Psychological Therapy for Trans People: A Complete Guide

Psychological therapy for trans people is often perceived with ambivalence: on one hand, as a concrete support tool; on the other, as a bureaucratic obstacle imposed from the outside. This ambivalence has specific historical reasons. For decades, psychology treated transgender identity as a pathology to be corrected. Today, the main scientific organizations—APA, WPATH, WHO—recognize that trans identity is not a mental disorder and that the role of therapy is not to change who you are, but to support you on a journey that is yours [1][4][5].

This article explains what it means to undergo therapy as a trans person in 2026: what approaches exist, how the Italian system works, how to find a competent professional, and when therapy is a personal choice versus a formal requirement. For data on the mental health of trans people and the minority stress model, refer to the dedicated article on salute mentale e persone trans.

The Role of Therapy: Support, Not Gatekeeping

The first point to clarify is the function of psychological therapy in the trans context. There are two conceptually opposing models.

The Gatekeeping Model

In the traditional gatekeeping model, the psychologist or psychiatrist acts as a “gatekeeper”: they decide if the person is “trans enough” to access medical care. This model dominated clinical practice for decades, and significant traces of it remain in many contexts—including Italy. The professional evaluates, diagnoses, and authorizes. The person must prove they meet specific, often rigid criteria to get the green light for hormone therapy or surgery.

Criticisms of this model are documented in the literature [7]. Gatekeeping creates an asymmetrical power dynamic where the trans person must “convince” the professional, producing incentives to hide doubts, complexities, and nuances that would be normal in any identity exploration process. Several studies have documented how this model leads people to present stereotypical narratives (“I always knew I was in the wrong body”) to gain access to care, regardless of the complexity of their actual experience.

The Informed Consent Model

The informed consent model, increasingly adopted internationally, reverses this logic. The healthcare professional does not decide for the person: they provide comprehensive information on risks, benefits, and alternatives, and the person makes an autonomous, informed decision. In this model, the psychologist’s role is not to authorize but to accompany. Therapy is not a mandatory prerequisite for accessing care, but a resource available to those who desire it.

The WPATH Standards of Care Version 8 (2022) take an intermediate position: they maintain the recommendation for an assessment by a mental health professional before certain medical interventions, but emphasize that this assessment must be a collaborative process, not a test to pass [4]. The SOC-8 specify that the professional’s role is to ensure the person has received adequate information and is capable of making an informed decision, not to judge the “legitimacy” of their gender identity.

The Ongoing Debate

The debate between gatekeeping and informed consent is not academic: it has direct consequences on people’s lives. Data shows that barriers to accessing care are associated with worsening mental health [13]. A 2022 study published in JAMA Network Open found that trans youth who could not access hormone therapy within 3-6 months of their first clinical contact showed a 2- to 3-fold increase in depressive symptoms and suicidal ideation [12]. Waiting lists and lengthy evaluation pathways are not neutral: they have a measurable clinical cost.

At the same time, competent psychological accompaniment can be a precious resource, provided it does not become an instrument of control. The distinction is between therapy as support and therapy as a filter.

Affirmative Therapy: Definition and Principles

Gender-affirming therapy is the approach recommended by major international guidelines [1][4]. It is not a single therapeutic model, but an orientation that can be applied within different theoretical frameworks—cognitive-behavioral, psychodynamic, systemic, humanistic.

What “Affirmative” Means

An affirmative approach recognizes three fundamental principles:

1. Gender identity is not a pathology. Trans identity is a natural variation of the human experience, not a disorder to be treated. This position is shared by the APA, WPATH, and the WHO, which removed gender incongruence from the mental disorders chapter in the ICD-11 [1][4][5].

2. Distress stems from the context, not the identity. The gender dysphoria, anxiety, and depression experienced by many trans people are largely the product of minority stress—discrimination, social and family rejection, internalized transphobia—and not an intrinsic consequence of being trans [13].

3. The therapist’s role is to support, not direct. The affirmative therapist does not aim to determine if the person is “truly trans” or to guide them toward a specific conclusion. They create a safe space for exploration, respect the person’s timeline, and support them in the decisions they choose to make.

The 2015 APA guidelines for psychological practice with transgender and gender nonconforming people are organized into five areas: foundational awareness, stigma and discrimination, lifespan development, assessment and intervention, and professional training [1]. In 2024, the APA adopted a formal statement supporting evidence-based inclusive care [2].

