Towards a more nuanced exploration: An interview with Sasha Ayad (4th Wave Now)

This piece originally appeared here, on 4thwavenow.

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 Sasha Ayad, M. Ed., LPC, is a Licensed Professional Counselor who works in private practice with teens and young adults who are questioning their gender. We interviewed Sasha via email for this post.

She uses an exploration-based approach to seek out underlying issues and help her teen clients move towards self-awareness, resilience, and long-term well being. She also conducts occasional consultations for parents whose teens present with gender issues first emergent around puberty.In a monthly newsletter, Sasha’s reflects on interesting psychological material, and relates it back to the phenomenon of a sudden presentation of gender dysphoria in adolescence. She also offers advice for parents as they guide and support their gender-questioning teen. Readers can sign up here to receive the newsletter and Sasha’s PDF on how to search for effective therapists and individualized treatment.Sasha has a full caseload and long waiting list, so is unable to take on new clients. However, Sasha offers a subscription-based Patreon account with videos designed to help parents engage in trusting and productive dialogue with their gender-questioning teen. _____________________________________

Tell us something about your background, training, and work as a therapist.

In undergraduate school, I studied psychology and history. My graduate program was focused in counseling psychology, or the clinical practice of therapy. I’ve worked in the field of behavioral therapy and mental health in Houston, Texas since 2005, and in a counseling capacity since 2008. I spent many years working with young children on the autism spectrum through applied behavioral therapy. In the field of domestic and sexual violence, I worked as an individual and group therapist with women and children. I also developed and ran the first counseling program at a state-supported residential facility for adults with intellectual disabilities and concurrent mental illness. In recent years, I worked as a school counselor for underserved populations at a top-ranking charter school. I am now working in my private practice full-time, based here in Houston. Most of my work is conducted online, and I see teen and young adult clients from all over the country and internationally.

I specialize in working with adolescents who are questioning their gender and most of my clients are female. I also conduct occasional consults for families who have children presenting with Rapid Onset Gender Dysphoria, and create content for my monthly newsletter and video series. I am a Licensed Professional Counselor (LPC) in Texas, and I hold a master’s degree in Education.

What specifically sparked your interest in working with adolescents and adults who have gender identity issues?

 My interest in this population developed and grew organically out of my own desire to better understand the growing phenomenon. When I was a young graduate student, my understanding of this issue was limited and I was marginally familiar with the conventional, textbook examples of childhood gender dysphoria: a person, who from a very young age, is completely convinced their body is the “wrong sex.” In these cases, the wrong body self-concept develops, seemingly independent of societal norms and environmental influences. I used to think, “what a strange and troubling experience: to really believe you have the wrong sexed body.”

Even back then, I did hold skepticism about this narrative, with its heavy reliance on gender-atypical preferences and behaviors supplying the “evidence” that the child is actually in the “wrong body,” and therefore needs to socially and medically transition, however outcome data shows some patients may benefit from a medical gender reassignment.

Around 2012 I began more deeply investigating this idea of gender identity out of personal interest and professional curiosity. Keep in mind, this was before the huge boom of trans-identified kids in the years to come. I started to wonder how things like socialization, gender norms, or even sexual trauma may play a role in the idea of the “wrong body.” I also became curious about the underlying suppositions of “gender identity”: that one’s “correct” biological sex or “authentic self” is always correlated with feelings of congruence between mind, spirit, and body (i.e. innate gender identity). Couldn’t “cis” also people feel varying degrees of gender/sex incongruity at times?

As time went on, I eventually discovered the work and writings of detransitioned people. I read about how quickly they were “affirmed” and shuttled towards a path of medical intervention, circumventing thorough evaluation or less invasive means of symptom-reduction, which are foundations of ethical therapeutic practice. I became very disturbed by what seemed to be a failure of mental health practitioners, who were responsible for their care, to look at these young people as whole and complex individuals. Were many in our field simply blind to the myriad factors, both social and subconscious, that might contribute to the feeling of being “trapped in the wrong sexed body?” I grew quite baffled that therapists were treating gender identity without any of the thoughtfulness, intuition, or even clinical curiosity typically afforded to other presenting problems – not to mention the care historically mandated by our psychological ethical standards. And looking at the sheer number of young girls suddenly adopting a trans identity around puberty, I became curious about this emergent population of gender dysphoric girls (and some boys).

