https://doi.org/10.1177/1359104519838313 Clinical Child Psychology and Psychiatry 2019, Vol. 24(2) 322 –337
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Co-ordinating meaning within a gender identity development service: What can the theory of the co-ordinated management of meaning offer clinicians working with young people, and their families, exploring their gender identities
Ashley Miller and Sarah Davidson
The Tavistock and Portman NHS Foundation Trust, UK
Abstract
Working with young people who present with diverse gender identifications and their families requires consideration and acknowledgement of a range of contexts (including relationship, family, social and cultural) as well as the influences of prior experience and language. Family members often present with diverse understandings and hopes from their referral to the Gender Identity Development Service and look to us to meet these. This article considers the contribution of Cronen and Pearce who introduced the theory of the co-ordinated management of meaning (CMM). We focus on their ideas about communication, the complexities of communication, meaning, context and multiple perspectives. This article relates to our practice as well as considers useful ways to work with families and young people, within a highly contested field.
Clinical examples are used to illustrate how we have made use of the theory and models of CMM to facilitate engagement, build therapeutic rapport, facilitate understanding and support those we see in a way which takes into account the many contexts of their lives.
Keywords
Gender identity, family therapy, systemic therapy, co-ordinated management of meaning, CMM, young people, gender, dysphoria, trans, transgender
Introduction
This article will outline the context the authors are working in with gender diverse young people and their families. We will give an account of some of the dilemmas and challenges we experience, within a continually shifting and changing, and highly contested field (Cretella, 2016; Ehrensaft,
Corresponding author:
Ashley Miller, The Tavistock and Portman NHS Foundation Trust, 120 Belsize Lane, London NW3 5BA, UK.
Email: [email protected]
Article
Giammattei, Storck, Tishelman, & Keo-Meier, 2018; Ristori & Steensma, 2016; Temple Newhook et al., 2018). We will then explain the theory of the co-ordinated management of meaning (CMM) and describe some of the ways we find this theory helpful in our work. The focus will be on those aspects of the theory which support us to work with complexity, multiple perspectives and a range of contexts, and to work in collaborative ways with the young people and families we meet. We will then illustrate further using examples of our work with young people, their families and their networks. We hope this article and the ideas outlined will be of help to other clinicians and practi- tioners working with gender diverse young people.
Terminology
We will use the term gender identity to refer to a person’s felt sense and expressions of their gender.
Gender identity is often used as an umbrella term to encompass a range of ways of identifying around one’s gender, which do not fit with binary ideas of gender identity matching one’s gender assigned at birth (the latter often based on physical sex characteristics). We will also use the term gender identity to refer to the broader processes by which young people explore and develop their gender identity and expressions. Gender identity has been deconstructed and used variously by different groups over time to highlight the different ways that gender is experienced, understood and expressed. It can include the diverse ways that people may describe themselves, for example, trans, non-binary, non-conforming, gender fluid, gender-expansive and gender-creative. We are aware that the terminology in this field is rapidly changing, dynamic and used by different groups in different contexts (R. Pearce, 2018; Simmons & White, 2014).
Societal context
Gender identity (particularly with regard to young people) is a very live topic in wider society (Thomas, 2018) both in the United Kingdom and more broadly across the world. There are strong views about the idea of young people identifying in different ways around their gender identity, with a polarisation of views about how best to work with this population. This can lead to strong divisions in the wider societal context with some parties questioning the idea of physical intervention in chil- dren and young people, and others suggesting that physical intervention should be offered at a much earlier stage than national and international guidelines and protocols currently recommend (Cretella, 2016; Ehrensaft et al., 2018). Ristori and Steensma (2016), for example, state that
[c]urrently, the limited empirical evidence in favour of a particular treatment makes treatment for teenagers with GD a controversial issue that raises intense, and often polarized, debate. (p. 18)
Di Ceglie (2018) uses the metaphor of ‘Scylla and Charybdis’ to describe the delicate balance that must be maintained to avoid being drawn into polarised positions in this field, and some of the costs involved even when one is able to manage this balance.
We are aware that young people who identify and express their gender in diverse ways fre- quently face discrimination, stigmatisation, violence and harassment (European Union Agency for Fundamental Rights (FRA, 2014). Meyer’s (2003) minority stress model highlights the ways in which these experiences can impact people’s emotional well-being and sense of themselves.
Service context and challenges
The authors work in a national gender identity development service (GIDS) for children and young people. We are the only commissioned National Health Service (NHS) for gender diverse youth in
the country and the only service to offer physical interventions for gender dysphoria on the NHS.
This can, at times, mean that physical intervention is the main focus for the families and young people attending. The service works with children and young people who are questioning their gender and identify in a range of ways around their gender identity. The aim is not to change a young person’s gender feelings or expression; rather, the service works in a holistic way and con- siders the developmental needs of children, young people and their families as they negotiate their gender identity in the different contexts of their lives.
