For the past several years, I have provided and supervised counseling services for transgender persons and their family members and conducted workshops for mental health professionals, school counselors and educators on optimal ways for responding to the needs of transgender youth and adults. The purpose of this article is to share information for understanding transgender persons and describe current practices for treating transgender persons and their families.
A person’s gender typically is assigned at birth and is determined primarily by external genitalia but also can be confirmed by gonads, chromosomes, hormones and internal organs. Newborns are usually designated male or female and, on rare occasions, intersex. Gender identity refers to the subjective sense of who one is as far as male, female or other. Gender identity is determined more by the brain than by sexual anatomy. It is not something that any of us choose. Most people have a sense of their gender identity by age 4, although this sometimes happens earlier and sometimes later in life.
Cisgender persons are those whose gender identity and expression are aligned with the cultural and social expectations of the gender they were assigned at birth. The majority of persons are cisgender. Gender-nonconforming persons are those whose gender identity or expression are inconsistent with societal expectations typically associated with males and females. Some gender-nonconforming persons do not fit into the gender binary (male or female) as others do and may consider themselves to be gender fluid, gender queer or gender nonbinary. Transgender persons (about 0.6 percent or more of the U.S. population) have a strong inner sense that their bodies and the gender assigned to them at birth are incongruent with their gender identity. They may be assigned-at-birth males who identify as female (male to female or MTF) or assigned-at-birth females who identify as male (female to male or FTM).
It is important for counselors to understand how their transgender and gender-nonconforming clients identify, especially given that gender identity is now considered to be more a spectrum between male and female and may indeed be a galaxy of possibilities. Some gender-nonbinary persons do not seek hormone or surgical treatment and are comfortable with a more nonbinary gender expression, whereas others do seek medical interventions. With some exceptions, transgender persons desire and, if at all possible, pursue hormone and surgical treatment to experience congruity between their bodies and their minds. In other words, most transgender persons desire and pursue transition to the gender with which they identify. Transgender persons are the focus of this article.
Counselors and the general public need to understand that there is a difference between gender identity and sexual orientation. Some people make the erroneous assumption that transgender and gender-nonconforming persons are gay. The truth is that they, just like cisgender persons, may be gay, straight, bisexual, pansexual or asexual. Stated simply, sexual orientation refers to who one wants to sleep with, whereas gender identity refers to who one wants to sleep as, meaning as male, female or some other gender identity in that galaxy of possibilities.
Etiology of transgender
Family members and the general public often want to know how this happens or why some people are transgender. The etiology of transgender may be understood as a complex interaction of social/cultural, cognitive and primarily biological factors, consistent with explanations of gender identity in general.
A growing body of evidence suggests that being transgender is a congenital condition caused by varying degrees of testosterone exposure in utero. Research also suggests that transgender persons possess brain characteristics more like the gender with which they identify than the gender they were assigned at birth. Furthermore, some genetic studies show a high concordance rate among identical twins, thereby adding further credence to a primarily biological explanation.
So, there is growing evidence that transgender persons are, as Lady Gaga says, “born this way.” Being transgender is not a function of socialization, improper parenting or exposure to traumatic events. Rather than playing a role in the etiology of being transgender, socialization tends to squelch transgender and gender-nonconforming identities. Besides, most transgender persons are less concerned with why they are and much more focused on being who they are. Contrary to prejudicial views held by some in the general public that transgender persons are mentally ill or merely pretending to be the opposite sex, being transgender is best considered a medical condition that can be treated successfully with hormonal and surgical treatments and psychosocial support.
Although being transgender is not a mental illness, most transgender persons experience dysphoria at various times in their lives. The dysphoria experienced by transgender persons is likely attributable to having to live in a body (and social role) that does not feel congruent with their sense of self in a society that misunderstands and discriminates against them.
The gender dysphoria diagnosis (302.85) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) indicates that it may include symptoms of depression, anxiety, fear, guilt, low self-esteem, shame and self-hatred. For some transgender persons, these negative emotional experiences may lead to self-harm, substance abuse and eating disorders. A more detailed description of the criteria that must be met to assign this diagnosis is provided in the DSM-5.
It is our job as mental health professionals to treat the dysphoria and associated symptoms, not the person’s gender identity. The inclusion of any diagnosis in the DSM-5 specifically for transgender persons is controversial. Many view the diagnosis as stigmatizing, even if it was included in the DSM-5 to support access to and insurance coverage for mental health and medical services.
