4.7 What the research tells us about affirmative practice

There is research evidence of the benefits of affirmative practice. A 2023 systematic review found that affirmative therapy was associated with reduced distress, depression, anxiety, suicidality and substance use as well as better coping and emotion regulation, self-esteem and self-acceptance (Expósito-Campos et al., 2023). A survey of trans (including non-binary) clients found that affirmative practice was associated with better therapy outcomes and client satisfaction (Pepping, Cronin and Davis, 2025) while a trans-affirmative approach, a nurturing therapeutic bond and recognition of both authentic gender and client experiences of cisnormative stigma were all associated with better therapy outcomes in another systematic review (Mezzalira et al., 2025).

Trans people will come to therapy with a range of issues that may require and respond to different approaches. Practising affirmatively is about being non-discriminatory in the way we practise our individual modalities, i.e., making sure a range of therapeutic modalities are accessible to trans clients by ensuring they are affirmative. Practising affirmative therapy is not a separate approach and it is not just for trans people – it is just as important to be trans affirmative in our stance with clients presenting as cis, because they or a loved one may at some point come out as trans, or they may have transitioned historically and not be out to us.

There is a small but growing body of literature on modality-specific trans-affirmative practice, such as:

• Pachankis et al.’s (2020) evidence for affirmative, minority-stress-focused CBT interventions for anxiety and depression.

• Haziza and Pehkonen’s (2025) proposal of the value of psychodynamic group psychotherapy for trans people.

• Crowter’s (2022) argument for the radical value of a person-centred approach – especially unconditional positive regard – for working with trans clients.

Pachankis (2018) presents existing quantitative evidence for affirmative practice and argues for creating a further evidence base for its effectiveness. Examples of such a growing evidence base include Pachankis et al.’s (2020) evidence for affirmative, minority stress focused CBT interventions for anxiety and depression.

Austin and Craig (2015) discuss adapting CBT for trans clients with depression and anxiety, while Livingstone (2011) outlines the benefits of a phenomenological, affirmative, person-centred approach to counter experiences of pathologisation and shame.

The ICTA project suggests that further research is needed to inform and improve practice, in particular:

• Which kinds of services/approaches are a priority for developing and evidencing affirmative practices – for example, our data suggests a high need of domestic and sexual violence services, services for neurodiversity (autism, ADHD, dyslexia, etc.)
• Quantitative evidence to back up the qualitative evidence of the benefits of a non-directive, trans-affirmative approach in which clients can explore gender identity without being steered or suppressed, or fearful that expressions of uncertainty will undermine them.