Di Ceglie (1998) has outlined therapeutic aims for working with children and young people whom we see (see Appendix 1). Much of the work involves enhancing resilience and coping and supporting meaning making and the tolerance of uncertainty (see Wren, 2016). While the service does have access to endocrinology, all young people and families seen by us receive psychosocial support of the type set out here. This article describes the approaches clinicians use to broaden out the conversations we have with young people and families.
As highlighted, much is unknown in this field, the evidence base is limited and there are few long-term outcome studies. There are also continual shifts in the way young people identify around their gender, and present to services. As a service we have experienced unprecedented increases in the number of young people presenting for support with their gender identity in recent years. In addition, there are greater numbers of assigned females than assigned males (G. Butler, De Graaf, Wren, & Carmichael, 2018) being referred than previously. We are unclear about the reasons for this increase and these shifting patterns (possible hypotheses include greater social visibility, social media influences and the availability of a broader range of gender identi- ties (Di Ceglie, 2018)). We have also noticed a greater number of young people presenting in non-binary and gender fluid ways.
We have also noticed increased complexity in the work, including young people presenting with a range of psychosocial issues as well as risk and safeguarding concerns (including accessing hor- mones through the Internet). These trends have been observed in other centres working within this area (e.g. Kaltiala-Heino, Bergman, Tyolajarvi & Frisén, 2018; Kaltiala-Heino, Sumia, Tyolajarvi,
& Lindberg, 2015).
In this shifting constantly changing context with many unknowns, there can be a wish to hold onto some certainties. Some of the challenges above can present ethical and clinical dilemmas for clinicians, which Di Ceglie (2018) suggests can create anxiety around decision making leading to unhelpful action or inaction. The authors have found that the CMM approach gives us a framework for thinking, an approach to our work and some tools which are invaluable for helping us to engage with families. This framework supports us to recognise the different contexts that our language and understanding arise from, to consider the ways we communicate with young people, families and others, and to negotiate polarised and contested subjects. We hope this article may be of help to other clinicians working with gender diverse young people.
CMM
CMM was initially developed by Barnett Pearce while working in the field of communication theory. From 1977, he formed an ongoing collaboration with Vern Cronen. CMM was developed independently of systemic family therapy. However, with its emphasis on the co-construction of meaning within relationships and the importance of context, there soon developed inter-disciplinary exchanges with the family therapy field (see Cronen, 1994; Cronen & Pearce, 1985). Ideas by Bateson (1973, 1979) about patterns of connectedness, the way connections work in a circular rather than a linear way and the way meaning is dependent on context (which may be marked by time, place and relationship) were also very influential in the development of this thinking.
Many systemic and family therapy practitioners subsequently incorporated CMM theory, ideas and
techniques into their ways of working (e.g. Afuape, 2011; Hedges, 2005; Oliver, 1992, 1996;
Roper-Hall, 1993; Tomm, 1987).
W. B. Pearce (2007) highlights three key principles of CMM, which are that (1) there are mul- tiple social worlds, (2) these social worlds are made in interactions and through conversations with others and (3) we are all active agents in the making of social worlds (W. B. Pearce, 2007). The concept of social worlds suggests that there are multiple ways of living and organising one’s social interactions and that each of these contain their own rules and logic. So, for example, families, schools or local communities may operate as different social worlds (and within each of these there may be many more social worlds). These social worlds are viewed as arising out of and shaped by the conversations and interactions people have, and are viewed as ever shifting and changing.
CMM views people as part of networks and systems of relationships, rather than as separate from and making meaning independently of their social contexts, and focuses on what is done with communication (W. B. Pearce, 1994). Conversations between people are seen as ‘the means by which the events and objects of our social worlds’ (W. B. Pearce, 1994, p. 52) are co-constructed.
In other words, concepts such as ‘gender’, ‘male’ and ‘female’ do not exist independently as enti- ties waiting to be named, rather they are created in specific conversations and are further defined by actions in the world resulting from these interactions. This also fits very much within a social constructionist paradigm1 (Gergen, 1999).
It is suggested that our task in interactions is to actively manage the meanings that make up our lives and to co-ordinate these with the meanings of others, to bring coherence to our social worlds (W. B. Pearce, 1994, 2004/1999). Meaning and action are viewed as very much interlinked with meaning arising out of our experiences and influencing the meanings we give to others’ behav- iours, and informing our subsequent responses in a recursive way (see also Oliver, 2014). CMM’s focus on meaning making (W. B. Pearce, 2007) and the ‘interactive and contextual’ nature of the way ‘meanings and identities’ arise out of our interactions in the world (Creede, Fisher-Yoshida, &
Gallegos, 2012, p. 27) are pivotal in thinking about our work at the GIDS. In our work, we spend a great deal of time exploring young people and their families’ understanding of gender, how this has been informed and what the consequences are for behaviours and actions. West and Zimmerman’s (1987) conceptualisation of ‘doing gender’ as changeable and culturally bound fur- ther illustrates this.