How It Differs from Conversion Therapies

The distinction between affirmative therapy and conversion therapies (GICE — Gender Identity Change Efforts) is clear and unambiguous in the scientific literature.

Conversion therapies aim to change a person’s gender identity to align with their sex assigned at birth. The APA, in its 2021 resolution, unequivocally condemned them: attempting to change gender identity is “inappropriate” because the incongruence between sex and gender “is not a mental disorder” and such attempts “may be harmful” [3]. Documented harms include increased depression, anxiety, suicide risk, and internalized transphobia.

In Italy, there is still no law explicitly banning conversion therapies, although professional boards discourage the practice. Several European countries—including Germany, France, Greece, and Spain—have banned them by law.

The fundamental difference: affirmative therapy works with the person’s identity, conversion therapies work against it.

Types of Psychotherapy for Trans People

There is no single therapeutic approach for trans people, just as there isn’t one for any other population. The choice of therapy type depends on individual needs, the therapist’s training, and mutually agreed-upon goals. Here are the main ones.

Cognitive-Behavioral Therapy (CBT)

CBT is among the most studied approaches in the context of trans mental health. A 2019 study published in Clinical Psychology: Science and Practice described a model of affirmative CBT specifically adapted for transgender and gender nonconforming people [6]. The model works on:

• Cognitive restructuring of thoughts related to internalized transphobia (“I will never be man/woman enough”, “My identity is not valid”)
• Management of social anxiety related to passing, misgendering, and daily interactions
• Development of coping strategies to deal with discrimination and rejection
• Gradual exposure to feared situations, such as coming out in specific contexts or expressing one’s gender in public

CBT is particularly useful for working on concrete and measurable short-to-medium-term goals.

Psychodynamic Therapy

The psychodynamic approach explores unconscious dynamics, early relationships, and relational patterns that influence how a person experiences their gender identity. In an affirmative framework, psychodynamic therapy does not look for the “causes” of trans identity (which does not need to be explained) but works on:

• Processing experiences of rejection and discrimination and their impact on self-structure
• Past and present family and relational dynamics
• Grieving unlived experiences (a childhood in the correct gender, lost opportunities)
• Building a coherent and integrated sense of identity

EMDR for Trauma

EMDR (Eye Movement Desensitization and Reprocessing) is a validated therapeutic approach for treating Post-Traumatic Stress Disorder (PTSD) and traumatic experiences. For trans people, it can be particularly indicated when there are:

• Traumas related to transphobic violence (physical, verbal, sexual assaults)
• Prolonged bullying during childhood or adolescence
• Traumatic experiences related to family rejection
• Traumas related to negative medical experiences (invasive exams, pathologizing interactions with healthcare professionals)

EMDR works on reprocessing traumatic memories, reducing the emotional impact of past experiences without the need to talk about them extensively. For trans people carrying the weight of years of discrimination, it can be an effective tool.

Group Therapy

Group therapy for trans people offers something individual therapy cannot replicate: direct contact with peers who share similar experiences. Research on resilience in trans people identifies peer support as one of the most effective protective factors [13].

Therapeutic groups can be:

• Unstructured support groups: sharing spaces facilitated by a professional, where participants bring up the topics they feel are most urgent
• Psychoeducational groups: focused on specific topics (anxiety management, coming out, preparation for medical transition)
• Structured therapeutic groups: with a defined program and specific therapeutic goals

Many LGBTQ+ associations in Italy offer peer support groups that, while not therapy in a clinical sense, serve an important function of validation and connection.

Family and Couples Therapy

Gender identity is not lived in isolation. Therefore, therapy involving the person’s relational system can be fundamental.

Family therapy. Family support is the most powerful protective factor for trans people’s mental health. The Family Acceptance Project study showed that LGBT youth with high levels of family rejection are 8.4 times more likely to attempt suicide [14]. Family therapy can help relatives process their reactions, understand the trans person’s experience, and build a supportive environment. For a deeper look at this topic, see the article famiglie e persone trans.

Couples therapy. Transitioning can bring significant changes to a couple’s dynamics. Couples therapy can work on communication, adapting to physical and relational changes, and renegotiating intimacy. It’s crucial that the couples therapist has specific expertise in trans issues: an untrained professional risks pathologizing the transition or unknowingly siding with the cisgender partner.