I eventually stumbled upon this brilliant podcast interview with Lisa Marchiano, and my jaw dropped to hear another professional bravely speaking her mind and echoing some of the same fears I held. I reached out to her immediately and soon got connected with your work at 4thWaveNow, Transgender Trend, and many other resources for parents. Then in 2015, as a school counselor, I was required to take part in a training on “Supporting Trans and Gender-Diverse Youth.” To my disappointment (but not my surprise) the presenter (who was not a psychologist, but an advocate) completely failed to put forth a nuanced, thoughtful analysis, and even skirted issues when I brought them up during the training. I arranged several meetings with my manager at the time, the head of the counseling program – my goal was to present her with evidence of wider phenomenon and some of the less obvious problems with the unidimensional, non-scientific training we were receiving. She graciously and thoughtfully listened to my concerns but admitted that there was so much she didn’t understand about the changes in the LGBTQAI movement, and she felt it was important to continue developing our counseling program according to the gender identity activists.

I believe proponents of this affirmation narrative deliberately use “newspeak” and made-up language to confuse professionals into a state of self-doubt and subsequent willingness to dismiss their own intuition and clinical knowledge. And that’s exactly what might have happened to my manager, who is an incredibly brilliant, experienced, and competent social worker.

At that point I decided I would no longer take part in organizations that are committed to an activist cause rather than individualized, holistic, clinical perspectives on gender dysphoria. Schools are promoting this one-sided view unquestioningly to their mental health staff and to the children they claim to serve. I also realized there is a scarcity of therapists working with these children in a manner that adheres to comprehensive clinical standards. On the other end of the spectrum, some religious therapists seemed to avoid or discourage any type of gender and sexuality exploration, which is also not helpful to the client.

So, I decided to build the kind of therapy practice I thought was lacking for trans-identified youth. I started my practice part-time in 2016 and have been working independently in private practice full-time since July 2017.

Do you have a personal interest in this issue? Do you have relatives or friends who are affected by the current wave of transgender identifying children and adolescents?

Not until recently. A few years ago, when I worked as a middle school counselor, there was one child who was especially memorable; I spent much time with her, both as my counseling client and while chaperoning extracurricular activities during my three years at the school. She stood out from other students in multiple ways. Despite having many brilliant and creative peers, she excelled in so many disparate domains, being a fantastic sketch artist, dancer, writer, and academic learner. She had impeccable grades in every subject and treated her peers with kindness and fairness. She created incredible logos and t-shirt designs for clubs and school events, and played leadership roles in many campus groups: anime, drama, orchestra, art, and more. I have several beautiful pieces of art that she’s created for me over the years, mostly portraits of female characters, reminiscent of Japanese-style manga.

Her appearance was also creatively inspired: she experimented with various hair-cuts, styles, and colors, and expressed her own personal fashion sense (and progressive political leanings) through graphic jewelry and buttons on her messenger bag. I always praised her for carving out her own sense of style and individuality. She identified as bisexual at the time, and she was a great student-leader in my GSA club, showing initiative and often taking responsibility for large portions of our meetings.

I was always careful in how we navigated conversations about gender and gender identity and she seemed to be well-grounded in her own unique expression of female identity. She was never particularly feminine, especially as a seventh grader, when there is immense social pressure to look a certain way. She always had lot of friends, was overall quite happy, and she was just one of those kids I never thought I’d have to worry about. I imagined her starting a graphic design company one day, or maybe being a video game software engineer. Really, her options are limitless. I found out recently that she has come out as trans, and that she wants to transfer to a different school so she can start her new life as a “trans boy.”

In my hours and hours of being with her, she never expressed thoughts of gender dysphoria, though I do remember that once she drew a picture of a pensive “non-binary” character and “their” girlfriend. It feels like our best and brightest, our most creative and unique girls, are suddenly taking a detour as they devote a huge amount of energy and time to questioning their gender.

