Clinical Impact Statement: Clients who identify as transgender or gender diverse who seek psychotherapy need competent, affirmative treatment and practitioners. In this article, the authors provide resources and recommendations for therapists to improve their provision of affirmative psychotherapy.
Recently, the population of people who identify as transgender or gender diverse has become more visible in U.S. society. Likewise, there have been calls by psychologists and counselors for more research and scholarship related to gender identity and issues that people who identify as gender diverse might face or present with in therapy. Psychotherapists have a number of guidelines and resources to assist in providing affirmative work with gender diverse clients. For example, the American Psychological Association (APA) published the Guidelines for Psychological Practice with Transgender and Gender Nonconforming People (APA, 2015). The Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) developed their Competencies for Counseling Transgender Clients in 2009. The World Professional Association for Transgender Health (WPATH) published its Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People in 2011 (SOC 7.0) and is currently working on making revisions for SOC 8.0. A number of helpful articles and books to assist therapists have been published in recent years, such as Hendricks and Testa’s (2012) framework for clinical work with transgender and gender nonconforming clients; Singh and dickey’s (2017) text on affirmative counseling and psychological practice, as well as their instructional video on the topic (2018); and Budge’s (2015) article on writing letters for transgender clients.
It is beyond the scope of this article to provide a thorough, extensive review of the literature that is available. Instead, we pull from our own clinical experiences working with gender diverse clients and discuss some of the common themes and issues we frequently see. A caveat is that this article is based on our own experiences, which are limited to clients we have seen in the last approximately 10 years in rural, suburban, and urban areas of the Midwest and Southwest regions of the U.S. Our experiences have included private practice, college counseling centers, medical/hospital settings, public schools, and local LGBTQ centers. Therapists in regions such as the east and west coasts or who practice in different settings may have different experiences, and clients may need different types of resources, or may have better access to resources than our clients have. This article is based on our own professional opinions, is not exhaustive, and we are sure we have missed some things— we welcome others to share their own unique experiences in future publications.
To us, one of the first and most important things for therapists to understand is the importance of language when working with transgender or gender diverse clients. As recently as 2015, when the APA Guidelines were developed, the term gender non-conforming was used. More recently, it seems that the term gender diverse may be preferred as an umbrella term for anyone who does not identify as cisgender. The term cisgender refers to an individual whose sex assigned at birth is congruent with their gender identity. The term non-binary also appears to be more frequently used now than it was five years ago. However, some individuals may find terms like non-binary and non-conforming to be problematic, given that they define populations in relationship to societal expectations or based on who these individuals are not, as opposed to who they are. Thus, it is important for therapists to invite their clients to self-identify, and for therapists to share their own identities as well. Simple steps such as beginning to refer to gender identities rather than to gender identity provides verbal confirmation that the therapist views gender as reaching beyond fixed, binary categories.
Sensitivity to gender diversity has many implications for clinical practice. For example, clinical paperwork may need to be reconsidered. Having an open space on an intake form such as “Gender: _____” rather than offering choices might allow a client to use the language that is most appropriate. We prefer this to offering choices such as Male/Female/Other because this can be “othering.” Therapists should also initiate discussions about gender to fully understand how their clients identify rather than simply what terms their clients use to express their gender identities. We suggest that therapists self-educate and interact with transgender communities to stay current and competent. For example, simply watching online videos by transgender bloggers may provide valuable insight and growth. A great resource for therapists to keep up with terminology is the National Center for Transgender Equality (transequality.org). We also really like FORGE, which is based in Wisconsin but provides wonderful resources and publications that are applicable across the U.S. (forge-forward.org). The book Trans Bodies, Trans Selves: A Resource for the Transgender Community is also a valuable resource for clinicians wishing to gain insight and understanding about many dimensions of transgender experience (Erickson-Schroth, 2014).
Another issue that therapists should be aware of is the use of pronouns. Throughout this article, we use the pronouns “they/them/their” to refer to a singular client in examples. Again, we recommend that rather than assuming that a client who identifies as female would use she/her/hers pronouns, the therapist ask the client what the preferred pronouns are. This may also be included on an intake form with an open-ended response option such as “Pronouns: ______.” We also encourage therapists to offer their own pronouns at the beginning of a therapeutic relationship with a client. Demonstrating awareness that the clinician’s own pronouns are salient (and may not be assumed) communicates to the client that the therapist is thoughtful about the salience of gender identities in the therapeutic process.
