‘Gender identity work affects everyone’

'I'm involved in so many things. That's one of the joys of being a psychologist,' Laura says at the very start of our interview. Her new co-authored book, Gender Affirming Therapy: A Guide to What Transgender and Non-Binary Clients Can Teach Us, signposts her role as a gender, sexual, and relationship diversity specialist, a major element in her varied work. So, I asked her first what areas she was involved in at the moment, apart from writing and promoting the book.

'A lot of my time is taken up with Affirm, an online platform which trains mental health and other healthcare professionals to offer better support to gender-diverse clients and their wider network.' We discussed the importance of this sort of training later in the interview, but initially talked about the challenges of entrepreneurship. 'At first, I thought setting up Affirm would be easy, but I'm quickly having to learn about shooting and editing videos, how to create an online presence, salesmanship, and the hardships of making one's vision a reality. My co-founder, Michael Beattie and I constantly deal with ignorance about trans issues and we believe that our responsibility as psychologists specialised in this field is to advocate for our client's needs and rights.'

Laura says she is 'well aware of the politicisation of trans lives, and when I'm asked to speak in the media, I have to tread carefully to try and understand what an interviewer's own motives and views are, and whether the challenges faced by trans clients will be used to inform or as ammunition.'

Laura also has her own private practice where she deals with a wide variety of issues but specialises in working within LGBTQI+ communities. I asked her about her work with clients considering medical transition. 'I provide endorsements for trans and non-binary clients who are seeking to access hormone therapy and surgery. They undergo a two-stage process. The first stage involves an assessment to confirm that the client's experience of their gender matches the diagnosis of HA60 Gender Incongruence while providing a differential diagnosis. I look at their physical and mental health with a special attention to any history of trauma, and I ask about forensic history.

'The second part of my work is to examine whether accessing gender-affirming care is a good idea at that stage in the client's life and whether their expectations of the treatment are realistic. Even though rare, one of the main risks to consider is that of regret and de-transition, this happens in approximately 0.3 per cent of cases, and one of the main drivers is family and community rejection. I use a tailored therapeutic approach and I focus on understanding the person's needs and expectations from an intersectional point of view.'

Laura comments on this latter point: 'I grew up in Spain and my training was very CBT and evidence-based. We spent about one afternoon on psychoanalysis and I didn't know what counter-transference was until I came to the UK. However I've become very interested and studied a wide variety of approaches including compassion-focused therapy, mentalisation-based therapy, schema therapy, and others – drawing from all of these in my work. Feedback from patients suggest this makes my therapeutic approach both personable and affirmative.'

Drawn to the underdogs

Since Laura had raised the issue of her training, I asked her to tell me a bit more about how she had started in psychology and begun to specialise in the area she is obviously so passionate about. What's fascinating is the hugely different areas of work she's been involved in over such a brief time.

'My parents are South American, in the 70s they migrated to Spain, and that's where I grew up. Like with many other psychologists, both my parents suffer from mental health conditions. I was a parentified child, with an immigrant identity, and a small family unit. My supervisor once asked me "why are you so drawn to the underdogs?" Perhaps it's a blend of my personal journey and an innate draw to those facing adversity. Funnily enough, a neighbour recalls my ten-year-old self proclaiming, "One day I'm going to be a psychologist". And whilst I've always toyed with the idea of writing, I'm still on the fence about whether one book lets me wear the writer's hat!'

Laura tells me she does like 'boxes and classifications' but, at the same time, is fascinated by exceptions to these. 'During my traineeship, I worked at a variety of hospitals with physical health conditions, like cancer, chronic fatigue, and obesity. That focus on physical health gave me experiences which help me now in assessing clients who are considering accessing gender-affirming interventions.'