The effects of dysphoria are concerning. One statistic that is particularly startling is that 41 percent of transgender persons attempt suicide, compared with less than 2 percent of the general population. Other statistics derived from the 2011 National Transgender Discrimination Study of 6,456 transgender and gender-nonconforming adults:
- 57 percent have experienced rejection by their families
- 53 percent have been verbally harassed in public settings
- 97 percent have been harassed or discriminated against in work settings
- 28 percent have experienced harassment in medical settings
- As many as 27 percent have been refused medical care in the past
One encouraging statistic from this study is that 78 percent of those who completed their transition felt more comfortable at work and improved their job performance, despite mistreatment at work. This suggests that completing transition engenders greater confidence and comfort with self and may strengthen the transgender person’s ability to cope with stressful environments.
The World Professional Association for Transgender Health (WPATH) Standards of Care (currently SOC-7) provide state-of-the-art guidelines for the proper treatment of transgender adults and children. Treatment involves an integration of medical interventions, social support and community building, and mental health care. Treatment is integrative and collaborative with other professionals and is most effective when it includes advocacy and education within family, school, work and community contexts.
Medical interventions may include any or all of the following, depending on the age and gender identity of the transgender person:
- Puberty blockers that suppress the physical signs of puberty, which transgender adolescents often experience as distressing
- Hormone replacement therapy (testosterone for FTM and androgen blockers and estrogen for MTF transgender persons)
- Gender confirmation surgeries, including top surgeries (mastectomy and male chest contouring for FTM and breast augmentation for MTF transgender persons) and bottom surgeries (phalloplasty, scrotoplasty, metoidioplasty with or without urethroplasty, and hysterectomy for FTM, and orchiectomy, vaginoplasty and labiaplasty for MTF transgender persons)
Cosmetic surgeries may also be performed, such as tracheal shave and facial feminization surgery to help feminize facial features in MTF persons. Electrolysis or other hair-removal methods may also be considered by MTF transgender persons to feel and appear more feminine.
Androgen blockers and estrogen help to feminize the body in a variety of ways but do not feminize the voice, so MTF transgender persons may seek voice training to feminize their voices. Testosterone will deepen the voice and promote growth of hair on the face and body, so there is typically little need for FTM transgender persons to seek voice training or cosmetic treatments.
Social support and community building
Social support is very important for reducing the sense of isolation that many transgender persons experience. Many report that they first sought information and support for themselves on the internet, describing how comforting it was to find out there were other people like them.
Such support can be enhanced by actual support groups like those provided at the Dennis R. Neill Equality Center in Tulsa, Oklahoma. The Equality Center offers several groups in support of transgender and gender-nonconforming persons, along with many other services for LGBTQQIA (lesbian, gay, bisexual, transgender, queer, questioning, intersex, asexual) people. There are support groups for transgender men, women, children and teens, and for parents of transgender children and teens. I have served as a co-facilitator of the support group for parents of transgender children and teens for the past six years and have placed three to six graduate students at the Equality Center each year to provide counseling services and help facilitate support groups.
Open Arms Youth Project is another agency in Tulsa that provides social support for LGBTQQIA youth, and my graduate students have co-facilitated a weekly support group there. Other community organizations such as PFLAG (Parents and Friends of Lesbians and Gays) provide social support for family members. Gay-Straight Alliance groups in schools, and support groups and student organizations on college campuses, can serve as safe zones for adolescents and young adults.
Such groups for transgender persons and their family members provide useful information about medical, cosmetic and legal steps in the transition process. These groups are also central to the community building that provides hope and support for dealing with unaccepting environments and other challenges that transgender persons may encounter. Fostering the development of support services and participating in community-building efforts are among the ways that professional counselors can make a positive difference in the lives of transgender persons and their families.
Community building can also be helpful in organizing or participating in efforts to challenge legislation that would be harmful to transgender persons. Under President Obama, the U.S. departments of Justice and Education established guidance and took steps to protect the rights of transgender persons in the workplace and the rights of transgender students in the schools to use restrooms consistent with their gender identity. However, some state legislators, attorneys general and governors resisted these actions. Several state attorneys general filed suit against the Justice Department in 2016, and some state legislators have succeeded in enacting state laws that restrict the restroom usage rights of transgender persons.
