This programme is a treatment manual written for mental health professionals. It assumes clinical training, experience of working with adolescents and families or with adults, knowledge of gender identity issues, and a supervision framework. It replaces neither your clinical judgement nor your professional and ethical responsibility, and it does not make you competent either to establish a medical indication or to prescribe. Diagnostic criteria are reformulated in our own words and never reproduced: refer to the original manuals for the wording itself. It is not written for the people concerned or for those close to them. And if you are thinking of dying, contact your country's emergency services or a helpline today.
1. The programme at a glance
Indication. Adolescents, from puberty onwards, and adults who seek help for distress related to gender identity: suffering around the body, around how others see them, around a questioning that finds no way out, decisions to be made or discrimination endured, often accompanied by depression, anxiety, an eating disorder, trauma or autistic characteristics. For adolescents, four sessions are for the parents.
What the programme aims for. Exploratory and non-directive psychological support, that is, support that helps the person understand what they are experiencing without deciding in their place what they should conclude from it. It relieves distress, treats the associated difficulties with evaluated methods, and supports the person in their own decisions, whatever they may be.
What the programme does not aim for. It aims neither to change the gender identity of the person nor to steer them towards transition. Seeking to change gender identity would be a conversion practice, contrary to ethics and banned in France by the law of 31 January 2022 (section 3). Steering towards transition would amount to deciding for the person on a path whose medical decisions belong to doctors and whose life choices belong to the person. The work bears on distress and on functioning, not on identity, which is not treated as an illness.
Reference model. A comprehensive assessment, then a three-level formulation taken from the final report of the independent Cass Review (Cass, 2024) and applied here to adults as well: first what puts the person in danger, then the distress and the associated difficulties, and finally a plan built with the person for the gender questions (section 7). The associated difficulties are treated with the cognitive behavioural therapy (CBT) specific to each, and the weight of discrimination with the minority stress model (Meyer, 2003; Hendricks and Testa, 2012), described in section 6.
Format. Twelve individual weekly sessions of 50 to 60 minutes, to which are added, for adolescents, four 50-minute sessions with the parents: sixteen sessions in all for an adolescent, twelve for an adult, then three booster sessions, at one, three and six months. No trial has established the right number of sessions here, because psychosocial interventions in this field have been little and poorly evaluated (Heathcote et al., 2024); the format draws on the site's manuals on anxiety and depression, setting aside three sessions for assessment and formulation. This programme is not a precondition for any medical care: it does not give a green light, and its length does not count as a waiting period (section 13).
Mechanism targeted. Reducing what keeps the distress going: untreated associated difficulties, body-related avoidance, the anticipation of rejection and costly concealment, urgency or paralysis in the face of decisions, and family conflict. Giving the person back enough functioning and enough freedom of thought to decide for themselves, at their own pace, knowing what is known and what is not.
| Session |
Focus |
Session output |
| 1 |
Welcoming, making safe, setting the frame |
Name and pronouns noted, risk assessed, baseline measures |
| 2 |
The history and the request |
History heard, goals rated, main difficulty chosen |
| 3 |
The formulation and the plan |
Three-level map, session plan |
| 4 |
The associated difficulty: understanding and starting |
First step taken, record in place |
| 5 |
The associated difficulty: continuing |
Three steps taken, obstacle worked on |
| 6 |
The body: distress and safety |
Avoidance sorted, safe practices |
| 7 |
Minority stress, and the mid-point review |
Prediction tested, measures repeated |
| 8 |
Exploring without steering |
History reread, open questions written down |
| 9 |
Deciding: information, options, values |
Map of options, questions for the doctor |
| 10 |
Telling, or not telling |
A disclosure plan, or a decision not to tell |
| 11 |
Session with someone close |
What helps, said together |
| 12 |
Review, plan and next steps |
Measures repeated, written plan, boosters scheduled |
| Parent session |
When |
Focus |
| P1 |
Before session 1 |
Assessment, frame, confidentiality, safety at home |
| P2 |
After session 3 |
What is known, what is not known, how to respond |
| P3 |
After session 8 |
Decisions: school, name, medical questions |
| P4 |
After session 12 |
Review and next steps, partly with the adolescent |
What the person takes away. Nine printable worksheets, listed in section 40: my record, my map, my safety plan, my steps for the week, what I fear and what actually happens, my history and my questions, deciding at my own pace, the corner for parents and those close to you, and my plan for what comes next.