Use of pronouns seems to vary by geographic area, current trends, and age of the client. We have found that our older clients tend to prefer more traditional he/him/her, she/her/hers, and they/them/their pronouns. Younger clients, and clients in larger cities or on the east or west coasts, may use pronouns such as ze/zim/zirs or ey/em/eirs. The websites we mentioned previously also have great charts and fact sheets about pronouns. Therapists may worry about getting pronouns “right,” or may accidentally use incorrect pronouns. Like any error made in therapy, we believe it is best to have a transparent conversation about this, apologize, and make a conscientious effort to do better next time. We strongly advise against the use of terms like “preferred” or “chosen” gender or pronouns; this implies that gender identity is chosen in some way. As we know from transgender scholarship, gender identity is not a choice and implying that it is may create considerable fractures in the therapeutic relationship.
Another term that therapists may hear in relation to this population is transition or more accurately transitions because the singular form of this word assumes that one type or process of transition applies to all transgender populations. It is important to know that while people who identify as transgender may choose to transition, many do not. Also, transition is a completely individual experience: No two transitions are alike. As part of transition, some clients may change their names. Whether a legal name change has happened or not, it is important that the therapist use the client’s identified name and offer a place on the intake form for this information. We understand that for some legal purposes, such as insurance billing, it may be necessary to track two names simultaneously; we do not feel this is an undue burden for the therapist. We have worked with clients who have wanted to experiment with how different names “felt” over time, and who have asked us to use multiple different names over time. We reflect this in our case notes and refer to clients using their current, identified name and pronouns.
For many clients who transition, it is helpful to put together a timeline or plan, including financial cost or resources. It is important to remember that transitions may occur on a variety of levels or within a variety of life domains. Social transitions may occur interpersonally between transgender people and their loved ones, family, and friends. Legal transitions involve name and gender marker changes on government documents. Some transition-related actions may include coming out to family members, friends, or coworkers; legal name change; gender marker change on identification and government documents; wardrobe change; and therapy, if required for hormone replacement therapy or for gender affirmation surgery. For clients who identify as male, other aspects of transition could include binding or packing. For clients who identify as female, transition might include removal of body hair through electrolysis, practicing voice (sometimes through coaching), or wearing breast prosthetics. Within the context of clinical work, therapists may benefit from knowing the extent to which a client has transitioned or plans to transition. Therapists may feel the need to ask deeply personal questions about aspects of physical transition. We encourage therapists to recognize how invasive these questions may be and how trusted and privileged therapists are as they engage in these conversations. Such questions should never be made out of personal interest or outside of the therapeutic interaction, and these conversations should be led by the client.
For any client who is transitioning, being misgendered is a frequent source of frustration, hurt, sadness, and anger. In our experience, clients are more forgiving of strangers who might misgender them (although this, too, is frustrating), while being misgendered by their close family and friends is particularly hurtful and rejecting. Family members and friends often misgender, either deliberately or by accident, even after multiple reminders. When a client tells a therapist about an experience of being misgendered and the hurt related to this, it is important for therapists to validate this experience. These clients may get messages such as “you’re making a big deal of this,” or “you will always be my little boy/girl,” or “don’t be so sensitive,” so it is crucial for therapists to listen and empathize. On the other hand, we have also had clients who have attempted to diminish these experiences in therapy, and for whom it took a while to recognize the pain these experiences were causing.
Therapists may wonder what therapy should actually look like. The approach that therapists take does not need to differ from the approach they may take with other clients, but should be affirmative in nature. We recommend that any therapist who works with gender diverse clients fully familiarize themselves with the APA guidelines, the ALGBTIC competencies, and the WPATH standards of care, at a minimum. It is important to note that clients who identify as transgender or gender diverse may present with other concerns, and gender identity may not be their foremost concern. The therapist should work collaboratively with the client in a client-centered manner. For example, if a client transitioned years ago, and presents with concerns related to her current romantic relationship, then the therapist should focus on the romantic relationship as the presenting concern, rather than the transgender identity. On the other hand, if a client states that they want to work toward transition and are hoping for a letter of recommendation from the therapist, it is important for the therapist to assist with that. Therapists who are unable to write letters of support or to aid the client in transition-related actions must be upfront about this at intake. We have heard stories from clients and community members who saw therapists for months before discovering that their therapists would not provide supporting letters. This can be devastating for a client because it has the possibility of setting their transition back and may separate them from necessary and/or life-saving services.