It is also suggested that the processes between people take the form of rule-governed patterns of interactions and that there is logic to the way that we act in communication. Cronen and Pearce describe a hierarchical model in which rules are thought to develop out of the many social contexts of a person’s life, including relationship, family, social and cultural contexts (Cronen, 1994; Cronen
& Pearce, 1985; W. B. Pearce, 2007). These different contexts are said to place constraints as well as open up possibilities around ways of being and interactions. So, for example, there may be said to be identity, family and wider social and cultural rules around what it means to be female, male, non-binary or other gender identifications and the type of interactions one engages in.
The idea of context informing meaning and actions and vice versa is key to the CMM model.
Pearce suggests that different contexts function in a hierarchical manner with different levels of context exerting a greater influence on us in different situations and interactions. These contexts include speech acts (e.g. introducing ourselves in a group using our chosen name and pronouns), the episode within which these speech acts occur (e.g. the start of a sibling group on a GIDS family day); the identity level (the many different ways in which a sibling might define themselves – though in a group of this sort the higher context may be as a sibling); relationship level (siblings of young people attending the service meeting of other siblings for the first time); family level; com- munity level and so on. More general, broader levels are described as offering a contextual force on levels, embedded within or below, so, for example, our stories about being male, female,
non-binary, or gender queer could be said to be influenced by wider social discourses (Afuape, 2011; Burr, 2003) at a higher level of context and might define the conversations we might have in such a group.
Contexts at a lower level,2 or less instrumental level, may nevertheless exert influence on those stories at a higher level. For example, statements or conversation, at an identity or relationship level, about different forms of gender expression may expand the possible stories available about gender expression at a social and political level (Afuape, 2011; Wren, 2014). W. B. Pearce (2007) also describes what he terms ‘implicative forces’, that is, the way that actions in one context may impact the broader context.
A related model that comes out of CMM is the LUUUUTT model. The LUUUUTT model (Creede et al., 2012; W. B. Pearce, 2004/1999, 2007) provides a way to explore the diversity of stories that may be present in communication, some of which may be less ‘foregrounded’ or brought into awareness (Creede et al., 2012). The letters in this acronym represent, ‘Lived stories;
Untold stories; Unheard stories; Unknown stories; Untellable stories; Told stories; and storyTell- ing’ (Creede et al., 2012, p. 33). By holding these ideas in mind, we are encouraged to bring differ- ent stories to the fore, thus moving away from simplistic explanations and ideas to consider the multiple perspectives and complexities inherent in discussions around gender identity. So, using the example above, in a sibling group, there may be stories of support, stories of loss, stories of guilt, stories of pride and stories of activism, some of which may be heard, unheard, untellable, untold or unknown. The stories told by any individual in the group might also differ in different contexts.
Cronen and Pearce suggest a way of looking at the social world which, rather than suggesting that there are things out there to be found (e.g. linear explanations around gender), suggests that we look at the processes by which social worlds are made (e.g. ‘how do people do gender (Corbett, 1996) and what support do they need to do this well’ (Wren, 2014, p. 286)). CMM encourages us to look at the process of communication as well as the ways meaning is made. We are encouraged to think about the ways that we might act into critical moments (W. B. Pearce, 2007), (i.e. those turns in communication which may lead to a range of different outcomes, some more helpful/use- ful than others) and to consider ‘what kinds of social world we are making in our communications with others’ (W. B. Pearce, 2007). Human communication is viewed as a flexible, open and muta- ble process evolving in an ongoing joint interaction, which enables movement, shifts and evolving ways of being with each other. This, according to Cronen and Pearce, provides the potential for communication to be a transformative process where new and different ways of being may be generated. W. B. Pearce (1989, 2004/1992) also describes the concept of mystery, to demonstrate an awareness that the world extends far beyond the limits that our stories may place upon it.
We find these ideas particularly important when considering how we might act into some of the polarised debates and arguments and negotiate contexts at an individual, professional, team, service, organisational and wider societal level, where there are strongly held, differing opinions and practices. The CMM framework offers us a way of approaching our work with gender diverse young people and their families that considers the different contexts that inform their identity and encourages reflexivity and the consideration of multiple perspectives, while acknowledging the complexities. In an area of such uncertainty and unknowns, the authors find it helpful to keep asking themselves, ‘what kinds of social realities are we creating in our work with families?’
where the context is so polarised and contested, ‘how can we have helpful conversations both with clients and in our interactions with the external world?’ and in contexts where young people may face stigma and discrimination, ‘how can we have conversations with schools and other involved organisations, that lead to different, more supportive social realities for the young people we work with?’