The kids I meet in private practice are first introduced to me in the midst of their gender concerns, but it’s quite profound to have known someone before the identity-change, when they were happy and full of life. To think that she’s now disconnecting from her female-self can feel quite perplexing. It seems that her parents have fully accepted the wrong-body explanation and claim to have “always known she was a boy.”

How would you describe your therapeutic approach?

I’m pretty explicit with my teen clients regarding what to expect in therapy, because I believe truth, honesty and trust are foundational aspects of any successful relationship, counseling included. I tell them something like this: “I’m different from ‘gender therapists’ you might have read about online because I won’t just meet with you one or two times then write you a letter for endocrinology.

I believe my job is to help you explore who you are on a much deeper level. First I’ll spend a lot of time just asking questions and listening so I can try to understand what’s going on in your mind, heart, and body. Then we will work together to figure out what your particular experience of gender dysphoria looks like, where it might have come from, and what we can try to reduce your distress.

In sessions, I’ll encourage both of us to ‘be curious’ about your experience because the more you can learn about yourself in counseling, the better you’ll be at thinking for yourself and making good decisions about your identity, your body, and your life. Sometimes counseling can be hard but we will work together to gently face the scary or painful stuff and see if you can learn more about yourself and grow bigger in the process. We can also look for ways to loosen the grip that pain or dysphoria has over your life so that you can have more options and be more confident.”

As for the specifics, my approach is highly tailored to the constitution, mindset, resilience, age, history, development, and maturity of each client. I always start with trust and initial bonding, which can be hard with some clients who have been taught that therapists should act as nothing more than GD diagnosis signators for top surgery or hormones. With more open clients, who are less defensive and more conversationally or intellectually predisposed, we might discuss their personal philosophy of gender identity and I give them space to sort through any doubts they might bring to the table. With other clients, who are in a more sensitive or fragile place, I may approach their identity indirectly, focusing instead on the underlying pain that is somehow finding relief in this new self-concept.

I also like to pragmatically examine how taking on a trans identity will play out regarding a client’s self-confidence, their ability to exist in the world, how they relate to family, friends, and so on. Sometimes I have to start somewhere very basic, like assessing if the teen even understands what the words “male” and “female” mean, if they know anything about sexuality (age-appropriate understanding), or what they know about their own bodies.

The ideas that influenced my perspective at this point are quite eclectic and not restricted to the field of psychology, though I’m deeply grounded in a back-to-basics, individualized, and holistic approach. I draw from Acceptance and Commitment Therapy, Cognitive Behavioral Therapy, behaviorism, social psychology, anthropology, history, and Taoism. More recently, I’m returning to a deeper exploration of psychoanalysis and Jungian analysis, which I find to be tremendously useful in making both micro- and macro- interpretations of what’s happening with my clients. I also work closely with parents while respecting the confidentiality of the teen client. Having calls with my caseload parents every six weeks or so has proven to be incredibly important to the therapeutic progress of the teen client. Teen accounts of family dynamics often gives me insights into how parents can deepen their relationship with their teen or engage in more effective communication with them.

I’ve had very good feedback from my teen clients regarding their feelings of safety in session and ability to express themselves. I often hear that teens feel a great amount of pressure from others to “pick a label” and that our sessions are nice because they can explore gender without it needing to be so concrete. At times, a young person’s gender identity may be playing an important role in their ability to exert autonomy or feel successful in social relationships. In cases like these, we might explore the new-found confidence a client has gained and locate it’s source within the client, rather than affixing it to the identity persona. This is just one example of how it’s possible to work with gender identity in a nuanced way that isn’t necessarily challenging or a literal affirmation.

Are you able to work across state lines, or must your clients be in the state of Texas?

Unlike clinical psychologists, LPCs can see clients in other states and outside the country, though I practice based on the regulations in the state of Texas. I make this clear in my initial consent conversations and documentation with new clients.

How has your your practice been going so far? Have you received any hateful or angry pushback? If so, how have you handled that?

