11 Steps Toward a Trans-Inclusive, Gender-Affirming Therapy Practice

The out transgender and gender nonbinary (TGNB) community is one of the fastest-growing segments of the US population: in 2016, 1.4 million adults in the US identified as transgender (1), and in 2017, 12% of millennials identified as transgender or gender nonbinary (2). Researchers attributed the growth of the out TBNB population to increasingly accepting environments, increased gender diversity in media, and overall greater safety in coming out.

At the same time, these advances have not been experienced equally. Those whose identities lay at the intersection of multiple marginalized communities, and notably Black transwomen, remain at high risk for violence and rejection, and a staggering 48% of transgender adults considered suicide in the past 12 months (3). This creates an urgent need for compassionate and knowledgeable mental health care, and yet when individuals did seek help, a third who saw a health care provider had at least one negative experience related to being transgender, and nearly a quarter reported that they did not seek the health care they needed due to fear of being mistreated (4).

As a growing population, and one that is exposed to pervasive mistreatment and at elevated risk for psychological distress, it’s key that all therapists be equipped to talk about gender openly and competently, regardless of whether they plan to focus their practice on work with TGNB individuals. Below, therapists who specialize in gender-affirming care share insight into how you can begin investigating the impact of gender-based oppression and make your practice a safe landing place for folks of all genders.

1. Dedicate time for research and self-reflection, outside of session

In order to show up fully for each client who comes your way, it’s important to dedicate time outside of session to understanding how gender-based oppression impacts health and the experiences of daily life.

Barbara Warren, a psychologist in NYC and Director of LGBT Programs and Policies at Mt. Sinai explains, “As therapists, we have a responsibility to self-educate on gender identity and expression, whether or not we intend to work with TGNB clients or advertise ourselves as experienced in facilitating gender identity exploration and transition. Sometimes our clients will come to see us for another issue or concern and in the process the issue of gender identity and expression will emerge.”

Therapist Ben Davis, an expert in culturally competent care for trans and nonbinary individuals, reminds us just how pervasively the dominant culture can shape a therapist’s perspective, in and out of session: “Systemic racism, heterosexism, ableism, and cisnormativity have infiltrated our education, the measures we learn to evaluate clients, and even our diagnostic criteria,” he explains. “Recognizing that we have a lot to learn is the first step in realizing our own biases and privileges, and more specifically, how those affect our clinical care and relationships with our clients.”

The more time you spend intentionally seeking out educational resources and engaging with media that positively centers the narratives of TGNB individuals, the less clients may feel a burden to educate you themselves.

Shannon Cruz-Herr, a psychotherapist in NYC focused on providing LGBTQIA-affirming therapy, shares the importance of learning about all aspects of TGNB identity: “We've got to deeply learn about trans history as well as the continued fight for equity. We've also got to learn about the beauty, strength, and vibrant creativity of trans culture.”

Beyond researching experiences that may be different from your own, it’s also important to investigate and reflect on your own experiences of gender. For cisgender therapists, that includes examining the ways in which gender-based privilege has played a role in your life, and the experiences you have both in and out of session.

As Cruz-Herr says, “As therapists, we are always on the look-out for our countertransference and working to make our own biases conscious. For those of us cisgender therapists, we must also keep an eye out for our cis-fragility through these processes.”  For Nicole Issa, a psychologist who provides gender affirming therapy, the antidote is “trainings, supervision, and regular collaboration with LGBTQIA+ affirming providers.”

2. Affirm the experiences of transfolk within the context of their intersecting identities

When working with clients from any marginalized community, recognizing and affirming the impact of oppression on mental health is paramount to successful therapy. For TGNB folks, this may include direct instances of transphobia and discrimination, as well as the stress associated with belonging to a minority group: according to a 2015 survey of transgender individuals, both being unable to turn to family of origin for support and experiences of victimization were independently associated with greater psychological distress (5).