What distinguishes this programme from the other manuals on this site. Three things. It supports a question that is not a disorder to be made to disappear: what has to come down is the distress, not the incongruence. It moves forward in a field where the research is disputed and often of low certainty, and it presents the positions without deciding beyond the evidence (section 9). And it clearly separates the role of the psychologist, who assesses, treats the associated difficulties and supports the decision, from that of the doctor, to whom medical decisions belong (section 13).
2. Before you begin
The four preliminary decisions
Is there a current danger? Suicide risk, self-harm, violence at home or at school, rejection that threatens housing, hormones taken without medical follow-up. This comes before everything else (section 11).
What is the person asking for, and what are others asking for? Section 4 distinguishes the four entry situations, which do not call for the same work.
Who decides what? For a minor, treatment requires the agreement of those with parental authority, according to the law of the country, and the young person's own engagement, which is something else. Medical decisions belong to doctors, with the person and, for a minor, with their parents; life choices belong to the person. Your role is to treat the distress and to inform the decision, not to make it.
Should an associated difficulty come first? Severe depression, an eating disorder with physical consequences, a psychotic disorder or heavy substance use are treated first or in parallel, with their own protocol and often with a doctor (section 10).
What this programme does not treat
Children before puberty. The questions are different there, in particular that of early social transition (section 9), and support goes first through the parents and a specialist team.
Assessment with a view to a medical indication. Within a team assessing a request for hormones or surgery, this manual helps to conduct the psychological part, but the indication procedure is a matter for the team and the doctor (section 13).
A severe associated difficulty, on its own. It starts the treatment and refers to the dedicated manual when more is needed (section 33).
How to use it
Read the whole manual before the first session, in particular sections 3, 7, 9, 11 and 30: the position, the model, the state of knowledge, safety and how to conduct the exploration. Each session follows the same framework: the aim, the steps, what you say, the common errors and the criterion for moving on.
Two warnings specific to this indication.
Your neutrality will be tested from the first session. The person will wonder whether you want to make them change; parents will wonder whether you are going to "encourage it". The answer is the same for everyone, and it is given in session 1: this work has no preferred outcome.
Gender distress does not explain everything, and it is not nothing. You can attribute everything to gender identity and leave a depression untreated, which the Cass report calls diagnostic overshadowing (Cass, 2024); you can also attribute everything to another difficulty and never listen to the gender question for its own sake. Both errors are common.
3. A position: exploring without steering
What French law says
French law no. 2022-92 of 31 January 2022, prohibiting practices aimed at changing a person's sexual orientation or gender identity, created two offences. Article 225-4-13 of the Code pénal (the French Criminal Code) punishes "practices, behaviour or repeated remarks aimed at changing or repressing the sexual orientation or gender identity, real or supposed, of a person and having the effect of impairing their physical or mental health", with heavier penalties in particular when the victim is a minor. Article L. 4163-11 of the Code de la santé publique (the French Public Health Code) punishes "giving consultations or prescribing treatments while claiming to be able to change or repress the sexual orientation or gender identity, real or supposed, of a person".
Both articles provide for the same exception, in similar terms: the offence is not constituted when "the repeated remarks merely invite caution and reflection" (Criminal Code), or when "the health professional merely invites reflection and caution" (Public Health Code), "having regard in particular to their young age, the person who is questioning their gender identity and who is considering a medical pathway aimed at a change of sex". The law thus distinguishes what is prohibited, seeking to change or repress an identity, from what is permitted, inviting reflection and caution before a medical decision. This manual stays on the permitted side, without using it as a pretext: inviting reflection does not mean suggesting a conclusion.
