Tag Archives: gender

Affirming all shades of the rainbow

By Laurie Meyers May 27, 2020

Licensed professional counselor (LPC) Laura Brackett’s specialties include counseling LGBTQ+ individuals. A frequent complaint she hears from her clients is that those outside of the LGBTQ+ community — including some mental health practitioners — see it as one big, happy family that shares all of the same problems and concerns.

This is, of course, not the case. “There can be deep and painful divides between the various groups that make up this community,” says Brackett, an American Counseling Association member who practices and is the director of community engagement at Change Inc. in St. Louis.

That is especially true for marginalized communities within the LGBTQ+ population. For example, American society has made significant progress in accepting differences in sexual or “affectional” identity but remains distinctly uncomfortable with alternate gender expressions such as transgender and nonbinary, says ACA member Christian Chan, an assistant professor in the Department of Counseling and Educational Development at the University of North Carolina Greensboro. People can generally grasp (even if in some cases only reluctantly) being gay, lesbian or bisexual as being about whom one chooses to love. However, the idea of someone being assigned the wrong gender at birth or a person rejecting that they must choose the binary of either male or female undermines deeply held notions of what constitutes a person’s identity, explains Chan, whose research interests include intersectionality and issues affecting queer people of color.

Even the LGBTQ+ community tends to prioritize affectional identity over gender identity, says Chan, a member of the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC), a division of ACA. For too long, there has been a hierarchy of whose needs matter, he asserts, and transgender people — particularly women of color — have been at the bottom.

“Mental health providers are not really culturally responsive to the needs of [diverse] communities — particularly communities that have multiple identities,” he says. Even counselors who are affirming of LGBTQ+ clients don’t always take the time to consider clients’ intersecting identities and how those identities affect their mental health needs, Chan adds.

When transitioning is not an option

LPC Jessica Jarman Hayes says the transgender clients she counsels are often not out and almost “sneaking themselves into therapy.” Hayes, whose Columbia, South Carolina, practice specializes in LGBTQ+ issues, explains that being transgender anywhere in the surrounding area is just not accepted. If anyone in the communities where her clients live learned that these individuals are struggling with their true identity as a transgender woman or man, her clients would lose everything, she says. If married, their spouses would leave them and take their children. Their families, friends and neighbors would reject them, leaving them with no social support. The need for secrecy is so great that it can be challenging for these clients to even schedule appointments with Hayes.

Other of Hayes’ clients live out in isolated areas of South Carolina’s Low Country. They cannot easily get to her office, so their only option is teletherapy, sometimes from a car in the parking lot of a grocery store because they have no safe space available to them at home.

“It reminds me a lot of when I was working in domestic violence,” says Hayes, who is also a volunteer at the Harriet Hancock LGBT Center in Columbia. “You just have to be there to support them, sometimes for years, when they finally reach a place in which it [denying their identity] is no longer acceptable, and then come up with a plan to get out of Dodge.”

Violence is an ever-present threat for people who identify as transgender and gender nonconforming or “nonbinary.” According to the Human Rights Campaign report “Violence Against the Transgender and Gender Non-Conforming Community in 2020,” at least 26 individuals who were transgender or gender nonconforming were murdered in 2019. Most of the victims were African American women.

As the report notes, “These victims were killed by acquaintances, partners or strangers, some of whom have been arrested and charged, while others have yet to be identified. Some of these cases involve clear anti-transgender bias. In others, the victim’s transgender status may have put them at risk in other ways, such as forcing them into unemployment, poverty, homelessness and/or survival sex work.”

Hayes says the fear of violent retribution is another reason, in addition to fear of losing family and friends, that her transgender clients feel unable to express their identities in any way. One client hid underwear in a wall in the house, and their spouse gave them a severe beating when they discovered it, Hayes says.