Scope of the article
CMM offers a framework, a way of thinking about communication, that enables us to take a col- laborative approach, to take a position of working together to explore meaning and arrive together at a shared understanding and agreed plan going forward.
The aim of this article is to illustrate the ways in which CMM is useful in our work with gender diverse young people and their families. We hope this article will be of help to other clinicians and practitioners working with this population.
We will now describe ways in which these ideas are clinically, or as W. B. Pearce (2007) would say, practically useful in our work. We will look at more general applications before looking at specific instances of the work in practice.
Method
We have identified examples of our work which illustrate some of these ideas in practice. We will focus on discrete aspects of the work carried out to illustrate aspects of the theory of CMM that we find most helpful in our work. Case examples have been chosen because they demonstrate these ideas at an individual, family and wider network level.
All examples used in this article have been anonymised and identifying details changed. Where we have used more comprehensive and detailed case examples, for example, ‘Sam’ and ‘Casey’, we have spoken to the clients to ask for their permission to include their case examples in this article and obtained written consent. Casey was still being seen by the service and Sam had recently been seen at the time of contacting them.
Clinical application Beginnings
Lang and McAdam’s (1995) article is very helpful for thinking about how our different meanings may be negotiated in first meetings and to think of the importance of these beginning conversa- tions. In the GIDS, the first meeting can be an opportunity to find out about the families’ meanings and stories about the service and their hopes in coming to the service. For example, in a network meeting, where a 15-year-old was in the care of an extended family member, it was helpful to hear the family member’s story of the service connected to an article they had read in the national press.
The article included a letter from a parent which suggested that as a service we went ahead with physical interventions without the involvement or consent of the parent who felt excluded from the process. While we did not know the details of that case or the family involved and were unable to comment about that specific story, we were able to talk, with the carer and the young person, about our stories concerning the importance of family involvement. This led us to think together about how to make sure the young person’s caregiver continued to be involved in an ongoing way, including travel to appointments being facilitated. The young person was also keen that this was facilitated.
The first meeting can also offer a way to negotiate different perspectives around chosen names and pronouns. In some families, everyone may be at the same point with regard to names and pro- nouns. In other instances, families may have different views about which name to use. At the beginning of the meeting, during introductions, we usually ask if the name the young person has used to introduce themselves is their chosen name and if others in the family use the name. Where there is disagreement, we will try to think together, with the family, about the best way forward and whether it is possible for each of us to hold different positions yet still find a way forward. We
might ask the family and young, for example, ‘What would it be like for them as a family, and for the young person, for us as clinicians to use the chosen name in our meeting/s together?’
The initial meeting can also be a way to introduce multiple stories and perspectives. When giv- ing families information about the service, for example, we will often talk about the many ways that young people present (e.g. gender non-conforming, trans-male, trans female, non-binary, gen- der fluid, gender queer) to our service and also the many pathways and outcomes that young people may pursue. To illustrate, some young people may continue to identify in their identified (non- assigned) gender and may decide that physical intervention is the path for them, some may want some aspects of physical intervention but not others, and for other young people the focus may be more relational and much less connected to their physical experiences or interventions. These types of discussions enable us to set the scene for collaborative and shared ways of working together, in which the construction of meaning will be a joint endeavour, as we think with the young person and family about what is right for them.
Case number one: exploring different levels of context using the hierarchy model
The idea of different social worlds can be very helpful in our work where there are many different ways of understanding gender and where even the language and terminology used may change in an ongoing and continuous way. W. B. Pearce (2007) encourages curiosity and listening. The aim is not to work towards a definitive description of social worlds (W. B. Pearce, 2007), but to be curi- ous and listen to discover aspects one would not normally see (W. B. Pearce, 2007).
The following example takes a more detailed look at the use of the CMM model over three ses- sions with a family and also considers the use of circular questioning:
A 15 year-old, assigned female at birth, Sam, was referred by their general practitioner. Sam lived with their mother, father and younger sister in a suburb of a cosmopolitan city.
Both parents were originally from rural areas of the UK.
The referrer informed us that Sam was questioning their gender that they didn’t feel comfortable being female and had felt like this for a couple of years.
In their first meeting with us, Sam explained that they didn’t want to be categorised as either male or female, that they ‘didn’t want to be put in a box’. Sam had a good group of friends at school and outside of school and enjoyed painting and art.
First meeting with the family. When asked about their hopes for the meeting, Sam’s mother (Kay) said that Sam had ‘issues around their gender’ and that they would like them to feel good and com- fortable. Sam spoke about wanting to feel a bit more accepted and understood. Sam’s father’s (Max’s) hope was that Sam would not go down a route of physical intervention and that perhaps
‘she could come to terms with her body shape without surgical intervention’. Sam spoke of not liking being treated as a girl and not feeling comfortable with this. Kay spoke of her biggest fear being that this would be the start of a route that would end up with ‘the most extreme physical intervention’. The family found it hard to have conversations about their child’s gender feelings and expression and the young person found it difficult to speak with their parents.
