The Gender Affirmative Model

An overview of the evidence-based Gender Affirmative model of care currently seen as best practice. Also click HERE to see the Common Questions page.


We recognize that some youth will be exploring both gender identity and/or expressions as “poetry in motion” as they evolve into their adult gender selves.  This is no way any less authentic than any other youth’s gender articulation, and we as gender affirmative practitioners acknowledge that each youth is unique and needs to be understood for where they are coming from and where they are going, with no rush to action but no road blocks put in the way. 

Excerpted from: 

Gender Nonconforming Youth: Current Perspectives

Published in Adolescent Health, Medicine and Therapeutics.  Author: Diane Ehrensaft.  

"The gender affirmative model is defined as a method of therapeutic care that includes allowing children to speak for themselves about their self-experienced gender identity and expressions and providing support for them to evolve into their authentic gender selves, no matter at what age. Interventions include social transition from one gender to another and/or evolving gender nonconforming expressions and presentations, as well as later gender-affirming medical interventions (puberty blockers, cross-sex hormones, surgeries)…"

"The model is informed by the contemporary theory of gender development… with a recognition that although gender evolves over the course of a lifetime, gender identity appears to be a relatively more stable and consistent construct compared to gender expressions. Gender health is defined as a youth’s opportunity to live in the gender that feels most real and/or comfortable, or, alternatively, a youth’s ability to express gender with freedom from restriction, aspersion, or rejection.  When considering a child’s gender status, attention is paid to both gender identity and gender expressions, with the understanding that a child’s gender identity may communicate something very different about the child than a child’s gender expressions might."

"Therapeutic goals in the gender affirmative model include:

  • Facilitating an authentic gender self

  • Alleviating gender stress or distress

  • Building gender resilience

  • Securing social supports

"… [N]o assumption is made that every child exhibiting a gender nonconforming presentation is in need of mental health treatment. Because of the emphasis on social factors affecting the youth, interventions may be targeted at the surrounding environment, rather than the child’s individual psyche. This might include interfacing with schools, social and religious institutions, and policymaking bodies to remove the “social” pathology impinging on the child, such as transphobic attitudes and responses, gender policing, or bullying and harassment. Relatedly, parent consultations often take precedence over individual treatment of the child with provision of services to help a parent make sense of their child’s gender nonconformity, work through any extant conflicts and anxieties about their child’s gender, and move toward acceptance of their child."

"Individual treatment for the child is indicated for one of five reasons: 

  1. to assess a child’s gender status; 

  2. to afford the child a “room of their own” to explore their gender; 

  3. to identify and attend to any co-occurring psychological issues;

  4. to address and ameliorate a child’s gender stress or distress;

  5. to provide sustenance in the face of a nonaccepting or rejecting social milieu, which might include family, school, religious institution, or community. 

"Some professionals working in this model will call on psychometric or projective measures to gather information about the child; others will rely on observation, play, interviewing, and dialog. If assessment instruments are employed, every effort is made to use protocols that do not rely on binary measures of gender (e.g., Are you a boy or a girl?) and are not pathology oriented, but instead assess strengths as well as weaknesses and differentiate between gender expressions and gender identity. "

"The basic therapeutic tenet of the gender affirmative model is quite simple: When it comes to knowing a child’s gender, it is not for us to tell, but for the children to say. In contrast to the watchful waiting model, once information is gathered to assess a child’s gender status, action is taken to allow that child to exercise that gender. Therefore, if after careful consideration, it becomes clear that a young child is affirmed in their gender, demonstrating that the gender they know themselves is different than or opposite to the gender that would match the sex assigned to them at birth, the gender affirmative model supports a social transition to allow that child to fully live in that gender, whether that child is 3, 7, or 17 years old. Such decision-making is governed by stages, rather than ages, both for social transitions and later for medical interventions. Once the child’s gender comes into clear focus, which is posited as happening with a child of any age, no need is seen to hold off until adolescence to affirm that gender. This viewpoint is informed by data indicating the psychological harm that can be done, including heightened risk for generalized anxiety, social anxiety, oppositional behaviors, depression, compromised school performance, if a youth experiences themselves living in a gender that is inauthentic to them."