There is no protection for the abused in these cases because the local police do not take such incidents seriously, according to Hayes. This lack of concern is present even when a juvenile is involved, she says, recounting the story of a suicide hotline call from a transgender teen that got routed her way. The teenager was actively suicidal and in danger. The father had found girls’ clothing and had severely beaten the teen. Hayes called the police and made it clear this was a domestic violence incident involving child abuse and a victim who was actively suicidal.

“The police went in there and teamed up with the dad,” Hayes says. “They said, ‘If you would just stop pretending to be a girl, your dad wouldn’t have to do this.’”

For a time, the girl was able to maintain touch with Hayes by using a self-wiping app on her cell phone to avoid being detected. Hayes called the police repeatedly, but they continued to refuse to take action. Eventually, the father discovered the girl was making calls and took her phone, her computer and his computer out of the house so that she had no means of reaching out. Hayes and other volunteers at the Hancock Center have done their best to check on the teen’s welfare since losing contact but have been unsuccessful. Her school has been ordered not to give out any information, and the local police aren’t providing any help. A Columbia-area police officer has agreed to keep his ears open for any news, but thus far the Hancock Center hasn’t heard anything.

In search of support

Closeted transgender women (i.e., people presenting as men, in accordance with their assigned gender at birth, but who secretly self-identify as women) who are discovered are at risk of violence not just from spouses but, potentially, the spouse’s family, Hayes says. “This is seen as an act of great betrayal.”

Hayes recommends that all of her transgender clients use the time after their phone sessions with her (or any other time they have 15-20 minutes of private time) to connect with virtual support groups. She wants clients to find at least one “safety buddy” to whom they can reach out if they just need to talk or if something serious is going on. She also makes sure that all clients have the transgender peer support and crisis hotline number (Trans Lifeline: 877-565-8860).

Hayes also uses radical acceptance to help her clients cope with the inability to embrace their true identities. “OK,” she tells clients, “we can radically accept that this situation really sucks and is really uncomfortable, but we have to accept that we are in danger of losing a job or family, even if we never come out but someone else finds out.”

Hayes urges her transgender clients always to have a go-bag packed, but recommending places for refuge is a challenge. A few domestic violence shelters in Georgia are trans-affirming, but they are a significant car ride away. The Columbia area has some homeless shelters that will accept transgender individuals. Still, these are not always great options because some of them are run by religious organizations that require those seeking refuge to read “applicable” Bible verses. Hayes generally encourages clients to think of relatives with whom they could stay. Clients don’t necessarily need to explain the whole story of what is happening — just that they need to get away, Hayes says.

In an environment in which wearing gender-affirming underwear or painting one’s toenails can have devastating consequences, Hayes acknowledges that it is incredibly challenging to help make her clients’ situations more livable. Even so, she has found a few small ways for her transgender and nonbinary clients to explore their identities, including gaming, an environment in which having avatars of different or no fixed gender is common.

Another outlet she suggests — but only if clients believe their phones are safe from scrutiny — is the social media platform Tumblr, which is very graphics-oriented and functions a bit like a cross between Facebook and Twitter. Users can set up an account and post or follow others who share art, graphics, GIFs and other visual content. Crucially for Hayes’ clients, it’s also possible to search content without registering. Why is this an affirming outlet? Because Tumblr is a hive for many kinds of interests, including fashion, design, décor and art. Hayes tells her clients to use the platform to explore what their “aesthetic” (personal style) would look like if they had complete freedom, encompassing not just their appearance but also their surroundings. 

Hayes began her career counseling domestic violence survivors in the Miami area, where the shelters are transgender and LGB affirming and intimate partner violence between gay men or a trans woman and cisgender man is taken seriously by the legal system. Although Hayes, who considers herself a member of the LGBTQA+ community, has been in South Carolina for several years, she is still sometimes surprised by the virulence of the hatred many in the area feel toward transgender and other queer people. She echoes Chan in saying that although different affectional orientations are now more tolerated (even if sometimes grudgingly) in some quarters, alternative gender expression is still largely viewed as unacceptable. She believes there also remains significant transphobia within the LGBTQ+ community itself, which leaves her transgender clients with very few resources for social support.   