Using the framework of CMM enabled us to think about the way a young person telling their family about their gender feelings may lead to incoherence in the relationships (W. B. Pearce, 2007). The focus can suddenly become very much about the young person’s gender feelings, with the family at a loss to find a way to talk to each other about the different meanings and stories they
may hold. Within the CMM model, it could be said that the episode of the young person’s telling their family about their gender feelings became the higher context by which the family interactions were negotiated, impacting the family relationship and their confidence in moving forward.
W. B. Pearce (1994), comparing different communication paradigms, describes what he calls
‘The Transmission Model of Communication’ whereby communication involves the transmission of pre-existing external concepts ‘from one mind to another’ (W. B. Pearce, 1994, p. 19) in a linear and untainted way. He contrasts this with the Social Constructionist model of communication whereby meanings are constructed and evolve between people, in which the events and objects of the social world (W. B. Pearce, 1994, p. 19) are made in an active way between people. We are very much aware that sometimes, very much like the transmission model described above, we can find ourselves explaining about our service and our service ideals in the hope that what we know and understand about gender, including ideas of flexibility and exploring possibilities, will be ‘trans- mitted’ into the minds of fearful or worried families leaving them feeling more reassured. When this doesn’t work, we can find ourselves in the position of trying to be clearer and clearer, seem- ingly without effect. This pattern of communication could be observed in our early sessions with the family, with each party very much repeating their particular viewpoint. We now move to look at ways we were able to begin to co-ordinate our different ways of communicating with each other.
Third meeting with the family: widening the context. The meeting began with the story of difficulties talking about things and coming to terms with having a son rather than a daughter. Sam spoke of being ‘playful and imaginative and experimenting with their gender identity with friends’.
Kay replied that it made a change to think of it as ‘a creative thing, a happy thing that Sam could be exploring, to lighten it a bit’. We thought it would be helpful to stay with the words that had been introduced by the family. When we asked how the young person showed that they were being
‘imaginative’, ‘playful’ and ‘creative’, Max answered that Sam had ‘never accepted any assump- tions or taken for granted knowledge from a young age’.
Sam gave an example of not using specific structures for their painting and of doing it their own way. When we asked about who else was imaginative, playful and creative, Sam’s parents spoke of being of a similar mind themselves. They spoke of wanting to support Sam with this and of always wanting to be flexible. They told stories of coming from creative backgrounds, not wanting to take anything for granted. They also spoke of Sam ‘not taking the easy route or conforming’
We asked Sam’s parents what helped them to have these qualities, what it was about their family origins or backgrounds. Max spoke of his parents ‘always encouraging the children to think for themselves and to be their own person’. When we asked for an example of this, Max spoke of being on holiday as a boy and returning home with a punk hairstyle. Max said this would have been very unusual in the town where he grew up and he expected his parents to say something when they got back; however, they didn’t and he felt encouraged to be who he wanted to be. Max also told a story about his parents going to war and the impact he thought this may have had on their openness to difference.
In our conversation, being creative, imaginative and playful also became linked with being your own person and thinking for yourself. When Sam was asked what he recognised about being one’s own person and thinking for himself or herself in their parent’s descriptions, Sam spoke of Kay taking a different name and having different personas in her work (due to the nature of this work).
Widening the context away from a story about problems and difficulties to multiple stories look- ing at the family’s different contexts over time allowed us to move away from a single limiting story (Lang & McAdam, 1995). This enabled previously untold, unknown and unheard stories (Creede et al., 2012; W. B. Pearce, 2004/1992, 2007) to be brought to the fore (e.g. stories of crea- tivity and non-conformity) and a discussion about different aspects of oneself and what different contexts and relationships constrain or allow. The conversation included stories (see also the
‘storyTelling’ aspect of the LUUUUTT model) about being parents of young children and how that called for safer, more cautious, responsible and careful ways of being, as well as a desire to express their creative, imaginative and playful sides again as the children grew older. There were also sto- ries about the family doing things differently to the norm in the context of a very staid, conserva- tive area. We also used circular questioning (Anderson, 1987; Cecchin, 1987; Cronen, Lang, &
Lang, 2009; Tomm, 1987, 1988) to make connections between the family’s stories, meanings and different contexts (including time contexts). Circular questioning is a form of questioning used in systemic and family therapy which focuses on relationships between people and patterns of rela- tionships. So, for example, it is suggested that asking about similarities in a family (e.g. ‘Who else in the family thinks outside the box?’, ‘Who else in your family supports you to think outside the box?’) may be helpful when there are areas of conflict and feelings of insurmountable differences.