What the guidelines say
The Standards of Care of the World Professional Association for Transgender Health, in their eighth version (WPATH, the international professional association that publishes these standards; Coleman et al., 2022), recommend facilitating the exploration and expression of the adolescent's gender openly and respectfully, "so that no one particular identity is favored", and not offering conversion therapy. The Cass report, commissioned by NHS England, writes that the intention of psychological intervention is not to change the person's perception of who they are, but to explore their concerns with them and to relieve their distress, whether or not they go on to a medical pathway, and that equating this approach with conversion would deprive young people of the support they deserve (Cass, 2024). The Haute Autorité de santé (HAS, the French National Authority for Health), in its guideline on adults, recalls that conversion therapies have been shown to be harmful and are prohibited, and that gender identity should not be the subject of a specific psychiatric assessment (Haute Autorité de santé, 2025).
These sources diverge on many points (section 9). They agree on this one: the psychologist does not seek to change an identity, and does not impose one either.
The debate over the word "exploratory"
For some clinicians, exploratory psychotherapy, "neither affirmation nor conversion", should be the first treatment offered to any young person with gender dysphoria (D'Angelo et al., 2021). For others, "gender exploratory therapy" discourages affirmation in favour of a search for the supposed pathological roots of a trans identity, and bears strong similarities to conversion practices (Ashley, 2023). The Cass report observes that the words "affirmative" and "exploratory" have become weapons in a polarised debate (Cass, 2024). This manual takes neither side; it defines what it means by exploring.
What "exploring without steering" means
Exploration has no preferred outcome. A person who concludes that they are trans, that they are non-binary, that they are not, or that they do not yet know, has equally succeeded in their exploration. Failure would be a decision taken under pressure, wherever that pressure comes from.
You explore the experience, not the legitimacy. You ask what the person is going through, since when, what they hope for and what they fear. You ask them neither to prove that they are "really" trans nor to set their doubts aside.
Associated difficulties are treated for their own sake, openly. A depression or a trauma is treated because it causes suffering, not to test an identity, and you never investigate covertly (section 30).
The symmetry rule. Before a question that bears on identity, ask yourself whether you would put it in the same way to a person describing the opposite path. If the answer is no, the question steers. This is a rule of this manual, not a research finding, and it is the simplest tool for maintaining neutrality.
Vocabulary
Use the name and pronouns the person gives you, when speaking, in writing and in the record, as the HAS recommends to all professionals (Haute Autorité de santé, 2025). It is a condition of the alliance, not a position taken on the outcome.
This manual uses "trans person" for a person who lives or identifies in a gender different from the one associated with the sex observed at birth, "non-binary person" for a person who does not place themselves, or not only, in one of the two categories, "sex assigned at birth" for the sex recorded at birth, and "questioning person" for a person who does not yet know. "Gender dysphoria" refers to the DSM-5-TR category, which bears on distress, and "gender incongruence" to the ICD-11 category (section 8). Ask the person for their own words, and use them.
4. Four entry situations not to be confused
1. An affirmed identity, and another kind of suffering
What you observe. A trans or non-binary person, whose identity is settled, seeks help for depression, anxiety, exhaustion, a break-up or the aftermath of an assault.
What this implies. You treat the difficulty they have come for, taking into account the minority stress that may be maintaining it, and you do not open an exploration of identity that they have not asked for. Many have met clinicians who brought everything back to their identity, or who on the contrary looked for "any other reason"; the Cass report records both complaints (Cass, 2024).
2. An open questioning
What you observe. A person, often young, who does not know, who "needs to be sure", who oscillates, or who suffers from their body without knowing what they will do about it.
What this implies. A space for exploration with no deadline imposed by you, and support for decision-making when a decision comes up: these are sessions 8 and 9.
