Paper Summary Therapeutic Models 2019

Towards a Gender Exploratory Model

Slowing things down, opening things up, and exploring identity development — Anastassis Spiliadis (2019)

Full citation: Spiliadis, A. (2019). Towards a Gender Exploratory Model: slowing things down, opening things up and exploring identity development. Metalogos Systemic Therapy Journal, Issue 35.
Author: Senior Systemic & Family Psychotherapist, Gender Identity Development Service (GIDS), Tavistock and Portman NHS Foundation Trust, London.
Source PDF: View original PDF

A Tavistock (UK) clinician argues there is a third way between rushing to affirm a trans identity and attempting to change it — a "Gender Exploratory Model" (GEM) that slows things down and explores the broader meaning of a young person's distress before any irreversible medical decisions.
Neither "just affirm" nor "try to fix" is adequate. Pure affirmation can bypass important developmental questions; reparative approaches are harmful and unethical. GEM sits between those poles.
The model involves the whole family in extended assessment (not just the young person) and explores bullying, sexuality, online influences, and identity development alongside gender questions.
A detailed case study shows a 15-year-old who arrived certain of a transgender identity and wanting immediate hormonal treatment — and after ~18 months of exploratory work, chose not to pursue medical transition and returned to using his birth name and male pronouns.
For parents: slowing down is not the same as blocking. Exploration is not conversion therapy. Your voice and perspective in the room matters.

Why this paper matters

This paper was written in 2019 by a clinician inside the UK's GIDS at Tavistock — at the time the world's largest gender identity clinic for children and adolescents, and subsequently subject to the critical Cass Review (2024). It is notable because the author was working within the system and arguing, from the inside, that the field was moving too fast and needed a more thorough, exploratory framework.

The paper offers a theoretical model and a worked clinical example. It is not an outcomes study, but rather a practitioner-level framework paper — describing how exploratory therapy with gender-questioning youth can be conducted ethically without being either affirmative-by-default or reparative.

The problem: two bad poles

Spiliadis identifies two dominant approaches in the field that he considers inadequate on their own:

1. The gender affirmative model

This approach, initially developed in the USA, actively affirms the young person's stated gender identity and supports early social and medical transition on the basis of the young person's "privileged access" to their own gender experience. In practice, this often means:

Taking the young person's self-diagnosis as authoritative
Moving quickly toward hormonal interventions (GnRH analogues / puberty blockers, then cross-sex hormones)
Treating exploration or questioning as inherently harmful or invalidating

Spiliadis does not describe this as malicious, but he challenges the assumption that speed equals compassion. The model does not adequately account for the complex, heterogeneous presentations increasingly seen in clinical practice.

2. Reparative / conversion approaches

At the other pole, some practitioners have historically attempted active therapeutic interventions designed to change the young person's gender identification — "therapy" aimed at making them accept their natal sex. This approach is explicitly condemned across the UK's healthcare establishment as unethical and harmful, and is covered by the Memorandum of Understanding (MoU) against conversion therapy signed by NHS England, UKCP, and others.

Spiliadis is clear: he is not proposing this. He notes that the MoU itself explicitly allows psychotherapy that helps people "explore therapeutic options to help them live more comfortably," as long as the clinician is not actively "guiding" toward a specific identification.

The Gender Exploratory Model (GEM)

GEM is framed as a systemic-developmental approach — grounded in family therapy and systemic practice, and attentive to the young person's developmental stage. Its core commitments:

Respect, but don't rush. Acknowledge and respect the young person's expressed gender identity without treating that expression as the end of the inquiry.
Embrace uncertainty. Clinicians and families do not know how a young person's identity will develop. "Safe uncertainty" (Mason, 1993) is the appropriate clinical stance — holding open multiple possible futures without prematurely closing them.
Explore broadly. Gender-related distress does not exist in isolation. It intersects with sexuality, bullying, peer relationships, online communities, family dynamics, cultural background, and broader adolescent identity development. All of these deserve space.
Involve the family. Most assessment sessions include parents or carers. Parents' perspectives and concerns are treated as clinically important, not obstacles.
No pre-set destination. The therapeutic process does not aim for a specific outcome — not "trans" and not "cis." The aim is that the young person reaches a more richly understood sense of themselves, and can make informed decisions.

Three domains of clinical action

Spiliadis borrows a framework (Lang, Little & Cronen, 1990) to describe how GEM operates in three domains:

Production — the practical assessment process: preferred names, pronouns, care planning, and the young person's stated wishes for medical transition. This domain is taken seriously; it is the legitimate presenting concern.
Explanation — exploration of meaning: what does the gender distress mean to this young person? How does it connect to their history of bullying, their emerging sexuality, their family relationships, their online communities, their cultural context? This is where the depth work happens.
Aesthetics — how the clinician explores: the language they use, how they hold uncertainty, how they avoid foreclosing identity. For a 5-year-old, using "trans" as a fixed identity label may be inappropriate; "gender questioning" keeps more possibilities open. Clinicians' own positionality (gender, culture, professional role as gatekeeper) is made transparent to the young person.

The case of "Peter" — a detailed illustration

Spiliadis presents an anonymised case that illustrates GEM in practice. This is the most concrete and useful section of the paper for parents to understand what the model looks like on the ground.

Who Peter was at referral

Peter (referred as "Louise") was a 15-year-old male-bodied young person referred to GIDS by a school counsellor. Peter had socially transitioned — using a new name, wearing stereotypically feminine clothes, experimenting with make-up, having obtained a legal name change via deed poll. Peter's parents were fully supportive and had consented to the name change. Peter was certain he was trans, certain he wanted oestrogen and eventual surgery, and was frustrated to have to go through a lengthy assessment instead of being fast-tracked to medical treatment.