Family struggles

When ACA member Bethany Novotny moved from Pittsburgh to Johnson City, Tennessee, to begin teaching as an assistant professor of human services at Eastern Tennessee State University (ETSU), she wasn’t sure how friendly her new surroundings would be to those identifying as LGBTQ+. Novotny, who went on to start a local lesbian dine-out group, was pleased to find that Johnson City had a robust LGBTQ+ community and that it and the university were a haven among the surrounding Appalachian towns for queer young adults.

Over time, Novotny, who is an LPC in Pennsylvania, found that students viewed her as a safe and sympathetic person to talk to. That rapport, her desire to help transgender and nonbinary students, and Novotny’s friendship with staff at the campus counseling center led to her taking over ETSU’s transgender support group, now called ASPECTS — Aligning Support, Pride, Education and Community for Transgender Students. The group originally included only students who had been referred by the campus counseling center. But Novotny opened it up to all transgender and gender-nonconforming students because she feels they have unique challenges apart from the rest of the queer community. “People are more afraid [discussing alternative gender expression] than they are when we talk about sexual orientation,” she notes.

Novotny supervises while students lead the group, which meets once a week. The students share practical information such as where they can go to receive hormone therapy and find affirmative health care providers. Obtaining these services usually requires traveling to either Knoxville, Tennessee, or Asheville, North Carolina, which is a challenge, especially for those students who don’t have cars. Novotny says the group often works together to make sure members get rides when necessary.

Not surprisingly, acceptance is a constant topic in the group, Novotny says. The students feel safe — many for the first time in their lives — at ETSU, but they still have to navigate family and community attitudes when they go home on breaks.

“We would talk about coping skills [before breaks],” Novotny says. “Sometimes they would choose to stay with a friend or another family member. I would remind them to have a crisis plan — making sure if things got bad, they knew what to do.” A crisis plan resembles a suicide safety plan, with a list of local and campus resources, shelter locations and the number for the national suicide hotline.

Once, a student who had started taking hormones decided that they should come out to their family on break. The group talked it through for several weeks beforehand, Novotny says. The student’s parents did not take the coming out announcement well, and the student was forced to seek shelter with a cousin. The cousin turned out to be very supportive and even helped the student come out to their grandmother, which they never thought possible, Novotny recounts. All too often, however, students would return to school without getting any affirmation from their families.

Although revealing oneself as transgender is particularly challenging, coming out to family and friends isn’t easy for anyone in the LGBTQ+ community. Even among families who want to support and affirm their loved ones, the coming out process can be a difficult transition, Brackett says. Some family members — often parents in particular — grieve letting go of the future they had envisioned for their loved one, she adds. “That’s not to say that they reject their family member’s future as an LGBTQ+ person, simply that they may need to adjust the specifics of what that future may be. Maybe the vision was of a son who [would have] a wife and children, and now that vision needs to be adjusted to [having] a husband instead of a wife,” Brackett says.

In other cases, families fear their loved one will become an entirely different person, she says. Brackett explains to families that although changes in expression and personality are very likely, it isn’t a foregone conclusion that in coming out, their loved one will undergo a complete transformation.

“Even when there are substantial changes, I try to remind families that the person they knew was possibly more of a mask than they want to accept,” she explains. “This person is now trying to discover who they really are, and that process will take time. It’s important to be patient, be curious, be respectful, and [for families to] find their own support.”

Novotny says many of her group members have parents who struggle because they perceive the transition of their child’s gender expression — from the one the student was assigned at birth to their true gender — as an alteration that has transformed their child into someone they don’t recognize. This comes in part from a lack of exposure to and understanding of what being transgender means.