Consider this example of affirmative therapy: Imagine that Sam is your client. Sam is a 22-year old male-identified client who was assigned female at birth. Sam uses they/them/their pronouns. Sam tells you that they reached out to make an appointment with you because they are feeling frustrated with their previous therapist. Sam tells you that they are limiting and controlling food intake. Sam has periods of depression and suicidality and uses substances to cope. Sam also states that they are experiencing high levels of gender dysphoria. In this case, how would you proceed with the client? Would you focus on the disordered eating? Would you focus on the depression and suicidal thoughts? The client states that they think about dying or suicide more days than not. Does the client need treatment for substance abuse before going forward with psychotherapy? Would you recommend the client receive hormone therapy?
Clearly, it is important to consider the client’s safety. If a client is imminently in danger, then appropriate steps/precautions have to be taken. However, in our clinical judgment and experience, approaching the client as someone who is autonomous and who knows themselves as a gender diverse person should be foremost in the therapist’s mind. Budge (2015) provides an excellent discussion about the gatekeeping role that therapists are currently asked to play and whether this fits with our ethical code and moral principles.
With this client, as you explore issues related to gender, you learn that they are limiting food intake because experiencing menstrual periods heightens gender dysphoria and, subsequently, depressive symptoms. You learn that Sam’s family has rejected them completely so they are working 30 hours per week while maintaining a full course load at college. We recommend working with the client to explore gender, the current living situation, and to put gender first as a priority, while also doing frequent check-ins regarding suicidality and eating. WPATH (2011) guidelines strongly establish that being allowed to transition, and starting hormone replacement therapy, reduces depressive symptoms and improves mental health. Furthermore, starting hormone replacement therapy could reduce or halt menstrual cycles, which could also diminish gender dysphoria experienced by this client.
Though we have only been able to brush over the many themes and presenting concerns that may arise in work with gender diverse communities, we hope that this brief overview will provide a first step for therapists who wish to increase their competence with gender diverse clients. The body of literature regarding transgender and gender diverse affirmative practice is growing exponentially and therapists have the opportunity to reach this community in informed and thoughtful ways like never before. We hope you will choose to incorporate transgender affirmative awareness into your own practice.
Cite This Article
Koch, J. M. & Knutson, D. (2018). Practice recommendations for psychotherapy with gender diverse clients. Psychotherapy Bulletin, 53(2), 44-48.
American Psychological Association. (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70(9), 832-864. doi: 10.1037/a0039906
Association of Lesbian, Gay, Bisexual, and Transgender Issues in Counseling. (2009). Competencies for counseling with transgender clients. Alexandria, VA: Author.
Budge, S. (2015). Psychotherapists as gatekeepers: An evidence-based case study highlighting the role and process of letter writing for transgender clients. Psychotherapy, 52(3), 287-297. doi: 10.1037/pst0000034
dickey, l. m., & Singh, A. A. (2018). Affirmative counseling with transgender and gender diverse clients [DVD]. United States: American Psychological Association.
Erickson-Schroth, L. (2014). Trans bodies, trans selves: A resource for the transgender community. New York, NY: Oxford University Press.
Hendricks, M. L., & Testa, R. J. (2012). A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the Minority Stress
Model. Professional Psychology: Research and Practice, 43, 460-467. doi: 10.1037/a0029597
Singh, A., & dickey, l. m. (Eds.). (2017). Perspectives on sexual orientation and diversity. Affirmative counseling and psychological practice with transgender and gender nonconforming clients. Washington, DC: American Psychological Association.
World Professional Association for Transgender Health (2011). Standards of care for the health of transsexual, transgender, and gender nonconforming people: 7th Version. Retrieved from http://www.wpath.org