The Evaluation Pathway in Italy: ONIG Protocols

In Italy, the gender affirmation pathway is coordinated by ONIG (National Observatory on Gender Identity), which brings together the main specialized centers across the country [8]. ONIG centers include CIDIGEM in Turin, the Careggi center in Florence, SAIFIP at San Camillo-Forlanini in Rome, the Bari Polyclinic, and others [9].

What the Pathway Entails

The ONIG protocol involves a psychological evaluation and support pathway structured in several phases [8][11].

First phase: intake and assessment. The person is welcomed by a mental health professional (psychologist or psychiatrist) who gathers their clinical and personal history, explores their experience of gender identity, and assesses any co-occurring mental health conditions. The goal of this phase is not to determine if the person “is really trans”, but to understand the overall picture and rule out conditions that could temporarily influence the perception of gender identity.

Second phase: ongoing psychological support. The ONIG protocol requires a minimum period of six months of psychological support [8]. The frequency of meetings varies from center to center, but generally involves biweekly or monthly sessions. During this period, the professional and the person work together on exploring identity, managing distress, preparing for subsequent steps in the pathway, and assessing available personal and social resources.

Third phase: psychodiagnostic report. At the end of the evaluation process, the professional writes a report describing the person’s history, the pathway undertaken, and clinical conclusions. This report is necessary to access hormone therapy through the National Health Service (SSN) and, in some contexts, for surgery [11].

Real Timelines

The official timelines of the ONIG protocol (minimum six months) often do not correspond to reality. Waiting lists for the first appointment can range from a few weeks to several months, depending on the center and the region. The complete pathway, from accessing the center to starting hormone therapy, takes on average 8 to 18 months. In some areas, wait times are even longer.

The variability between centers is significant. Some centers have adopted more streamlined protocols, with reduced evaluation times for adults presenting a clear and established history. Others maintain longer and more structured pathways. There is no uniform standard applied nationwide.

What to Expect Concretely

If you are approaching an ONIG center, here is what to expect:

• The first interview is generally to get to know you: the professional will ask about your history, experiences, and expectations. You do not have to “prove” anything.
• Subsequent interviews delve into your gender experience, family and relationship history, your resources, and any difficulties.
• You will not be asked to “live in the desired gender” for a period before accessing care (the old “real-life test” has been abandoned by most centers, in line with WPATH SOC-8) [4].
• Psychological tests may be administered, such as questionnaires on gender dysphoria, personality, or mental health. These tools are used to build a comprehensive picture, not to “filter” you.
• At the end, you will receive a report that will allow you to proceed with the medical pathway, if you wish.

For a complete overview of the first steps of the pathway in Italy, see the article Iniziare la transizione in Italia.

Therapy for Specific Needs

Support for Coming Out

Coming out is a process, not a single event. Therapy can support the person in planning and managing this process: who to tell, when, how, and in what order. A competent therapist helps assess the risks and resources in each specific context—work, family, school, friends—and develop strategies to handle reactions, including negative ones.

Therapy for Trans Youth

Therapy for trans adolescents and young adults has specific characteristics recognized in the WPATH SOC-8 [4] and the American Academy of Pediatrics guidelines (2018) [15]. Central themes include:

• Exploration of gender identity during a developmental phase where many aspects of identity are evolving
• Management of school dynamics: bullying, use of name and pronouns, safe spaces
• Mediation with the family: parental involvement is crucial, and the therapist can act as a bridge between the youth’s needs and the family’s concerns
• Evaluation for potential access to puberty blockers: in specialized centers, this assessment follows specific protocols

A critical aspect is that trans youth require professionals with dual expertise: in gender issues and in developmental psychology. A therapist experienced with adolescents but untrained in trans identities risks pathologizing; a therapist trained in trans identities but lacking developmental expertise risks missing the complexity of the developmental phase. For an in-depth look, see the article bambini trans.

Support During Medical Transition

Therapy during medical transition is not mandatory in all contexts, but can be useful for:

• Managing expectations about physical changes and the timeline of hormone therapy
• Processing emotional reactions to bodily changes (which can be positive but also complex)
• Preparing for surgical interventions and managing the post-operative period
• Navigating changes in relationships and social dynamics

Support for Nonbinary People

Nonbinary people face specific challenges in therapy, as the healthcare system is often structured on a binary model (M to F or F to M). An affirmative therapist recognizes the validity of nonbinary identities and supports pathways that may not fit conventional molds—for example, a partial transition, low-dose hormone use, or the choice not to undertake any medical transition while still identifying outside the gender binary.