Unfortunately there have been two separate attempts to formally attack my license, both of which I have responded to strongly, since they are gross mischaracterizations of my work. When people submit formal complaints to a licensing board about a practicing clinician, it’s most often a client or former client who feels maligned and harmed by a direct personal interaction. In the attacks made against me, however, it was other activist-clinicians who lodged the complaints.

One attack is from an activist with whom I’ve never even spoken, from the other side of the country. The other complaint was really shocking since it was submitted by a former colleague of mine with whom I felt a strong sense of mutual respect and camaraderie during our time working together. The lack of professionalism and integrity she displayed with this covert act of aggression has been very sobering. When colleagues don’t even attempt to reach out to one another and discuss their concerns, and instead go after someone’s livelihood, the profession itself feels degraded. In addition to these types of serious attacks, of course, common trolling and insulting comments on my social media accounts or blog posts happen occasionally. However, when I speak with people about my practice face-to-face, I am typically met with far more inquiry and curiosity than vitriolic responses.

Exceedingly the response I’ve gotten about my work from clinicians and parents has been positive. Therapists indicate that they find my work insightful and that it has helped them better treat their own gender-questioning teen clients. My approach is very much grounded in foundational ethics of clinical practice, so the fact that it’s sometimes called “controversial” should raise a red flag about the novel and unscientific recommendations being pushed by gender identity organizations (and now by the APA).

Do you believe there is such a thing as a “truly transgender” child or adolescent? Why or why not?

It’s hard to answer a question when the terms of each word haven’t even been defined well. There’s no definition for “transgender” that isn’t completely circular in logic. Perhaps a better question is, “are there some children for whom the benefit of social and medical transition outweighs the risks”? Or maybe, “are there some children who, in order to live vital meaningful lives, must live in the gender role of the opposite sex”?

To cover all my bases, let me include a question the gender therapist might ask too: “if a child is threatening to kill themselves, isn’t it better to support their transition?” My answers for adults would look very different, because I do believe that for some, a transgender identity and transition are a means of true individuation and authenticity. For children, however, let me tailor these questions a bit.

1. “Are there some children for whom the benefits of social and medical transition outweigh the risks”? If by “risk” we mean feelings of body discomfort or incongruence, then trying to prevent that risk seems impossible. Discomfort and biological limitations are ubiquitous and necessary aspects of human experience, and it’s always been true that body discomfort is particularly acute in adolescence. The struggle associated with changing social roles around femininity and masculinity, hormonal and physical changes of the body, independence and safety, social cohesion and isolation, assertiveness and passivity, and every other fundamental human developmental endeavor requires us to grapple with our own pain and limitations. Without that struggle we don’t develop resilience, we don’t learn about ourselves, and we don’t learn anything about living in the real world as it is, materially or socially. With the growing evidence that social contagion plays a role in puberty-onset gender questioning, we should be exceptionally cautious before medicalizing any kind of identity exploration. That being said, it may be that classic cases of absolute insistence on being the opposite sex from the age a child could walk and talk are a different story. Of the hundreds of families I’ve talked to, only a few of them have kids whose gender dysphoria started in early childhood. Perhaps those families are more comfortable with medically transitioning their children, so they don’t contact me as much. Since I’ve not really worked with those kids, I don’t feel I’m qualified to prescribe their best treatment.

2. “Are there some children who, in order to live vital meaningful lives, must live in the gender role of the opposite sex?” A “good life” doesn’t come from never experiencing discomfort, or conversely from always being perfectly comfortable, which I addressed in the previous question. But perhaps someone assumes that a girl who prefers or expresses strong masculinity would do better living “as a boy”? Are certain traits or behaviors literally incompatible with being a female in society, or a man in society? Well, what does this say about our capacity to broaden independence and make room for personal preferences? And if someone does take on non-conformist roles, should they not also develop the personal resilience and emotional fortitude to stand firm in their own presentation with strength and individuality? I think there’s something inherently flawed about expecting all of society to completely abandon every aspect of our historically stable gender roles and it’s also flawed to say there’s no room for individuals to choose how to express themselves on the spectrum of femininity and masculinity. I would like to emphasize again that adults should be free to explore a medical gender transition as an option, but may also find it meaningful to consider these interesting questions for themselves.

