agency and systemic hermeneutical injustices). The ability to consider a transition possible is therefore at least in part contingent upon societal permissions. Part of which is the knowledge that variance within sexed bodies exists before any conceptual identity that results in recognition by categorisation. The possibility of transition is contingent upon the idea that “male and female” are explicitly not homogenous, universalizable, singular metrics, but rather categorical descriptors that contain the property of variance. Thus, to assume that a pre transition person is or was, simply a universalised cis gender person with stereotypically “male” or “female” idea’s thoughts and experiences would be an unsound assumption.

Conclusions and implications for therapeutic practice

So, in the case of our young lesbian, their assigned gender at birth is less relevant than their recognition of difference and principle of self-report in consultation with the therapist. This then places agency and autotomy with the client. The “therapist dilemma” is in fact a non-dilemma, because we can trust the clients self-report. This would not, of course, prevent the therapist from being curious and exploring with the client their experience of their gender and sexuality. The dilemma only comes if the therapist feels obliged to convince the client one way or the other. These sorts of dilemma’s arise from the therapist’s own belief about supposed (il)logicality and (im)possibility of transitional bodies/identities. In other words, BME/MVP conceptualisations.

The MVP model of sex makes visible the logic that one may be observationally assigned female at birth, whilst it remains perfectly possible that one may subsequently discover that one is attracted to women, as well as realising that transition is something one needs. Why? Because the principle of bio-physiological variance in “that which makes us any given sex” allows for a pre-disposition to either/both simultaneously and/or separately. To deny so is to take a position of metaphysical scepticism which forces one to adopt the view that either transition or sexuality is/is not “real” and therefore one, other or both, should be disallowed (Bettcher, 2018). This would constitute an ethical stance contingent on a belief in the truth of the two premises examined above and is the same historical argument that at one time posited “same sex attraction” as “not real,” and simply a [pathological] choice (Blanchard, 1985, Broster, 1944, Playdon, 2022).

Spaces that systemically refuse to recognise variance within human sex and sexuality as part of the condition of human Being, rather than the exception to it, therefore present a risk to inclusive GSRD practice. Such stances promote a universal acceptance of the assumption that not being different is the natural, and thus preferred, state of affairs. As stated previously, we are not denying the material, biological and empirical reality of sex and sexual reproduction, but rather we invoke a consideration of the idea that the material actualities of sexed bodies, understood as an MVP assemblage, maybe different to binary conceptions of them.

A trans lived experience as viewed through this lens is not mutually exclusive with any given sexuality (as attraction). To suggest it must be so, would be to reify an implicit “should” within a framing of purpose and prescriptive linguistics of Human Being, that limits human Doing (Deleuze 1994, 2015, Playdon, 2022, Serano, 2022). Therefore, those of us working in GSRD therapy and healthcare must remain mindful that such mutually exclusive prescriptivism risks a regression to isomorphic reproductive essentialism (eugenics) and a dogmatic epistemic fallacy, that would underpin systemic attempts at the denial and removal of any given difference (Deleuze 1994, Bhaskar, 2008).

We would suggest that thinking difference differently is fundamentally connected to the principle of judgemental rationality, and can function as a site of resistance, warding off the risk of a return to regressive dogma. We can apply judgemental rationality whilst remaining inclusive as it is essentially about considering how we might value difference, making sense of it whilst formulating a plan to work within it. Therefore, the invitation of this article is for practitioners to apply the concept of difference differently, locating it prior to the concept/identity/category, and not between. In so doing we open the door to recognising that our ideas about concepts, identities and categories need not be as fixed as we might previously have assumed. This allows for the possibility of emergent knowledge, and greater flexibility of approach, thus helping us to avoid the pitfalls of universalising normative binary positions. Were we not to do so, then the resultant collapse of the sex, gender and sexuality triad may result in superficial argumentation of expression rather than “Being”, which in the opinion of the authors, would be to miss the point of therapy entirely (Deleuze 1994, Butler, 1990).

Disclosure statement

No potential conflict of interest was reported by the authors.