How to Find an Affirmative Therapist

Finding a competent professional is one of the most practical challenges for trans people in Italy. Here is some practical guidance.

Where to Look

• ONIG Centers: The centers of the National Observatory on Gender Identity have multidisciplinary teams with trained psychologists and psychiatrists [9]. The map of centers is available on the ONIG website.
• Infotrans.it: The Italian National Institute of Health’s portal offers a map of services dedicated to trans people in Italy, including listening points and psychological support [10].
• LGBTQ+ Associations: Many local associations offer psychological counseling desks with professionals trained in gender issues, often at reduced or free rates.
• Word of mouth in the community: Direct experiences of other trans people are often the most reliable resource for identifying competent professionals. Forums, social media groups, and associations can be useful sources.

Positive Signs (Green Flags)

A competent and affirmative professional:

• Uses the person’s chosen name and pronouns from the very first meeting, without resistance or hesitation
• Does not question gender identity as a starting point. They do not ask “Are you sure?” in a way that implies doubt about the identity’s validity
• Has specific training on trans issues, or is actively training. They are familiar with WPATH and APA guidelines [1][4]
• Distinguishes between gender identity and mental health: they do not treat being trans as the cause of distress
• Respects the person’s autonomy: they do not impose timelines, do not slow down the process without documented clinical reasons, and do not use the therapeutic relationship as leverage for power
• Is transparent about their approach: they clearly explain how they work, the expected timelines, and what the evaluation process entails
• Is willing to consult with other professionals on the team (endocrinologist, surgeon) collaboratively

Warning Signs (Red Flags)

Pay attention if the professional:

• Refuses to use correct pronouns or systematically “forgets”
• Tries to explore the “causes” of trans identity as if it were a symptom to be explained (childhood trauma, family dynamics, social influences)
• Asks invasive questions about sexuality or the body that have no clinical relevance
• Suggests that trans identity might be “a phase” or the result of confusion
• Prolongs the evaluation process without clear reasons, adding months of waiting without explaining why
• Imposes conditions not required by protocols (e.g., requiring specific clothing or a “real-life test” period)
• Is unfamiliar with international guidelines (WPATH, APA) or openly ignores them
• Expresses negative personal opinions on trans identity, transition, or the person’s choices

If you encounter these signs, you have the right to change professionals. The therapeutic relationship is based on trust, and no protocol obliges you to continue with an inadequate therapist.

When Therapy is Required and When it is a Choice

In Italy, the line between therapy as a personal choice and therapy as a formal requirement is not always clear. Here is a practical map.

When It Is Formally Required

• To access hormone therapy through the SSN: ONIG centers generally require a psychodiagnostic report [8][11]. The minimum duration of the pathway is six months. In the private sector, practices vary: some endocrinologists accept reports from professionals outside the ONIG circuit, others require the full pathway.
• For gender affirmation surgery: WPATH SOC-8 recommend assessment letters from mental health professionals for surgical interventions [4]. In Italy, chirurgia generally requires one or two psychological reports, depending on the type of intervention.
• For legal gender recognition: The legal process for cambio documenti may require psychological documentation, although jurisprudence is evolving.

When It Is a Personal Choice

Therapy is a resource, not a moral obligation. Many trans people choose to attend therapy regardless of the medical or legal pathway, to:

• Address minority stress and its consequences on mental health [13]
• Process experiences of discrimination or violence
• Manage coming out and family relationships
• Work on self-esteem and internalized transphobia
• Navigate complex life phases (adolescence, parenthood, aging)

Just as many trans people do not feel the need for therapy, and this is an equally valid choice. Not all trans people suffer from psychological distress, and therapy is not an automatic consequence of being trans.

Online Therapy

Online therapy has become a well-established reality, accelerated by the COVID-19 pandemic. For trans people, it offers specific advantages:

• Geographical accessibility: particularly important in Italy, where specialized services are concentrated in the Center-North. A trans person living in a small town in the South can access a competent professional without relocating or facing long journeys.
• Greater choice: the ability to choose from a larger pool of professionals increases the chances of finding a therapist with specific expertise and an affirmative approach.
• Safety: for people who have not yet come out or who live in hostile environments, online therapy eliminates the risk of being seen entering a clinic with signs that could be recognized.
• Continuity: in case of relocation for study or work, the therapeutic relationship can continue uninterrupted.

