Over the past few years, visibility for the transgender community has risen to an all-time high. It is no surprise that mental health professionals are witnessing what appears to be an influx of transgender and gender-variant individuals in care. In reality, gender variance has always existed; however, the recent increase in visibility has created a forum for transgender people to have a more open dialogue with service providers. But many mental health providers and their agencies say they feel unprepared and ill-equipped to provide ethical and culturally competent treatment in response to these emerging issues.
The field of mental health is dynamic and ever-evolving, and the presence of unique and unfamiliar issues is commonplace in our profession. To achieve clinical competency, we are called to educate ourselves about gender identity issues in the same way that we are called to educate ourselves in other matters. While clinical competency is a cornerstone in this endeavor, a knowledgeable provider cannot affect change in a stagnant system. The intention of this article is to provide guidelines for the professional to increase competency and identify the infrastructure needed to create a safe and affirming treatment environment.
Transgender individuals face a variety of challenges throughout their lifespan. From a very early age, children are socialized to understand gender as a culturally constructed binary of male-female, prescribing what is considered to be socially acceptable behaviors, preferences, and expressions. In doing so, this gender binary creates outliers. In an effort to avoid isolation and fulfill the need for belonging, children may feel compelled to participate in gender-conforming behaviors that are at odds with their true sense of self. This creates a paradox in which both conformity andnon-conformity produce distress in the individual. As transgender individuals explore their gender identity, they may also face ridicule, disapproval, or even complete rejection from those around them.
Historically, mental health providers have been critiqued as pathologizing gender non-conformity and conceptualizing treatment as an effort to make the client more comfortable in their assigned sex. This ideology is most evident in earlier versions of the Diagnostic and Statistical Manual, which classified gender incongruence as a mental illness. The recent publication of the DSM 5 and the new diagnosis of Gender Dysphoriahave created a paradigm shift, in which we no longer view gender variance through the lens of disease. Instead, the goal of treatment is to alleviate the discomfort and distress associated with the incongruence between one’s gender identity and assigned sex at birth.
As helping professionals we must become culturally competent in our work with this population and set the stage for acceptance. There are many practical ways to embody this effort. We must first consider the role of our personal values and how they may impact the treatment we provide. At times, the values of the helping professional may conflict with the values or behaviors of the client. These conflicts must be recognized and addressed to prevent potential influence on the therapeutic experience. Furthermore, as professionals we must take every opportunity presented to challenge the misinformation, lack of acceptance, and outright hatred which may occur around us, and embrace our role as advocates for change.
The most critical aspect of treatment in working with gender-variant individuals is the establishment of a strong and healthy therapeutic relationship which is immersed in unconditional positive regard. Unconditional positive regard is crucial in relationship-building, and it must be accompanied by established practical measures which allow the individual to feel safe and respected:
- Never assume. All gender-variant individuals are unique. We must be careful not to generalize the transgender experience. It is vitally important to ask our clients to self-identify so that we can adopt their language and refer to them correctly.
- Always use the client’s “preferred” name and pronouns.Misgendering our clients, whether intentionally or unintentionally, has a lasting and significant negative impact and can set the tone for treatment.
- Respect privacy and confidentiality. Information about a client’s gender identity is personal. We should discuss with the client how, when, and with whom information is to be shared.
- Be knowledgeable. Helping professionals should have at least a cursory knowledge of the different social and medical transitions available to a transgender person. Additionally, professionals should be mindful that not all transgender individuals will wish to transition.
- Be informed. Be prepared with information on support services and other resources available to the client in their area. At times, you may need to invest time and effort into finding reputable and safe resources for your transgender clients.
- Be realistic. The transgender population will inevitably encounter resistance and hardships in society. Helping professionals should be prepared to have dialogue with clients about potential safety concerns, and promote resiliency through the development of coping skills and supports.
Apart from the role of the professional in offering competent care, we must also address the therapeutic setting. Even in environments which strive for inclusivity and equality, there are often subtle forms of aggression, or microaggressions, which shape the experience of the transgender individual in that environment.The creation of safe spaces is a powerful tool, but it is important to note that safe spaces cannot thrive where hate speech and microaggressions are permissible.The implementation of a standard operating procedure creates a framework to establish a safe space and ensure that quality of care is afforded to transgender individuals.
Some recommended components of this standard operating procedure are:
- Establish placement guidelines if necessary. When admitting clients to inpatient or residential settings, admissions should work to obtain information regarding the client’s placement preferences and gender identity. These preferences should be communicated to the agency leadership making placement decisions. All efforts should be made to accommodate the client in the environment of their choosing.
- Facilitate preparation of staff (and peers as necessary). There should be clear expectations for staff to respect the dignity of each client. However, additional accommodations may be needed for the safety of transgender clients. In addition, it may be necessary to prepare existing clients for the arrival of a transgender individual. This approach should be carefully considered by the treatment team and include input from the client and their supports.
- Respect gender expression. Clients have the right to be treated fairly and should be permitted to outwardly express themselves within the established dress code and safety regulations of the program.
- Address bullying and harassment immediately. Staff should take a firm stance against bullying and harassment and address issues as they arise, ensuring the physical and psychological safety of the client at all times.
- Avoid microaggressions. Microaggressions are subtle negative comments and/or behaviors towards marginalized groups that often exacerbate stereotypes. Examples include:“I have a cousin like you,” or “You are so pretty for a trans girl.”
- Remove gender rigidity. This includes the use of gender neutral signage, gender-affirming language, and the elimination of gender stereotypes.If possible, provide clients with the use of gender-neutral or single-occupancy bathrooms and/or changing rooms.
We must endeavor to improve both as individuals in practice and as members of a larger system, in order to provide optimal treatment to the transgender community within an environment in which we embrace individuals on their own terms. This environment will allow the individual to authenticate themselves; to be resilient and grounded in their role while existing as an outlying member of the normative culture.
As helping professionals, the culture of inclusion and acceptance begins with us.
Thespina Arcure, M.S., is a therapist and the Senior Clinical Program and Staff Development Specialist for KidsPeace. She is also a certified LGBTQIAA trainer.
Jonna Finocchio is a licensed clinical social worker and clinician within the KidsPeace Diagnostic Program. She is also an LGBTQ consultant for KidsPeace Community Programs, as well as a speaker and advocate for improving the quality of healthcare for transgender people.