W. B. Pearce (2007) also talks about the importance of questions: to promote dialogue and a consideration of the position one is taking, to ‘open up conversations rather than close them down’
(W. B. Pearce, 2007, p. 63) and to promote curiosity and listening. W. B. Pearce (2007) stresses the importance of curiosity for hearing others’ perspectives and views rather than forcing them into our preconceived ideas. The latter, again, is an important part of trying to remain open to the meanings of the young people we see.
By thinking about the constraints placed on playfulness, imagination and creativity and on being one’s own person (e.g. local area, family roles), we were able to have a discussion about the constraints around different gender expressions. We spoke about the way being online might ena- ble one to escape from physical constraints of one’s body and gender. We were also able to consider ways of resisting these constraints, for example, through online personas, friendship groups, family support, the creative community around the family and a voluntary sector group for young people questioning their gender. At times in our work, we may refer to ideas of ‘the gender police’ and concepts such as ‘gender warriors’ (J. Butler, 1990) to think about the ways families and young people are able to resist wider social pressures (see also Wiseman & Davidson, 2011). We also found Partridge’s (2006) ideas on the use of metaphor as a way to connect meanings at different levels and to open up new possibilities very helpful to keep in mind during this meeting.
At the end of the meeting when asked what they might take away with them, Sam replied (refer- ring, it seemed, to the stories they had heard their parents tell) that they would take away that other people have the same struggles, and that they maybe don’t need to fight against them so much. Max and Kay said that they would take away ‘that it was not as different as they thought and fitted with their beliefs and ideals as a family’.
Case number two: working with wider contexts using the hierarchy and LUUUUTT models
It can be hard to hold a position of multiple possibilities given the wider social and cultural context which calls upon certainty around gender and the realities of everyday life (Richards, Barker, Lenihan, & Iantaffi, 2014; Wren, 2014). It is therefore important to hold in mind the different aspects of a young person and their family’s identity (Burnham, 1992, 2012; das Nair & Thomas, 2012; Riggs & das Nair, 2012; Roper-Hall, 1998) and how these other aspects of identity and context (e.g. class and culture) impact the possibility of defining oneself in alternative non- heteronormative ways. At these times, it may be more important to advocate for the young person in those wider societal situations where they feel unsafe or unheard (see also Imber-Black, 1986, for a discussion about levels of intervention). Richards et al. (2014) also argue for intervention at the level of those wider social structures which promote gender stereo-typing (e.g. shops which market toys along gender lines) rather than at the personal level:
Casey is a 14 year-old, assigned male at birth, with a diagnosis of Autism Spectrum Disorder. Casey was referred to our service when she was 10 years-old, for assessment and support around gender identity issues and possibly delaying puberty. She lived with her mother, father and an older brother.
When she first came to our service Casey wore female clothing at home and when she went out with her family, as well as more neutral clothing.
The family reported that Casey had called herself different female associated names at different times.
Casey told us that when role playing, she played at being a girl. Casey had grown her hair long by the age of about 7 and currently had clothes in her wardrobe from across the gender spectrum, including unisex clothes. She enjoyed wearing girl’s clothes and when swimming chose to wear a one piece swimming costume.
Casey’s parents spoke of her being unhappy in the past when she was unable to express her feelings about her gender. After buying her first girl’s swimming costume and more girls’ clothes, her anxiety and unhappiness were said to be reduced. Casey had spoken a great deal about being a girl before this time.
Working at an individual, relationship and family level. During the early part of our work with Casey, she expressed little difficulty or distress about the thought of bodily changes. She did not seek a change of name or change to using she/her pronouns, even when this was raised as a possibility within meetings.3 The family were very thoughtful about how to keep the possibilities open for Casey and how to manage this in day to day life.
Our meetings involved ongoing discussion about how her family and those around her could keep being thoughtful and mindful of gender identity and Casey’s gender development while also keeping possibilities open. It was important to facilitate as much conversation of different possi- bilities and outcomes as possible and the different contexts within which these could be held in mind. Our assessment report was shared in a draft form with the family which we went through jointly, making corrections, changes and clarifying points. Again, this enables us to construct a collaborative and shared narrative and to work alongside families when thinking about the care plan and recommendations going forward. As part of Casey’s plan, we acknowledged the impor- tance of keeping a flexible and open mind with regard to Casey’s and the family’s wishes and preferences at that time, in an ongoing way. Keeping a flexible and open mind is often placed in the context of the dynamic and fluid nature of development and understanding over time, thus highlighting the importance of revisiting discussions rather than seeing conversations and deci- sions making as fixed and unchanging.
Our work together included thinking about how Casey’s brother understood and responded to Casey’s gender identity. Casey’s brother, while supportive, spoke, for example, about finding it
‘awkward’ to know what to say when friends asked him about Casey’s gender presentation. We thought with Casey and her brother about how they both might respond to questions from peers that might feel private and about the difference between private and public (Di Ceglie, 1998;
Wiseman & Davidson, 2011).