3. “If a child is threatening to kill themselves, isn’t it better to support their transition?” If a child is threatening to kill themselves, we should take a huge pause and think of the big picture. The most empathetic thing we can do initially is to listen with care, but we, as adults, also need to determine if this child is thinking clearly. Since when do emotionally unstable, demanding children get to use threats to dictate decisions as important as fertility and surgery? Furthermore, if a child is that disturbed or troubled, then they are clearly in no position to make good choices about their long-term well being. The use of this threat by some advocates is incredibly manipulative and has no precedent whatsoever in the field of psychology. Over the last ten years, I’ve worked with dozens of young people who are actively struggling with self-harm and making suicidal statements (whether related to gender identity or not). These behaviors can serve many functions, not the least of which are expressing psychic pain, gaining attention and care from adults, or trying to manipulate people in power into making a concession of some sort. Children who haven’t developed the emotional or relational tools for self-soothing will use any means necessary to express pain and gain what they are seeking. I don’t mean to deride a child’s methods; she’s doing the best with what she has at the time. But these are reflections we must take very seriously as clinicians. So giving into these types of threats does far more harm than good for the child. We need to instead, conduct thorough risk assessments, create conscientious collaborative safety plans with the child and family, and work through underlying issues if we really care about the child’s safety and well-being (as therapists have always done with suicidal ideation).

In the current atmosphere, professionals who question the “affirmative” approach to therapy for trans-identified kids may be risking their careers. Do you think the concern is overblown?

This is a touchy area so I want to start by saying that I can understand the pressures therapists feel from their institutions to make politically favorable choices and statements. Many clinicians also have their own family to be responsible for and feel financial pressures to not “rock the boat.” In recent times, some professionals have been demoted or sanctioned for sharing their clinical impressions, which indicates a horrific direction our field is headed down. However, we have all taken vows of high ethical standards and we are responsible for making sure the work we do reflects our professional integrity.

Personally, as I’ve considered this question, I find myself asking: what’s the point of having a career based on helping others if you have to lie every day about harm that’s being done? And what does the collective and cumulative impact of lying and silence about this issue amount to in the long run? Honestly, I don’t know what is going to happen in the next five, ten, or twenty years. In recent times whenever skeptical, intelligent, and nuanced articles about transgender children appear, there’s often a dangerously aggressive and thoughtless effort to dismiss and diminish important arguments. The way things are going, I would not be surprised if things “get worse before they get better.” That being said, I am not worried about the work I’m doing because I believe it to be the right thing to do. Standing up for ethics is easy until it’s not. I am deeply committed to standing up for individualized treatment, nuanced assessment, and a least-invasive-first approach, even if that means it puts me at some personal/professional risk. I strongly encourage other clinicians to speak the truth and be honest about what they are seeing in their clinical practice. Complicit silence only makes more room for oversimplified caricatures of our patients, and in the end, the gender-questioning teens will be the ones who suffer from our lack of nuance as professionals. What will it take for more therapists to come out publicly in offering alternatives to the transgender-affirming approach to therapy?

Individuals clinicians should be thinking more broadly about adolescent psychology, questioning suspicious claims carefully, educating themselves on multiple perspectives, and finally, acting with honesty and courage. Because when I talk with most therapists one-on-one, there’s a deep intrinsic knowing that the field has spiraled out of control with regards to childhood transition, but people are afraid to even think deeply about it, question claims, seek out knowledge, or speak up.

The APA has issued “guidelines” for the treatment of what they term TGNC clients (transgender gender nonconforming). Though not binding, these guidelines are nevertheless considered “best practice.” Do you agree with them? If not, how does an APA member go about recommending changes to them?

I am not an APA member, since I am an LPC (Licensed Professional Counselor), and not a clinical psychologist. However, the APA is a powerful organization and their guidelines are looked to as aspirational principles which have significant impact on how therapy is informed and practiced. I disagree with the guidelines and believe they violate some of the most basic ethical standards, including beneficence, avoidance of maleficence, fidelity and responsibility. I believe the infiltration of political ideology into non-political organizations is the main confounding element in the organization’s ability to adhere to these professional values.