Laura didn't know what role she wanted to take up after her initial training. She travelled to Chile and got a job for about a year as a community psychologist living in the epicentre of what had been an extraordinarily destructive earthquake. Her job was to reduce teenage drop-out. 'Nothing prepared me for living in such a deprived area. In addition there was no supervision, so I was assigned 60 teenagers and told to assess them and identify who I could work with. Home visits could be very challenging and introduced me to trauma and family dysfunction. I was underprepared and at times very lonely, so I adopted a dog! In retrospect the whole arrangement was irresponsible, but it taught me so much, not least that you had to win trust as a psychologist, you couldn't expect it.'

Starting a private practice in Chile prepared her to do the same thing in England where she came in 2012 at the time of the London Olympics. 'I'm a great believer in instinct and it just seemed the right thing to do.' Getting the Health and Care Professions Council to validate her title in the UK was a long and laborious business so she worked as a live-in an au pair and as a refugee support worker among other things. Her first qualified psychology job was at a psychiatric hospital in Redhill before working with adolescents in Oxleas' CAMHS services.

Before taking the big leap to fully working for herself, Laura became Head of Mental Health Services at Teladoc Health UK and Ireland. 'This was one of the most challenging yet satisfying roles of my career, it involved designing what a psychological service looked like. I was involved in deciding the number of sessions a client might need; organising supervision; defining marketing materials; looking at effective recruitment and who the service was for. We set up a 24/7 call centre and after two years, I had a team of 80. I'm very proud of what we achieved there and the business skills I learnt.'

The beginning of Laura's involvement in gender identity work began when she applied for two jobs – one in gender identity, one in a specialist cleft palette service. And, as luck would have it, she was recruited at the London NHS Adult Gender Clinic (the GIC), leading her to where she is today. When the pandemic started, she realised that it would be possible to carry out her work online, and last year she moved back to Tenerife.

'No two trans people are the same'

What do you like about working in the area of gender identity? 'It pushes you to learn about history, politics, sociology, medicine, and it is constantly evolving. That's the first point. The second is that this work affects everyone, not just trans people. The way we perform our own masculinity and femininity and the role of a man or a woman are transforming. So, we too have to question how we are boxing ourselves to meet societal gendered ideals. Lastly, no two trans people are the same. For example, I recently worked with a trans man and a trans woman both of whom were wheelchair users, to me it was fascinating to learn how they were more or less likely to be gendered correctly if using their manual or electric wheelchair.'

In addition, 'as a psychologist you can really contribute to a fast-developing field. I remember getting really excited when in 2019 I realised that there was virtually no literature I could find on the relationship that trans people form with the mirror, and this drove me to start writing about what my clients had taught me.'

What are the issues in the future for the area? 'The closure of the Gender Identity Developmental Services within the Tavistock means all services that are not necessarily gender specific have to take gender-diverse clients. Many practitioners might never have met someone considering transition or questioning their gender. Practitioners need training to support trans people and to feel more confident when doing so. Many are afraid of saying the wrong thing and may not have done the work to challenge their own preconceptions. Hence our decision to set up Affirm. I see this shift as a broadening of gender services, making them more accessible and inclusive. It's crucial, however, to acknowledge the concerns and anxieties of the trans community, especially with the changes in the GIDS. My intention is always to advocate for better, clearer, and more compassionate services for all.'

You suggested that Spanish training and approaches are different from those in the UK. Is that still the case? 'Broadly, British culture emphasises the creation and following of rules, whereas Spanish culture treats rules as guidance. I have felt at home in the UK for this reason, it provides a sense of purpose and security that at times I struggled to find working in Spain. Also, it is interesting that in Spain you can only train as a psychologist, there is no equivalent of psychotherapists, counsellors, PWP, or any other mental health practitioner.'

And what does the future hold for you? 'I want to build a community of practitioners around Affirm, and I hope to have authored more books. I'm also intrigued by the potential therapeutic benefits of psychedelics, given the emerging research in this area. If the legal landscape changes and it becomes a mainstream treatment option, I'd be interested in exploring training as a psychedelic psychotherapist. It's about staying informed and open to new therapeutic avenues that can benefit clients'.'

- Read a chapter from Laura's book, which is reviewed here.