Limitations do exist: online therapy can be less effective for trauma work (e.g., EMDR often requires physical presence), emotional connection can be harder to establish through a screen, and not everyone has access to a private space to conduct sessions.

Italian regulations allow for online psychotherapy, provided the professional is regularly registered with the Order of Psychologists and follows the National Council’s guidelines for remote psychological services.

Costs in Italy

The costs of psychological therapy for trans people vary significantly based on the access channel.

National Health Service

Psychological support offered by ONIG centers and ASLs is free or requires payment of a co-pay (ticket, generally a few euros per session). The advantage is the low cost; the disadvantage is the waiting lists, which can be long, and the frequency of sessions, often limited to monthly or biweekly meetings.

Private Professionals

In the private sector, the cost of a psychotherapy session generally falls between 50 and 100 euros. Some professionals offer reduced rates (sliding scale) based on the person’s economic situation. The advantage is flexibility in choosing a therapist and session frequency; the disadvantage is the cost, which over a period of months or years can become significant.

Reduced-Cost or Free Resources

• LGBTQ+ Associations: several associations offer free or reduced-fee psychological counseling desks with professionals trained in gender issues
• Family counseling centers (Consultori): ASL counseling centers offer free psychological support, but specific expertise on trans issues varies
• Psychological bonus: the state contribution for psychological support, when available, can cover part of the costs of private therapy
• Universities: some universities with psychology programs offer reduced-cost psychotherapy services, provided by trainees under supervision

The Issue of Sustainability

For many trans people, the cost of therapy is added to other expenses related to the transition (hormone therapy, travel to specialized centers, possible surgeries in the private sector). This creates a disparity in access based on economic resources, which is documented in the literature: trans people with lower incomes face greater barriers to accessing mental health care, and consequently higher rates of untreated distress [13].

International Guidelines: What They Recommend

The main scientific and professional organizations have produced specific recommendations on psychological therapy for trans people.

WPATH SOC-8 (2022). The Standards of Care Version 8 dedicate an entire chapter to mental health [4]. They recommend that mental health professionals working with trans people have specific competence in gender issues, adopt an affirmative approach, and collaborate with the multidisciplinary team. They specify that psychological assessment before medical interventions must be a collaborative and transparent process, not an examination.

APA (2015, 2024). The 2015 APA guidelines are the reference document for psychological practice with transgender people [1]. The 2024 statement strengthens the stance in favor of inclusive, evidence-based care [2]. The APA explicitly recommends that professionals recognize their potential lack of competence on trans issues and train adequately before working with this population.

WHO/ICD-11 (2019/2022). The reclassification of gender incongruence in the ICD-11—moving it out of the mental disorders chapter—has direct implications for psychological practice [5]. It recognizes that trans identity is not a psychiatric condition, while maintaining the diagnosis to ensure access to care. This conceptual shift should translate into clinical practice that does not treat trans people as psychiatric patients.

A 2024 systematic review on the outcomes of affirmative interventions for gender dysphoria confirmed that the majority of studies report significant improvements in mental health, particularly regarding depression [15]. These data support the effectiveness of the affirmative approach and the importance of timely access to care.

What Therapy Is Not

We conclude with some clarifications on what psychological therapy for trans people should not be.

It is not a tribunal. The therapist is not a judge deciding if your identity is valid. If you feel like you are taking an exam, something is not working.

It is not a cure for being trans. Gender identity is not “cured” because it is not a disease [3][5]. If a professional, implicitly or explicitly, works to change your gender identity, they are practicing a form of conversion therapy.

It is not always necessary. Not all trans people need therapy. When it is required as a formal prerequisite to accessing care, it should be an accompanying process, not an obstacle.

It is not a luxury. For those who need it, therapy is a tool for healing. The economic and geographical barriers that limit access to it are not a neutral fact: they are a health equity issue that demands structural responses.

Research and international guidelines converge on one point: when therapy is affirmative, competent, and respectful of the person’s autonomy, it represents a concrete resource for the well-being of trans people [7][15]. When it is not, it can become part of the problem. The difference lies in the professional’s training, theoretical orientation, and the quality of the therapeutic relationship. Choosing carefully is a right.