3. An adolescent and parents caught off guard or in disagreement
What you observe. A recent announcement, a family in crisis, arguments about the name, school or a medical appointment. Often the young person wants to be recognised and left in peace, and the parents want to understand, to buy time or to be reassured.
What this implies. The parent module becomes central (section 28), confidentiality is addressed from the first meeting (section 15), and safety at home is checked (section 11).
4. A transition reconsidered
What you observe. A person who is interrupting a social or medical transition, regrets it or is questioning it, because their identity has changed, because the social cost is too heavy, because a medical effect troubles them, or because they no longer know.
What this implies. A welcome without judgement, an exploration of the reasons, screening for pressure and violence, and medical referral if physical effects are involved (section 34).
The three sorting questions
"What brings you here today, and what do you expect from these sessions?" It places the person among the four situations.
"What would you like me to call you, and what pronouns should I use?" Asked of everyone, it says from the outset that you are presuming nothing.
"What is weighing on you most at the moment?" It brings things back to the current distress, which is the indication for the programme.
5. What people describe
The five dimensions of distress
Body-related distress. A discomfort, sometimes acute suffering, in the face of certain sexed characteristics, present or anticipated: the chest, the voice, body hair, periods, the genitals. It shows in avoidance, of the mirror, the shower, sport, intimacy, photos, and sometimes in practices that alter appearance, such as chest binding. It varies a great deal from one person and from one moment to another.
Social distress. It comes from being called by a name one no longer recognises, from being misgendered, that is, referred to by a gender that is not one's own, or from having to explain oneself. It depends largely on the people around the person.
Questioning and uncertainty. The person does not know, or knows without knowing what to do with it. Uncertainty often becomes rumination: "what if I am wrong", "what if I wait too long". Others live with a long-standing, peaceful certainty, and it is their environment that weighs on them.
Stress related to discrimination. Harassment, rejection and violence weigh heavily, as do the fear of suffering them and the fatigue of hiding. The HAS recalls that the trans population faces an excess risk of violence and of precarity, and discrimination in access to care (Haute Autorité de santé, 2025).
Associated difficulties. Depression, anxiety, eating disorders, self-harm, trauma, autism or attention deficit disorder. They are common (section 10), and they are often what causes the most suffering at the time the person seeks help.
What varies
When the question arises. For some, from early childhood; for others, at puberty or later, with no visible earlier sign. The Standards of Care note that clinics are seeing more adolescents with no gender diversity expressed in childhood, and more non-binary identities (Coleman et al., 2022). The Cass report considers that gender expression depends on a variable mix of factors, such as a biological predisposition, early childhood experiences, sexuality and the expectations linked to puberty, that peer influence is strong in adolescence, and that the effect of online experiences remains poorly understood (Cass, 2024). No trajectory, on its own, tells you what the person will become.
What the person wishes for. Some trans people wish for no medical care, others for some and not for others; the HAS observes that there is no standard pathway (Haute Autorité de santé, 2025).
Stability over time. In adolescents, the Cass report writes that identity is not always fixed and may evolve, and that neither the diagnosis nor clinicians can reliably predict which young people will have a lasting incongruence (Cass, 2024). That is a reason to take time, not a reason to doubt what the young person is saying today.
What is particular to adolescence
Puberty makes body-related distress more acute, because the body changes without having been chosen. Adolescence is also the age at which people explore their identity in general, when peers matter a great deal and gender stereotypes weigh heavily; the Cass report recalls that exploration is a normal process at this age (Cass, 2024). And the adolescent depends on their parents, whose reaction makes up a large part of their distress or of their protection.
Strengths
Clear-sightedness about oneself, the courage it took to speak, the ability to find support, often a connection with other people going through the same thing: in a large survey, peer support attenuated the link between stigma and distress (Bockting et al., 2013). Look for the person's strengths in their life, not in a list.