In the early weeks of the Trump administration, the Justice Department and the Education Department rescinded the guidance that served to protect the rights of transgender persons and students. However, this past May, the 7th U.S. Circuit Court of Appeals ruled that a school district in Wisconsin violated the rights of a transgender student and upheld a lower court injunction requiring that the district allow him to use a restroom that aligns with his gender identity. This federal court ruling has far-reaching implications and adds to the growing number of judicial decisions that protect transgender persons from discrimination.
Nevertheless, the rights of transgender persons to use restrooms consistent with their gender identity remains both a national- and state-level issue, when all transgender persons want is to feel safe and comfortable using a restroom for the same reason that anyone wants to use a restroom. Counselors can be helpful to transgender persons by advocating for their rights. Considering that many transgender students report being bullied in schools, counselors can support anti-bullying state legislation and intervene, as appropriate and with their clients’ consent, in school systems where transgender youth experience harassment. The importance of the counselor’s role as an advocate for social justice is strikingly evident in our efforts to help transgender and gender-nonconforming persons.
Mental health care
Professional counselors can be helpful to transgender persons by providing informed, competent and compassionate mental health care. According to WPATH SOC-7, minimum qualifications to provide mental health care to transgender persons include a master’s degree in a clinical behavioral science field; training and competence in the DSM-5; documented supervised training and competence in counseling/psychotherapy; and continuing education in the treatment of gender identity issues and WPATH SOC. The Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (a division of the American Counseling Association) and the American Psychological Association have also published guidelines for treating transgender and gender-nonconforming clients.
Transgender persons present several common concerns to counselors and other mental health professionals. They may present with symptoms associated with gender dysphoria, such as depression, anxiety and suicidal ideation. Some may need help with substance abuse or other harmful means of coping with distress. It is also important to attend to any co-occurring mental health issues that may require a referral to a psychiatrist for medication. Be aware that some transgender youth develop eating disorders, and others may be on the autism spectrum, so collaboration with providers with specialized expertise in these areas may be necessary. Counselors also may need to attend to traumatic experiences and symptoms of minority stress associated with discrimination, stigmatization and harassment.
Other commonly expressed concerns involve:
- Disclosure to others (coming out)
- The timing and extent of transition
- The impact of transition on relationships with current partners/spouses/children (in adult transgender persons)
- Support or nonsupport of parents and extended family
- Concerns about passing as the gender with which they identify
- Reactions from employers, school personnel, leaders and members of their religious groups, and their peers at work or school
It is important to recognize that our clients’ age, stage of life and stage in the transition process will likely influence the concerns and issues presented. A Tanner Stage 1 child (birth to onset of puberty) may have issues with family, school and peers, whereas a Tanner Stage 2 child (onset of puberty) may present with family, school and peer group concerns, as well as worries associated with the changes that accompany puberty that can be very distressing for transgender adolescents. Young transgender adults may have concerns about reactions and treatment by employers and fellow workers. Older adults may share these same concerns and have compounding issues with spouses and children (whether young children or adult children), depending on the person’s age of coming out and transitioning. Transgender persons at any age or stage of life may have issues with their parents, siblings, extended family members, friends, church or faith, and the larger political/social climate for transgender persons.
Regarding ethical responsibilities, it is crucial that counselors are aware of, confront and alter their own biases, fears (transphobia), discomfort, gender-normative assumptions and lack of information about transgender persons. One of the best ways to do this, as with overcoming any discomfort with people we perceive to be different from us, is to get to know persons who are transgender. This requires openness to learning about their experiences, listening with empathy to their life stories and demonstrating respect. One of the major ways we show respect when working with transgender and gender-nonconforming clients is by asking them about and consistently using their preferred pronoun (she, he, them, etc.), the name by which they prefer to be called and their self-defined gender identity (transgender, gender queer, gender nonbinary, etc.).
It is also important that we are respectful of our transgender clients’ sense of timing for coming out to others, and the pace and timing for steps they wish to take in their transition. Some transgender persons seek multiple surgeries (top, bottom, cosmetic), whereas others choose not to take all of these steps in their transition or simply cannot afford every surgical intervention that they might desire.
Furthermore, passing as the gender with which they identify may be more important to some transgender persons than it is to others. Passing should never be more important to the counselor than it is to the transgender client. A counselor should never say to a transgender client (as one counselor did), “If you are ever going to pass as female, you need to do something about your face and your voice.” That remark by a counselor left one client feeling degraded.