In addition, a session examining the different meanings of the word transition, for the family, revealed a wealth of stories and conversations behind this word. This session enabled us to place Casey’s social transition within the wider context of a range of transitions being experienced by the family. It was also a helpful way to draw out the different meanings held rather than assuming that we were all talking about the same thing.
Working at a community and societal level. Casey transitioned to a secondary school while with our service. When meeting with schools and other members of a families’ network, we are
mindful of supporting the knowledge, expertise and different perspectives held by all parties, including the family. In this way, we hope to act into the episode of a school meeting in a way which co-ordinates our different meanings, so as to negotiate supportive outcomes which keep the young person and their family at the centre (see also Eracleous & Davidson, 2009; Fred- man, 2014).
A meeting involving a number of school staff members was attended by both the authors. As part of the meeting, there was discussion about the importance of seeing a young person’s gender identification as just one aspect of who they are. In particular, we were aware that there were a range of other contexts which were salient for Casey and which could be considered when thinking about supporting her school experience. These included her autistic spectrum diagnosis, her clear strengths and academic ability at school, her range of friendships and her interest in drama which enabled her to explore different aspects of her identity. Again the LUUUUTT model and Untold and Unheard stories facilitated making transparent the significance of these differences, in that we were keen to broaden the range of experiences discussed beyond gender.
There was also discussion about how the school might respond to questions from other children and the importance of agreeing with Casey and her parents about what they would like said. It was helpful to consider, with the school, that they had previous experiences of negotiating different elements of private and public aspects on a day-to-day basis (e.g. with children with physical health conditions) and their previous experiences considering what information they might not share about individual pupils, as well as the ways they might consider educational interventions at a broader level (such as in sex education classes). It was also helpful to think about their existing, robust, anti-discriminatory and anti-bullying policies. In this way, the school was able to consider their particular knowledge and expertise at a higher level to their worries of not knowing enough about gender identity.
At this point, Casey wanted to continue attending the school in a boy’s uniform and wished to wear her hair long. We were able to think with the school and the family about the range of contexts and forces, contextual and implicative, that each was operating from, for example, the school with its guidelines and differing expectations for girls and boys with regard to hair length; for Casey, her exploration of her gender feelings; and the family’s concern to keep options open. At the next school meeting, we were able to come to an agreement which enabled Casey to continue to wear her hair long without feeling the need to adopt a binary position around her gender expression.
There was also discussion about gender being a developmental process and that these issues would need revisiting over time with further meetings and conversations.
As we continued to meet with the family, Casey began to explore presenting in a more female /feminine way. First, requesting a change of pronouns and then deciding that she would like to wear a skirt to school. Casey and her family subsequently made a decision to pursue physical inter- ventions, beginning with the hormone blocker and latterly oestrogen.
Critique
One of our main critiques involves the complexity of the theory and the concepts which at times felt like learning a different language and could be said to require a specialist kind of knowledge.4 We often consider in our work what conversations are available to people. Burr (2003) talks about the way particular dominant discourses in society might position us in terms of our identity, giving rise to certain ‘rights, responsibilities, affordances and constraints’.
CMM has also been critiqued for the emphasis it places on language and conversation to the neglect of more embodied, nuanced ways of communicating (Nagata, 2012).5 In the GIDS, for example, we frequently have conversations with young people who talk about a real embodied
sense of ‘being in the wrong body’ and at times find it a struggle to articulate in conversation what might be considered their ‘more private and intimate reckoning’ (Wren, 2016, p. 87). In our work, we use a range of additional models to acknowledge different experiences, domains and literature, as befitting a multidisciplinary team (MDT) and in acknowledgement of a diversity of presenta- tions and outcomes in this area (e.g. Iantaffi & Barker, 2018; Wren, 2019).
We are also aware that wider stories about health services might create a context where young people feel they ‘have to tell a convincing story’ (Wren, 2014, p. 12). This may coincide with ethical and moral dilemmas we experience in our professional contexts. We are aware of these challenges and try to build a strong basis at a relationship level to have more helpful and collaborative conver- sations. We also encourage young people and their families to attend the young people’s groups, parent groups and family days we hold at our service as well as local support groups. In this way, we hope to support young people’s doing of their gender in a range of contexts in the world.
It should also be kept in mind that the theory of CMM is dynamic and continually changing rather than a prescriptive, how-to guide. So, for example, Nagata (2012) speaks of the importance of mindful awareness of the body in connection with self-reflexivity (see also Fredman, 2004).
Peterson (2012) on the other hand talks about how culture can inform embodied ways of commu- nicating and may ‘contextualise the verbal’ (p. 245).
Afuape’s (2011) development of the ideas in the context of liberation psychology can also be helpful in our work in the GIDS. Afuape (2011) highlights that CMM offers a both/and approach to looking at the way that social forces impact on the individual, as well as how the individual may impact on wider social forces in a recursive mannner. We find that our understandings and the conversations we engage in are constantly shifting and changing.