Trans-affirming psychologist Justin Martino-Harms shares the need to be aware of the myriad ways and degrees to which these experiences can impact TGNB individuals, and to understand and embrace identities beyond their gender: “Part of my responsibility is to be aware of all the big and small ways transphobia and other forms of oppression impact people,” they share. “Trans people aren't just trans, but all of us have complex identities, so awareness of racism, sexism, homophobia, xenophobia, and ableism are all essential to being actively affirming to trans clients.“

For Dr. Warren, this process begins at intake. “The assessment process with any therapy client includes not only the issues that the clients are seeking help with, but often learning about other experiences, relationships and social determinants that may be affecting or impacting those issues, concerns and feelings. All of the clients of transgender identity and experience I have seen are aware that they are affected by and challenged by minority stressors, which include actual and anticipated societal rejection, discrimination and bias, microaggressions, and even violence against TGNB people. For those clients who live at the intersections of TGNB identities and face racism, classism, and sexism, the effects can be overwhelming. Part of my role is to assist my clients to become aware of those connections and the impacts upon their mental health, when relevant and helpful, and to enhance their ability to address any trauma reactions and to develop coping strategies and support systems.”

3. If you’re not sure what a term means, ask, don’t assume!

One way to demonstrate your commitment to gender inclusive care is by familiarizing yourself with LGBTQIA+ terminology. Victoria Stanton, a therapist at the gender-affirming practice Arcus Behavioral Health and Wellness, says, “Being able to demonstrate knowledge and understanding the basics of LGBTQ+ culture may allow your client to feel more comfortable opening up about some of the nuanced language.”

Still, as the dictionary of terms folks may use to describe themselves and their identities continuously evolves, it’s important to admit the limits of your knowledge. If a client uses a term you’re not familiar with, Stanton recommends you just ask.

“Given the rapid development of language, it is difficult for many in the LGBTQ+ community to keep up to date with things as well,” she says. “I would just ask rather than risk missing out on a potentially important piece of information.”

Dr. Warren also encourages therapists not feign knowledge or avoid the topic, and provides helpful language for how to respectfully ask for clarification: “I am not familiar with (that term).  Would you be willing to share with me what that means to you? I will also make sure I do my homework to learn more about it.”

At the same time, as you conduct your research, be sure to keenly attune to the individual experience each client brings into the room, rather than make assumptions. Avoid applying generalizations or stereotypes to your client, or assuming similar experiences apply to another client who may use the same word to describe themselves down the line.

4. Use gender-neutral & affirming language

In order to avoid making assumptions about a client’s gender and the gender of the people they interact with (family members, friends, partners), and to affirm the experience of folks who do not identify with a binary gender, shift your speech patterns to use neutral terms.

Here are some gender neutral terms you can use:

• They / Them / Theirs - instead of “he/she,” “him/her,” “his/hers,” (until instructed of other pronoun usage; then use the specified pronouns).
• People, Folks, Friends - instead of “guys”
• Child or Sibling - instead of “son/daughter” or “brother/sister”
• Partner(s) or Spouse - instead of “boyfriend/girlfriend” or “husband/wife”

This also applies to the written content you put out online; for example, instead of saying that you work with “men and women” or “people of both genders,” you might say, “adults” or “people of all genders.”

Once instructed, it is vitally important to use a client’s designated pronoun. Davis explains, “Misgendering signals a clear unseeing or disbelief of a person's authentic identity, or communicates that the effort necessary to relearn those parts of a person's identity isn't worth the time or effort to do so.” To avoid further harm, according to Stanton, “If it remains difficult to use the correct pronoun, you may opt to use the person's name instead.”

Similarly, it’s important to ask how partners or other important individuals should be described: gender and sexuality are separate and discrete constructs, and identifying as transgender or nonbinary does not relate to if or how a client experiences sexual attraction. If it has not been made clear if or whom a client is interested in dating, don’t jump to conclusions based on their gender presentation or expression. Instead, use neutral terms, or if it seems relevant and important to treatment, consider asking in open-ended, nonjudgmental questions.

5. Take a systems approach, and then let clients guide how much gender is the focus of treatment

While the real impact of living as a marginalized person cannot be understated, it’s equally important not to assume that gender is always related to presenting challenges, or that it needs to be a focus of treatment. A good rule of thumb is to allow the client to be the guide.

Dr. Jolie Weingeroff, a psychologist at the LGBTQIA+ affirming practice PVD Psychological Associates, explains how she follows the client’s lead while also keeping in mind the impact of gender on a client’s experience: “I never assume that one’s gender identity or being trans, non-binary, or gender nonconforming needs to be a focus in therapy,” she explains. “At the same time, it is also important to understand the nuances of your client’s daily experiences.”

Cruz-Herr agrees: “We have to approach treatment with trans or gender non-conforming clients from a systems-based perspective, holding their trans/GNC identity in mind while respecting their lead in whichever direction treatment needs to go. We've got to see trans-ness as part of their identity, not their only identity.”