One student’s mother couldn’t even grasp the concept, telling her child, “You have a penis, so you’re a boy,” Novotny recounts. “The student was trying to communicate to [their] mom, ‘I’m still the same person. I’ve actually been this person the whole time, and you don’t see that. I am trying to share something scary and vulnerable with you.’” At the student’s request, Novotny helped them talk to their mother.

“I always respond first with empathy,” Novotny says. “I know that what they [parents] are going through is difficult, and I don’t want to minimize or dismiss their feelings. It’s all about meeting them where they are, even though sometimes I want to shake them and scream at how horrible they are being. I also worked to affirm the love and support that it took for mom to show up in my office that day. The fact that she was there was huge. She was willing to talk even though she didn’t understand, and I wanted both mom and my student to recognize what a big step that was.”

Novotny listened to the mother’s concerns and helped correct misinformation by inserting “tidbits of information that might help mom put the puzzle pieces together. I did this very gently and only where appropriate because I did not want to come off as though I was lecturing her,” Novotny says. “As an educator, I know how important it is to plant seeds. We may not always see that come to fruition, but it is so important to plant those seeds gently. … I also try to communicate to parents that they don’t need to fully understand to provide support, love, affirmation and acceptance.”

In some cases, the family conflict isn’t rooted in a lack of understanding but something more fundamental. Brackett, like Novotny, tackles these struggles with understanding and empathy.

“I seek to understand what their resistance or hostility is connected to and move from there,” she says. “Working with a family that has deeply rooted religious beliefs that condemn sexual or gender minorities is drastically different from working with a family that is afraid of the changes that may occur within their family system. At times it can be necessary to have these discussions without the LGBTQ+ family member present in order to not only protect them from hearing this process in its most raw form, but also to allow the family space to be open about what they are feeling. Additionally, recommending outside support groups or resources can help alleviate some of the misinformation and isolation the family may carry.”

Families also fear the treatment their loved one might experience in the outside world. “Will they be bullied or ignored or even physically hurt or killed?” Brackett says about some of the common concerns families voice. “Will they suffer mental anguish and be at higher risk for addiction or suicide?” 

“It’s important for families to remember that a huge protective factor for members of the LGBTQ+ community is the presence of a supportive family,” Brackett asserts. “When working with family members in this place of fear, I try to highlight for them the power they have in creating a safe and loving environment for their loved one. While a mother can’t make the world safe for her gender-nonconforming child, she can at least work to ensure that she is safe for them.”

The process of coming out

In some cultures, such as those Hayes’ clients live in, as well as other racial and ethnic communities, coming out may be dangerous to the LGBTQ+ individual and perhaps to their family. Or an LGBTQ+ person may have some family members who would support their coming out but others who would not be affirmative or accepting. Some individuals choose to honor both their LGBTQ+ identity and their familial or cultural identity by coming out only to certain family members or friends.

“I frame coming out as an ongoing process and remind my clients that the need for a grand unveiling isn’t necessary unless it’s important to them,” Brackett says. “Often, I see my clients come out by degrees, starting with the safest people or environments first to gain support. By identifying safe people and thinking through the possible outcomes of coming out, the client can begin to amass protective factors they need as they go through the process. Deciding not to come out to people they identify as unsafe or unnecessary doesn’t have to be framed as a betrayal to their identity, though it’s an understandable reaction. It can also be framed as a means of protecting themselves. They are not required to disclose information that puts them at risk.”

With any major life change, there is grief at whatever is lost, and this is very true in people who are negotiating the ways in which they want or don’t want to be publicly out, Brackett continues. “Being rejected by a family member or important institution like a religious community or friend group can be devastating,” she says. “Gentleness, empathy and nonjudgmental discussions are important in allowing clients the freedom to connect with the impact coming out is having on them. Holding the grief is important, but so is guiding them toward creation of a new life and support system: ‘Yes, this is horrible and heartbreaking. Is there someone who has acted differently or where you’ve felt acceptance?’”