What the exploratory work uncovered

The assessment consisted of 11 sessions (8 family-based, 3 individual) over 12 months, followed by 7 individual sessions over a further 8 months — approximately 20 months in total.

Online diagnosis. Peter had first shared distress online, with a US-based trans-affirmative community. That community told Peter he "must be trans." Spiliadis notes: the initial "diagnosis" was given by strangers online — not a professional.
Body-specific distress. Peter's primary dysphoria was about body hair. Spiliadis helped Peter explore non-medical options; laser treatment alleviated much of this distress and — crucially — slowed down the urgency to medically transition.
Bullying and homophobia. Through exploring the timeline and context, it emerged that Peter had experienced sustained homophobic bullying at school for gender non-conformity (interest in clothes, make-up). This had caused significant shame — and Peter had never disclosed it to his family.
Sexuality conflated with gender identity. Peter had avoided exploring sexuality, connecting it to the bullying shame. Gradual exploration revealed that Peter found pleasure in masturbation/ejaculation as a male body and had fantasies — but had concluded that medical transition was the only possible path to future intimacy and connection.
The family's "one-down" position. Peter's mother "occupied a one-down position" — she felt unable to express her own view and would support Peter in any decision. Spiliadis names this dynamic and works with it: a parent who cannot voice their own perspective is not actually serving the young person's best interests.

How it ended

Shortly after his 17th birthday, Peter came to a session with his hair cut short and without make-up. He reported having had a first intimate experience with another male-bodied young person, which he described as an important developmental step. He spoke about wanting to explore a more fluid identity rather than a stereotypically female one, and asked to pause his referral for hormonal interventions. In the final session, he asked Spiliadis to use his birth name and he/him or they/them pronouns. A 6-month review was planned, and discharge was anticipated.

"When asked what enabled him to understand himself in a different way to how he initially presented to GIDS, Peter spoke about the invitation from the GIDS to explore the meaning of his multi-layered identities. He was able to share how his initial frustration around the staged approach of our interventions was gradually alleviated by him feeling understood and listened to in the consulting room."

Key findings & takeaways for parents

What this paper argues parents should know:

Slowing down is not rejection. The extended assessment felt frustrating to Peter and his family — but it was what allowed Peter to arrive at genuine self-understanding rather than a premature medical path. The staged approach, done with care and respect, is not a barrier to care; it is care.
Online communities can be powerful but misleading. Peter received an informal "diagnosis" from strangers online before ever seeing a professional. That framing then dominated his understanding of himself for years. Parents should understand how formative these early online framings can be — and that they are not clinical assessments.
"Supporting any decision" may not be support. When a parent is in the "one-down" position — deferring entirely to the young person and feeling unable to express their own concerns — the young person loses access to genuine parental perspective. A parent's honest (loving) concern is part of the young person's relational world and deserves space in the room.
Comorbidities matter. Bullying, shame, sexual identity confusion, autism-spectrum traits, and mental health difficulties are all frequently present alongside gender distress. These are not proof that a trans identity is "wrong," but they can be important drivers of distress that deserve therapeutic attention in their own right.
Symptoms of gender dysphoria do not automatically predict a transgender identity. Body-related distress in adolescence can have multiple meanings. For Peter, much of the urgency around medical transition dissolved when he was helped to understand his own history more fully.
Gender identity and sexuality can be confused. For some young people — particularly those who have experienced homophobic bullying — the trans identity narrative can become entangled with emerging same-sex attraction. Exploration of sexuality is an important part of gender identity work, not a separate question.
The "hormone blocker as pause" framing has limits. Spiliadis cites Giovanardi (2017) noting there is genuine uncertainty about whether GnRH analogues simply "buy time" or whether they "arrest wide-ranging physical and emotional development." There are also "unknown unknowns" about how suppressing libido during early adolescence affects future intimate development.

Limitations and caveats

What this paper is and isn't.

This is a practitioner framework paper, not an outcomes study. There is one case example, not a cohort. It cannot tell us what proportion of gender-dysphoric young people would arrive at a similar place to Peter if given exploratory therapy.
Spiliadis explicitly acknowledges he is not claiming universal application — some young people have genuine, persistent gender dysphoria from early childhood that GEM will not "resolve."
The paper was written in 2019 from inside a service (GIDS/Tavistock) that was subsequently closed following the critical Cass Review (2024), which found the evidence base for paediatric gender medicine inadequate and called for a more cautious, exploratory approach. In retrospect, Spiliadis was raising concerns about the direction of the field that were borne out.
The paper is written primarily for clinicians, not families. Some sections (Domains of Action, systemic theory) are specialist clinical language that can be safely skimmed by parents.
It does not take a position on whether gender-affirming treatment is right for some young people — only that rushing to it without adequate exploration is problematic.

Connection to the broader evidence

This paper fits within a growing literature arguing for more thorough, exploratory assessment before medical intervention in adolescent-onset gender dysphoria:

The Cass Review (2024) reached similar conclusions at the system level — calling for more caution, longer assessment, and better evidence before prescribing blockers or hormones.
The GIDS follow-up literature has documented that many young people do not progress to medical transition — suggesting the population is more heterogeneous than a simple "trans or not" binary.
The concern about online community influence on self-identification connects to the social contagion / ROGD literature (see Section 3 of this guide).
The high rates of comorbidity (depression, anxiety, autism, trauma) in adolescent-onset cases are documented in Section 2, supporting the clinical case for thorough assessment.