For Dr. Martino-Harms, a client’s experience must always be considered in its totality. “Because I have base knowledge of how oppression shows up in my client's lives, I'm then able to focus on exactly what the client is looking to work on, but also be keenly aware of how oppression might relate to the work we are doing. For example, we might be working on depression, but then it becomes clear that the client is isolated because social connection is being hampered by transphobia.”

6. Beware of microaggressions

Microaggressions are subtle slights that serve to derogate, invalidate, or shame members of marginalized groups. For TGNB individuals, daily exposure to microaggressions might contribute to feelings of shame, low self-esteem, and psychological distress.

Ruben Hopwood, a gender-affirming psychologist, presents a few ways therapists may (knowingly or unknowingly) commit microaggressions:

Backhanded compliments

• “You look so good; I never would have known you’re trans.”
• “I thought you were a real [wo/man]. You look great!”
• “You’re pretty/handsome/attractive for a trans[wo/man].”
• “But you’re so attractive, why would you want to become a [wo/man]”
• “But if you are using your [genitals] and enjoy that now, why would you want to have surgery and lose that? What will your partner(s) say?”
• “You are so lucky you won’t ever have to experience ___ (e.g., PMS, menstrual cramps, pregnancy, prostate problems, erectile dysfunction).

Presumptions about sexuality

• Assuming all trans or gender diverse people identify as part of the LGBTQ+ community or want to be “out and proud.”
• Assuming that gay and lesbian trans people would not be able to find cisgender partners if they wanted to.
• Assuming all Black trans women use sex‐work for survival now or in the past.
• Assuming gender affirmation is all about sexual behavior (fetishing the client).

Unnecessary outing:

According to Dr. Hopwood, “More insidious microaggressions can include outing a client to another professional when it is not a necessity for the consultative support needed, and implicitly leading clients to tell a socially acceptable stereotyped narrative of their own gender identity development.”

At the same time that it’s important to avoid committing microaggressions, also pay close attention to where the urge comes from, and the beliefs that drive them. If they persist, consider seeking supervision from an experienced gender-affirming professional.

7. Avoid a focus on transition

Transition is a deeply personal and highly variable process; while the arc that has long accompanied trans tropes begins with “being born in the wrong body” and “ends” with medical transition, this a binaried way of looking at gender that does not reflect the experience of many TGNB individuals, and can cause real harm to assume as a goal.

According to Dr. Hopwood, assumptions about transition can amount to microaggressions, including:

• Assuming all trans and gender diverse people want gender affirming hormone treatments;
• Assuming that if someone needs a gender affirming surgery it must mean they’re really binary‐identified;
• Assuming that there is only one surgery and it is genital reconstruction.

Dr. Martino-Harms recommends staying client-centered, and also focusing on the client’s emotional experience with their body rather than the physical body parts. “When someone brings up transition, I let the client lead the conversation and stay focused on what they want to happen regarding their body. As a mental health professional, I really don't need to know anything about someone's body, and it's none of my business asking. Asking about the joy and affirmation, or the pain and dysphoria someone feels about their body is very different from asking about specific body parts. Our job is to understand our client's emotional experiences related to their body, not learn about the specifics of their body. Oftentimes a client will talk about specifics related to their body within the conversation, but it's not our job to ask about specifics.”

8. Apologize for mistakes

Folks at any stage of critical engagement with gender are liable to make mistakes. When those mistakes occur, for example, if the incorrect name is used, it’s important to acknowledge the harm done by apologizing and building a plan to avoid the mistake in the future. At the same time, dwelling on the error can distract from treatment and lead the client to feel guilty or like they need to comfort the therapist. To avoid this experience, Stanton suggests therapists should simply “Correct themselves and move on.”

To make amends after a mistake, Dr. Hopwood offers a three-pronged strategy for apologizing:

1. Name what you did

Say, “I am sorry I called you by the wrong name.”

2. Make no excuses

If you know the mistake you made, correct yourself by addressing the client by the correct name, and calmly restart the conversation again. If you do not know what you did, say, “I know that I have made a mistake, but I am not sure what it was. Would you be comfortable sharing that with me?”

3. Build a plan to address future recurrences

Say what you will do in the future to avoid this mistake while not making false promises, such as that you will never use the wrong name again. For example, you might:

• Invite the person to correct you in the future
• Make a note in the chart and/or alert other providers, if the person wants that information to be shared with the relevant parties
• Agree to ask at the start of each session if there have been any changes in name or pronoun since the last time you met.