Counselors can help clients build a new support system by working with them to change their concept of family, says ACA member Leah Polk, a licensed clinical social worker and clinical director at Change Inc. in St. Louis. Clients are not limited to their families of origin; they can assemble ones of their own choosing, she emphasizes. So, even though their families of origin may have set a priority on traditional scripts or rituals, the families they choose can be inclusive and view each member as inherently valuable, says Polk, whose specialties include LGBTQ+ issues. 

“The important part here is that the client gets to spend time identifying what is most important and valuable to them as it relates to family,” she explains. “They are able to map out how they establish family and gain reliable reflections that emphasize what they like about themselves.”

Peer support for transgender youth and young adults

Laura Boyd Farmer, an LPC whose specialties include affirmative LGBTQ+ counseling, helped found a peer group for youth and teenagers 10 years ago in the Roanoke, Virginia, area. She and other area professionals saw a need among the area’s LGBTQ+ youth, who were frequently ostracized and bullied and had little family support. “Our intention was to create a safe and supportive space,” says Farmer, a member of ALGBTIC. Farmer and others sat with teens in the area and asked them what they needed and what kind of support would be helpful. The result was Youth SAGA (Sexuality & Gender Alliance) of Roanoke.

“The kids created the name,” Farmer says. “They were very passionate that they wanted this to be a group for queer-identified kids, but also for anyone who was affirming of gender and sexuality diversity.”

SAGA meets twice a month, and there are always two leaders with mental health experience (Farmer and three volunteers take turns serving as the two leads). Meeting times are posted on Facebook, and the group gathers in public spaces such as coffeehouses, libraries and bookstores so that teenagers who are not out to their families will have a ready-made excuse to drop in.

The group follows two basic rules: Respect participants’ chosen identities, names and pronouns, and give everyone time to talk. Group members are also asked not to talk about what goes on at meetings outside of SAGA. All of the participants are so invested in preserving a place where they can find and give support that there has never been an issue with breaking confidentiality, according to Farmer.

The structure of each meeting depends on the size of the group. If only a few teens are present that week, the session is relatively informal, with group members simply discussing what is going on in their lives. With larger groups, leaders pass out pieces of paper so participants can write down any topics they would like the group to cover. The group leaders put all the pieces of paper in a bowl, which is then passed around. Each person removes a piece of paper and reads out the topic for discussion.

Topics range from concerns such as “My parents don’t want me to transition and I don’t know what to do” and “I don’t know how to come out to a family member” to the practicalities of expressing gender identity. The group has covered logistical questions about the physical and hormonal aspects of transition, as well as ways that youth can present themselves in a way that affirms their gender expression when their families are not letting them transition. The teens also ask each other about how to find good chest binders and affordable makeup.

Dealing with bullies and finding allies are also common topics, Farmer says. She recounts an approach to bullying that she thought was particularly effective: “This trans youth shared that he found the best way to deal with bullies was to choose a direct statement to respond with and to use it repeatedly,” Farmer explains. “For example, when a bully would say to this youth that he was really a ‘she’ and just confused, the youth would reply, ‘That sounds like a you problem.’ This kid also had his friends use the same response when they heard anyone say anything unkind about him or toward him. I loved this approach because it puts responsibility back on the bully to educate themselves, like holding up a mirror for them to see that whatever mean things they are saying are actually about them, not the person they are trying to bully.”

Sometimes the group features outside speakers. For example, because the intersection of religion with sexual and gender identity is a common concern in southwest Virginia, Farmer had a pastor lead a discussion on how spirituality and sexuality intersect. The pastor also talked about what the Scriptures actually say (and don’t say) about the topic and gave the group recommendations for discussing the topic with family.

Farmer emphasizes that SAGA is not a therapy group but rather peer-based support. Because discussions about sexual and gender identity sometimes include topics such as trauma that can be triggering for others, she and her co-leaders have developed a signal that group members can use if they are being triggered. If someone puts a hand on their heart, it is a signal for the leaders to gently and respectfully move the discussion away from the current topic. Farmer and the other leaders are careful to check in afterward to see whether the teen who brought up the topic wants to continue the discussion privately.