Challenges
Our work in this service has its challenges. As highlighted elsewhere in this edition, the area of gen- der identity can elicit strong views and opinions which can lead to polarisation and difficulties in engaging in dialogue both within the wider context and at times within the therapy room. In addition, we are observing a change in the presentations of young people accessing the service. There remain many unknowns and a limited evidence base with regard to the outcomes for young people accessing physical interventions. This can lead to many ethical dilemmas in our work, particularly those relat- ing to consent and developmental considerations around this, for example, at what age to facilitate social transition, particularly in pre-pubertal children, and when to provide access to physical inter- ventions including surgery (Ehrensaft et al., 2018; Temple Newhook et al., 2018). Our experience is that the discourses in this area about what is most helpful can be polarised into positions that advocate for either physically intervening as early as possible (this position is commonly associated with an affirmative approach) or exploring while not considering physical interventions at all.
Our use of CMM enables us to embrace a both/and approach which enables a reciprocal under- standing of the influence of the individual and social context (Afuape, 2011) and which can help us bridge some of these more polarised positions to provide care tailored to young people in their various contexts, including their developmental stage. We find it important to continually engage with the range of ways of understanding gender identity, including personal accounts, critiques and alternative perspectives (Erickson-Schroth, 2014; Latham, 2017; Marcus, Marcus, Yaxte, &
Marcus, 2015). These approaches encourage us to challenge our thinking, to hold a questioning, flexible and more uncertain position in our work with young people and their families, and mini- mise the possibility of us becoming fixed and rigid in our thinking and practice.
As well as trying to hold in mind ideas of curiosity and neutrality (Cecchin, 1987) and striving to keep a non-judgemental and accepting stance (Di Ceglie, 2013), we also keep in mind CMM ideas around ‘what we are constructing together’ in our work with clients and how we may develop ‘better
forms of communication’ and try to hold the development of collaborative relationships as the higher level of context (W. B. Pearce, 2007) in our work with young people and their families.
Conclusion
We believe that gender identity is complex, multifaceted and influenced by a range of interacting factors, including contextual and implicative processes. When working with young people and their families, we find it useful to pay attention to the multiple and changing contexts and perspectives involved, see how there may be differences between them and identify the resources and opportuni- ties available. By considering these with the families we work with, we hope to open up possibilities that enable young people to identify as they wish and be supported in doing so. We also recognise the need to work at multiple levels and with different groups to promote awareness over time. We further recognise the importance of understanding all the complexity within meaning making which can construct and constrain identity. Amid the many ways that gender identity can be understood, we find it important to be able to tolerate uncertainty at many different levels while maintaining awareness of and contributing to the currently minimal but growing evidence base.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publi- cation of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.
Notes
1. Although it is highlighted that social constructionism was not part of the very early thinking around co- ordinated management of meaning (CMM).
2. W. B. Pearce (2004/1992) describes this as a fluid process, which is continually in change and flux rather than a rigid and fixed hierarchy.
3. This changed in the course of our work with Casey, who came to express a preference for she/her pro- nouns. These pronouns will be therefore used in this article.
4. Hooks (2000), in the context of feminist theory, talks about the way that academic, ‘jargon’-filled writing may exclude and alienate those outside an elite group (Hooks, 2000, p. 22).
5. Nagata (2012) speaks of the importance of mindful awareness of the body in connection with self- reflexivity. See also Fredman (2004).
ORCID iD
Ashley Miller https://orcid.org/0000-0002-6232-4903 References
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Author biographies
Ashley Miller is a Principal Psychologist at the UK’s Gender Identity Development Service, where she has worked since 2012. She is also a psychosocial practitioner with the British Red Cross. She has previously worked: in tier 3 CAMHS, in a Fostering, Adoption and Kinship Care team; within a residential home for chil- dren and young people; and with adults in psychological therapies service and in a NHS Traumatic Stress Clinic.
Sarah Davidson is a Consultant Clinical Pscychologist at the Uk’s Gender Identity Development Service. This is a position she has held since 2006. She is also the Head of Psychosocial at the British Red Cross.
Appendix 1
Primary therapeutic aims
•
• To foster recognition and non-judgemental acceptance of gender identity issues;
•
• To ameliorate associated behavioural, emotional and relationship difficulties (Coates &
Person, 1985);
•
• To break the cycle of secrecy;
•
• To activate interest and curiosity by exploring the impediments to them;
•
• To encourage exploration of the mind–body relationship by promoting close collaboration among professionals in different specialities, including a paediatric endocrinologist;
•
• To allow mourning processes to occur (Bleiberg et al., 1986);
•
• To enable symbol formation and symbolic thinking (Segal, 1957);
•
• To promote separation and differentiation;
•
• To enable the child or adolescent and the family to tolerate uncertainty in gender identity development;
•
• To sustain hope (Di Ceglie, 1998).
