When Dr. Kopp asked me to write about working with LGBTQ-identified clients (waaaay back in September…or was it August?), I happily agreed. As many of you know, working with queer folks like me is my jam. But when I sat down to write, I wasn’t quite sure what to say. Should I write a “LGBTQ 101” kind of post? Should I focus on a particular issue within the LGBTQ community such as housing insecurity or bi-erasure? As a recovering perfectionist, I was gripped with decision paralysis. Then November rolled around. Transgender Awareness Week and Transgender Day of Remembrance are in November, so writing about gender minority-related topics seemed like a timely topic for my painfully belated post.

 I’ve been working with gender minorities since early in my graduate training, completed an APA accredited postdoctoral fellowship in LGBTQ Health, and have attended many other LGBTQ specific trainings/workshops. I’d like to share with you some things I’ve learned along the way that help me to avoid inadvertently harming my transgender, nonbinary, and GNC clients. Of course, none of us want to harm our clients, and, unfortunately it sometimes happens anyway. I’ve done it, and—based on what many of gender diverse clients have shared with me—you probably have as well. I remember when I misgendered a nonbinary client in a trans process group when I was a practicum student at a college counseling center. I felt awful—embarrassed, remorseful, guilty. In hindsight, I fell all over myself apologizing and probably made the situation more awkward than it already was. We need to hold ourselves accountable for our mistakes, be skillful in our repairs, and be willing to do the vulnerable work needed to be and do better. My comments here are intended to be brief and do not address all aspects important to the provision of affirming care.

First, here are a few definitions for those who may not be familiar with certain terms:

• Gender: characteristics of women/girls and men/boys that reflect socioculturally-constructed ideas, norms, behaviors, expressions, roles. According to the World Health Organization, “gender is hierarchical and produces inequalities that intersect with other social and economic inequalities.” The hierarchical and categorical aspects of gender are psychologically, socially, and economically damaging to all of us because they unnecessarily restrict what is considered “acceptable” behaviors, expressions, and roles.

• Transgender: an umbrella term that generally refers to people whose gender identity does not align with the gender they were assigned at birth (or even before birth) based on the appearance of genitals.

• Nonbinary: a gender identity label used by some who do not identify as being either women/girls or men/boys.

• Gender nonconforming (GNC): like nonbinary, can be a gender identity label used by some who do not identify as being either women/girls or men/boys but can also describe one’s gender expression.

• Cisgender: term used to describe people whose gender identity matches the gender identity they were assigned at birth (or even before birth) based on the appearance of genitals.

Please note that there are many more gender identities than those listed here.

Language Matters

Often, a client’s first experience of us is through our practice website and intake paperwork. Transgender clients tend to be highly attuned to linguistic cues that can undermine a clinician’s best intentions to be inclusive. If you’re an ally, saying you are “LGBTQ friendly” on your website or Psychology Today profile is great, but if the rest of your content doesn’t use inclusive language, your allyship may viewed as merely performative rather than knowledgeable and skilled. For example, a transgender client may be more inclined to call the provider whose website uses words like people, folks, women and femme-presenting individuals/men and masc-presenting individuals, and/or people of all genders rather than only women and/or men. Intake paperwork that allows clients to write in their gender and asks for pronouns communicates inclusivity, whereas asking clients to indicate their gender with the options of M or F or the often more painful M, F, or Other is exclusionary and “othering.” Also, if your paperwork includes a For Women section that asks for pregnancy- and menstrual cycle-related information, consider using a different section heading such as If Applicable because cisgender women are not the only people who can become pregnant and menstruate. Ask clients what name they want to be called and ensure all notes and reports use the client’s stated pronouns throughout the entire document. Consider the kind of signage you have on your restrooms—how might a gender minority client feel if they only see signs for men’s and women’s restrooms? If you do not have the ability to use inclusive signage for your restrooms, consider having a conversation with your clients about it.