Regarding TGNC, some trans activists have essentially co-opted gender nonconformity under the “trans umbrella.” Who does that leave? No one is 100% “conforming” when it comes typical gender expression. As you know we at 4thWaveNow support such gender atypicality in our kids, but we strongly resist the notion that this means they are somehow “transgender.”

I agree – even trying to amalgamate “gender non-conforming” people into some semblance of a group is an impossible task since, like you said, no one is 100% “conforming.” We all exhibit traits of masculinity and femininity, and it’s absurd to try and find some line that constitutes “cis” and “trans” – according to some of the definitions of those terms floating around. I believe concept creep is also playing an important role in how the definition of gender dysphoria has been broadened so dramatically in scope.

What are your views on the possible influences of parenting dynamics on children identifying as transgender?

It’s becoming harder and harder for parents to keep their children safe from questionable beliefs about gender, since they have infiltrated our medical and educational institutions. But I do recommend some possible means by which parents can safeguard their kids:

1. Due diligence in being aware of the types of ideas being taught at your child’s school: from early elementary all the way up to university. I know that’s a daunting task!

2. Do what you can to monitor your child’s internet use and actively talk with them about some of the ideas they come across. Engage your child and really listen: let them share their thoughts, use that time to gather information and establish safety around certain touchy topics. Then engage them in thoughtful, critical, and deep analysis (in an age-appropriate and thoughtful manner). As a side note, I never imagined myself to be someone recommending an invasion of your child’s privacy; I’ve always been quite open-minded. But spending too much time online has proven to have very dangerous potential, so the long-respected parental role of boundary-setting and limit creation is crucial here. For young teens, temporarily monitor their internet use to get a sense of what material they are viewing frequently. This will help you gauge what you need to attend to or talk about. In general, the more you can keep them offline, engaged in fun, social, real-life 3D activities, the better. Go outside together, leave your phones at home, go for hikes, take them fishing, and just generally reestablish a connection to the natural world.

3. Help them regulate their eating and sleeping cycles, which play a crucial role in mood and depression. Sometimes kids stay awake, staring at a screen all night, filling their mind with anxiety-producing content. Set their bed-times, take their phones away overnight, and make sure they eat regularly and get plenty of physical exercise, real-life play, and social interaction (I know it’s easier said than done).

4. Have a clear sense of your own family’s values and moral direction. What do you believe in? What ultimately guides your decisions, behaviors, beliefs, etc? How do you create meaning in life? Give them a strong foundation based on your own belief system. Model what you want them to learn. Don’t be dogmatic, but help them make connections to what is true and supports their long term well-being. Even if they explore other ideas in their teenage years (which is part of their own individual morality-development), having a loving stable foundation gives them something to come back to or build upon.

5. Don’t obsess over gender, but also don’t try to pretend it’s completely irrelevant. Set boundaries around any kind of physical manipulation or medical intervention. Binding breasts is a physical manipulation which can be harmful in the long run. Hormones and surgery should be off the table for children. But don’t get hung up on haircuts or clothing.

6. Don’t argue with your child about whether or not they are “actually trans.” Don’t bother thinking back about their childhood, wracking your brain for “signs” of being different or non-conforming. A more pragmatic framing is to think about the real discomfort they are having, and ways to deal with it that don’t require completely transforming into a new person. That being said, take the time to really listen to the gripes they have with their sex roles, social problems, or body discomfort. They likely have some very poignant observations and ideas to share if you can get past scripts and jargon.

7. Don’t be afraid of emotions (your own or your child’s) in conversations with your teen. I’m not sure if this is a cultural thing, but I’m sometimes surprised by how afraid parents are that they might upset their child. I come from a family and culture in which open expression of emotions is very common and I have found it can be very healing when done carefully. Being honest about what you think is incredibly important, and deep emotional talks with your child are going to get turbulent – and that’s ok. It’s necessary to tell your children the truth, disagree, and show your own vulnerability. Go ahead and lovingly explain how you see things, while knowing that their feelings are real and important too. They need to hear the truth from someone who really loves them, because they aren’t going to get the full picture from friends or the internet.