Instead, it is counselors’ responsibility to reduce the shame associated with self-stigmatization and internalized transphobia that transgender clients may experience and to help them replace that shame with pride. Knowing that the antidote to shame is self-esteem and pride, counselors must help these clients identify positive resources and strengths. It is our responsibility as counselors to cultivate a safe therapeutic environment for transgender clients — a safe zone where they feel supported, affirmed, respected and appreciated for their courage and resolve.
It is helpful for counselors to know that transgender clients are likely to want to take steps to change their names and gender markers on legal documents such as driver’s licenses, birth certificates, passports, academic/school records, medical records, Social Security cards, bank accounts, credit cards and other financial records such as trusts and wills. The ease or difficulty in making such changes depends on the jurisdiction and particular offices involved (and, if the transgender person is a minor, the support of parents or legal guardians). Ideally, counselors will know or learn enough about making changes to legal documents to be able to direct their clients to people and resources that will be helpful.
When mental health professionals work with transgender clients, they can expect that these clients will ask them to provide a support letter for medical treatment at some point. Such letters should include results of an assessment to determine if the diagnosis of gender dysphoria is warranted and if any co-occurring conditions are present (such as substance use or abuse, smoking, eating disorder, etc.) that could affect medical treatment. For more detailed information about letters to physicians and surgeons, counselors should consult WPATH SOC-7 and obtain continuing education to enhance their knowledge of the “gatekeeping” role of mental health professionals. SOC-7 makes clear that the role of mental health professionals involves much more than assessment and letter writing; it includes support, collaborative care, education, systems intervention and advocacy.
Families of transgender persons
Although family members vary in their degree and pace of acceptance, most struggle adjusting to the change in their identity as a family. When individuals come out as transgender in mid or late adulthood, cisgender spouses or children may be affected. Couples or family counseling may assist cisgender spouses and children in making accommodating adjustments to the changing gender identity of a spouse or parent.
Some couples work through the issues associated with such a change and maintain their love and commitments to stay together, whereas for others, such adjustments are too difficult. Some couples part amicably and the individuals remain friends, whereas others feel betrayed, and if minor children are in the home, custody battles sometimes transpire. Counselors can help spouses and children (whether younger or older) by providing information about being transgender, enlisting their empathy and caring for their transgender loved one, and empathizing with their feelings, which may include grief, shame, anger and worries about their family.
When a child, teenager or young adult comes out as transgender, parents and siblings also make accommodating adjustments in their identity as a family. Counselors can assist parents by supporting them in their grief and worry about the well-being of their transgender child. Counselors can also serve as a resource for information about gender identity and the coming out process, and they can assist parents and their transgender children in determining when and how to inform grandparents, extended family members, friends, school personnel and church personnel. Advising parents about books and articles to read and websites to educate themselves about their transgender child or teen can also prove beneficial. Two books I recommend as helpful resources for parents and professionals are The Transgender Child by Stephanie A. Brill and Rachel Pepper (2008) and The Transgender Teen by Brill and Lisa Kenney (2016).
Parents and other family members often struggle, at least temporarily, with the names and pronouns by which their transgender loved ones want to be referred. Counselors can encourage family members to be intentional about using these names and pronouns, while also recognizing that mistakes happen and that it will take practice to get everything right consistently.
Whether working with parents in counseling or in support groups, counselors can address parental concerns about medical and cosmetic interventions and procedures for changing legal documents. It is important for counselors to support and affirm appropriate action when parents of transgender youth express concerns about bullying or harsh treatment by peers or school personnel, their child’s depression or suicidal ideation, and negative reactions by extended family or others. I have witnessed parents and family members of transgender youth change from being grief-stricken to becoming empowered advocates for their transgender child. In our parent support group, it is common for parents to share their concerns, challenges and triumphs.
The more I work with transgender persons, the more impressed I am with their courage and resolve to be genuinely who they are in a world that can be hateful. The more I work with their parents and family members — and with mental health professionals, educators and others who support transgender persons and stand up for their rights — the more I am encouraged that understanding and compassion will ultimately triumph over ignorance and hate.
Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.
Al Carlozzi is a professor of counseling and counseling psychology at Oklahoma State University (OSU) and serves as director of the OSU-Tulsa Counseling Center. He has provided counseling services and supervised the provision of services to transgender and gender-nonconforming clients, conducted numerous continuing education workshops on treating transgender persons and their families, and collaborated with the Dennis R. Neill Equality Center in Tulsa, placing graduate students there as counselors and co-leading a support group for parents of transgender children and teenagers. Contact him at firstname.lastname@example.org.
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