Gender Transition Does Not Have to be Binary…or Anything at All

Not everyone who identifies as transgender or nonbinary or GNC has gender dysphoria, and not everyone will want to transition. If a client decides to pursue gender transition, know that their transition will be unique to them. In general, there are three domains in which people may choose to transition. Social transition may include asking to be referred to by a different name and pronouns, dressing differently, wearing a different hairstyle, or even moving one’s body in different ways. Legal transition typically involves changing one’s name on all identification sources (e.g., passport, driver’s license, social security) and accounts (e.g., health insurance, banks). Medical transition may include a variety of interventions from hormone replacement therapy (and/or “blockers” to suppress puberty from progressing in adolescents) to an array of surgeries (e.g., mastectomy, hysterectomy, scrotoplasty, orchiectomy, penectomy, tracheal shave) and/or injectable fillers for contouring. Gender minority clients who choose to transition may want some interventions but not others.

Masculinity and Femininity are Orthogonal Constructs

Because of the gender binary rooted in our white Euro-centric culture, I viewed masculinity and femininity as two ends of one spectrum for many years. It wasn’t until I began studying gender and transgender issues in graduate school that I learned masculinity and femininity are in fact orthogonal constructs that allow for an infinite array of expressions. For instance, a person could display few masculine characteristics and few feminine characteristics, or many masculine characteristics and many feminine characteristics, or any combination in between. The Gender Unicorn does a good job of illustrating the orthogonal nature of these and other characteristics.

The gender binary that situates masculinity in opposition to femininity has served two purposes: 1) maintain an oppressive patriarchy and 2) cause unquantifiable pain and suffering for humanity. In 2019, after reviewing more than 40 years of research, the APA concluded “traditional masculinity” (i.e., stoicism, competitiveness, dominance, aggression) was psychologically harmful because it socialized boys to suppress characteristics historically deemed feminine (e.g., expressing emotion). Optimal human functioning involves both feminine and masculine characteristics.

Intersectionality is Key

As noted by the WHO above, gender and socioeconomics are inextricably linked. Gender minorities are nearly four times more likely to live in households with annual incomes of less than $10,000/yr and twice as likely to be unemployed than the general population (Grant et al., 2011). Consider: cisgender men have more socioeconomic privilege than cisgender women, who have more socioeconomic privilege than gender minorities. Overlay race onto this structure and you’ll find white cisgender men at the top of the ladder, followed by Black cisgender men and white cisgender women (who traded places early in our nation’s history for the next rung; e.g., Davis, 1981), followed by Black cisgender women, and so on until the lowest rungs where you will find Black and Indigenous transgender women and other gender minority-identified folks.

This is a truncated, and therefore insufficient, summary of how white supremacist patriarchal dynamics benefit the socioeconomics of certain groups in our culture. We who benefit from this system should examine ways to promote equity. It is also important to reflect on how identity intersections impact your gender minority clients’ abilities to access affirming health services and differentially privilege their abilities to pursue gender transition if they so desire. We clinicians should reflect on how minority stress (e.g., Mayer, 2003) exacerbates health disparities and negatively impacts the daily lived experiences of our gender minority clients. For instance, some research on minority stress has focused on emotion regulation as a mediating factor (e.g., Hatzenbruehler, 2009). Research suggests that the overall impact of minority stress reduces one’s ability to regulate emotion, thereby increasing the probability of poorer mental and physical health outcomes (Skinta, 2021).

Conclusion

If we choose to work with gender minority clients, it is an ethical imperative that we obtain the education, training, and/or supervision needed to mitigate the risk of doing harm. Even the most experienced among us may still unintentionally microaggress and harm our clients. Unfortunately, it happens, and that is why it is so important for us to have done (and continue to do!) our own work around our privilege and power beforehand so that we have the humility and skills necessary to attempt a repair (Skinta, 2021) and to provide affirming care.

For those looking for additional information about transgender issues, an excellent resource is the National Center for Transgender Equality. Those interested in findings from the largest comprehensive survey of transgender Americans can do so here.

Non-hyperlinked References

Davis, A., Y. (1981). Women, race, and class. New York: Vintage Books.

Grant, J. M., Mottet, L. A., Tanis. J., Harrison, J., Herman, J. L., & Keisling, M. (2011). Injustice at every turn: A report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force.

Hatzenbuehler, M. L. (2009). How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychological Bulletin, 135, 707-730.

Mayer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674-697.

Skinta, M. D. (2021). Contextual behavioral therapy for sexual and gender minority clients: A practical guide to treatment. New York: Routledge.