“The beauty of this group is that I don’t have to know the answers,” Farmer says. “The kids are sharing their wisdom with others. It’s a beautiful thing to witness.”

Providing affirmative counseling

Even professional clinical counselors who have experience with the LGBTQ+ community may have biases and blind spots, say the practitioners Counseling Today interviewed for this article. Brackett and Polk offer some suggestions for counselors who want to make sure they are offering affirmative counseling to LGBTQ+ clients.

“The first thing I recommend is self-reflection on how you are connected to the LGBTQ+ community outside of being a clinician,” Brackett says. “Understanding your own involvement and comfort within the LGBTQ+ community will help you be present with these clients in an authentic way.”

She suggests that counselors ask themselves the following:

  • Are you a member of the LGBTQ+ community? If so, what elements do you connect to versus what elements do you find yourself separated from? Are there parts of the queer community that you (consciously or unconsciously) avoid or dislike? If so, why? Do you feel like you “belong,” and how does that impact your willingness to connect with others in the community? How do your opinions change if the race, ethnicity, income, gender or gender presentation of the person changes?
  • If you don’t consider yourself part of the LGBTQ+ community, how open and connected are you to people within it? Do you seek out or seek to avoid places or events that are heavily attended by the queer community? How comfortable do you feel when you are in those spaces? How do your opinions change if the race, ethnicity, income, gender or gender presentation of the person changes?

“Remember that there are generalized experiences, and then there are your client’s experiences,” Brackett continues. “Trust your client to tell you their reality. It may align with your own experiences or general narrative you have of the LGBTQ+ community, but it may not. Your goal is to be present with them where they are, as they are.”

Polk has some additional suggestions:

  • Allow the client to determine the pace. It is not the counselor’s job to set an agenda for coming out or transitioning.
  • Frequently reassess goals in therapy. What the client needs when they enter therapy is often not the same as what they need after eight to 10 sessions have taken place.
  • Monitor for clients’ sense of safety and agency. For example, ask them how their relationships are and how they experience safety in an environmental context (e.g., employment, social events, political environment).
  • Continue to scan and assess for co-occurring disorders such as substance abuse. Individuals who identify as LGBTQ+ tend to have a disproportionate number of stressors that could lead to comorbid emotional and mental health concerns.

“Additionally, I would suggest some form of participation in LGBTQ+-affirming communities,” Polk says. “For example, attend a support group, view LGBTQ+ art [and] film, or read literature written by queer authors. Ask to interview LGBTQ+ counselors, or seek out LGBTQ+-specific supervision and psychotherapy training. Finally, perform a self-assessment of your own attitudes and biases of LGBTQ+ people to determine your growing edges in counseling.”

Brackett offers a closing thought: “If you find that you are uncomfortable with LGBTQ+ clients or are concerned about your ability to work with this population, seek out clinical supervision, and engage in your own therapy.”

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

  • Affirmative Counseling With LGBTQI+ People edited by Misty M. Ginicola, Cheri Smith and Joel M. Filmore
  • Casebook for Counseling LGBT Persons and Their Families edited by Sari H. Dworkin and Mark Pope
  • Group Counseling With LGBTQI Persons by Kristopher M. Goodrich and Melissa Luke

Continuing Professional Development: LGBTQ (aca.digitellinc.com/aca/specialties/137/view)

  • “Transgender — Moving From Awareness to Advocacy” with Becca Smith
  • “Affirming Counseling Practice With Queer People of Color: From Margins to Center” with Adrienne N. Erby and Christian D. Chan
  • “Resiliency Factors of Trans-College Students: Implications for Professional Counselors and Higher Education Professionals” with Jane E. Rheineck and Matthew Lonski
  • “Lesbian, Gay, Bisexual, Transgender and Queer Youth: Family Acceptance and Emotional Development” with Julie Basulto
  • “The Counseling Experiences of Transgender and Gender Nonconforming Clients” by Rafe Julian McCullough, Lindy K. Parker, Cory Viehl, Catharina Chang, Thomas M. Murphy and Franco Dispenza