9. Build gender inclusive practice logistics

The safety of your practice extends to client experience outside of direct contact with you, too. Here are a few considerations to set up an inclusive space:

• Restroom access: If you’re choosing a new office location, look for one that has private access to a single stall or gender neutral restroom. If you share your space and don’t have an all gender restroom, make a plan with suitemates to designate one as such.
• Waiting room & office decor: Consider what materials are available in your waiting space: do they positively feature gender diverse people, and include inclusive and affirming messages? Are there other physical symbols of inclusivity in your office, such as a Trans flag?
• Online presence: Take a deep look at how and when you describe the clients you work with on your website and directory listings. Are topics related to the care of transfolk integrated into every page of your website and piece of your bio, or relegated to one separate tab or paragraph? And, if you feature badges of trainings you’ve taken or organizations you belong to, when was the last time you engaged with those communities? Are they still a good reflection of your learnings in the present day?
• Intake paperwork: Routinely ask for a client’s name and what pronouns they use at intake, and provide a “fill in the blank” question for gender identity so that clients can use their own language to describe themselves rather than a binary or multiple choice. If possible, avoid asking for a “dead” name; if a client is in the process or has had a legal name change, you may only need to know their chosen name, even for insurance purposes.

10. Engage in the local LGBTQ community

As you continue to further your education in gender affirming care, consider turning to local community leaders and organizers.

According to Dr. Martino-Harms, “Understanding the details of experiences that are common for trans people within your local community or region is the best place to start. Attending local events hosted by LGBTQ organizations, following local LGBTQ organizations on social media, or finding another therapist in the area who specializes in supporting trans folks and asking to buy them lunch. The more local and personal your education can be, the better. The experiences of trans people can vary widely depending on city and state laws, as well as regional differences in culture.”

Davis agrees, “Engaging with the community outside the confines of the clinical environment may be the most educational. Consider seeking out trans led organizations and events, following trans leaders on social media, and engaging in advocacy from a strength-based (rather than pathology-based) framework.”

For Dr. Warren, “This is often where the personal and the political meet: getting involved in support groups, educational initiatives and organized advocacy efforts can be a powerful antidote to oppression, create new support networks and be very empowering to the individual client.”

11. Commit to continued learning

Undoing the work of systemic oppression does not happen overnight: it takes a consistent practice of engagement, learning, and unlearning.

Davis reminds us of the importance of ongoing work. “Consider committing to an ongoing practice around inclusivity. Seek out professional development and continuing education that discusses up-to-date best language and practice, and dialogue with informed colleagues about community needs. One common complaint is that therapists signal trans inclusivity at first glance, but lack the essential knowledge to support a client throughout their care.”

After consulting local resources, here are other therapist-recommended resources to continue learning about gender-affirming therapy, gender identity and trans experiences.

Formal trainings

• NYC - Biannual Trans Identity Symposium, Sponsored by Institute for Contemporary Psychotherapy
• Philadelphia - Trans Wellness Conference

Books

• Trans Bodies, Trans Selves, Laura Erickson-Schroth
• A Clinician's Guide to Gender-Affirming Care: Working with Transgender and Gender Nonconforming Clients, lore m. dickey and Mira Krishnan

Articles

• Interpersonal Psychoanalysis and Sexuality, Mark Blechner (2011)
• Understanding Gender throught the Lens of the Transgender Experience, Jack Pula (2015)
• The Body One Is: The Best Form of Containment or The Crying Game Redux, Aisha Abbasi and Susan McNamara (2015)

LGBTQIA terminology

• National Center for LGBT Health Education at the Fenway Institute

Professional & non-profit resource centers

• The World Professional Association for Transgender Health
• American Psychological Association LGBT Resources
• Human Rights Campaign Insurance Resource
• The Trevor Project Trans & Gender Identity Resources
• PLAG Transgender Resources
• Gay Lesbian Straight Education Network

Other media centering trans experiences

• Documentary: Disclosure
• TV Show: Pose
• Annotated TGNB reading list from the NYPL

Sources

1. How Many Adults Identify as Transgender in the United States?
2. GLAAD: Accelerating Acceptance 2017
3. The Report of the 2015 U.S. Transgender Survey
4. Ibid.
5. Demographic and Psychosocial Factors Associated With Psychological Distress and Resilience Among Transgender Individuals