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources/self-care-resources)

  • LGBTQ
  • Grief and loss

Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (algbtic.org)

 

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Laurie Meyers is a senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Beyond LGB

By Stephen P. Hebard and AJ Hebard February 26, 2015

Counselors are familiar with the meaning of the word oppression. We take a multicultural counseling course that covers the definition during the early developmental stages of our counseling career. Many of us feel the weight of a biased system that puts immense pressure on us, both systemically and individually. We may even advocate for ourselves and others who are underprivileged and overburdened.

Still, we may unknowingly perpetuate oppression through a lack of awareness of our privilege. Whereas sources of oppression such as racism, sexism and heterosexism are familiar, we infrequently consider privileges granted by gender identity status. Transgender individuals — those

Laverne Cox, the first openly transgender person nominated for an Emmy award, appeared on the cover of Time magazine last year for an article about the relatively recent rise of transgender awareness in society.

Laverne Cox, the first openly transgender person nominated for an Emmy award, appeared on the cover of Time magazine last year for an article about the relatively recent rise of transgender awareness in society.

who do not identify with their assigned gender at birth or whose expression of gender differs from societal expectations — are perhaps one of the most oppressed and least supported populations that counselors must acknowledge.

According to the 2012 report by the National Coalition of Anti-Violence Programs (NCAVP), 41 percent of transgender individuals have attempted suicide, which is more than 25 times the attempted suicide rate of the general population (1.6 percent). Fifty-three percent of all anti-LGBT homicide victims were women who were transgender. Youth populations are not excluded from transgender oppression. In grades K-12, more than 75 percent of transgender students experience harassment, more than 33 percent are physically assaulted and 12 percent experience sexual violence. Also according to the NCAVP report, 29 percent of respondents on a housing survey who identified as transgender or gender nonconforming said they had been denied access to shelter because of that identity. An overwhelming 41 percent of black transgender individuals reported being incarcerated “due only to gender identity/expression.” Unfortunately, these glaring statistics represent only the tip of the iceberg regarding transgender oppression and transphobia in society.

Clearly, a massive gap exists between counselor competency and the lived experiences of transgender people. Our helping profession must make a conscious shift in its understanding of gender as it relates to the human body. As part of multicultural competency, it is imperative that we fully understand that cissexism is oppressive and begin to advocate for a more inclusive paradigm. We must understand diversity and identity beyond lesbian, gay and bisexual (LGB) and develop a comprehensive knowledge of transgender identities to truly practice nonmaleficence. This shift must occur in our textbooks, our curriculum, our intake processes, our communities and, perhaps most importantly, our interactions with transgender clients.

Glossary of terms

The following list of words and phrases is intended to explain only the basics of the language surrounding transgender issues today.

Male: Someone who identifies as male. There are no other requirements.

Female: Someone who identifies as female. There are no other requirements

Cisgender: Someone who identifies with the gender they were assigned at birth (not transgender).

Transgender: Someone who does not identify with the gender they were assigned at birth or whose expression of gender differs from societal expectations.

Gender binary: Social structure that says there are only two genders: male and female.

Nonbinary: Those who identify themselves other than male or female.

Gender identity: The gender with which a person identifies (e.g., male, female, agender, genderfluid).

Agender: Not identifying with any gender or having no gender.

Genderfluid: Identifying with different genders at different times, which change from one to another in a fluid manner (e.g., “Today I feel like a boy, but last week I didn’t have a gender at all”).

Sexual orientation: Clarifies what gender(s) an individual is attracted to (e.g., gay, straight, bisexual).

Cissexism: An axis of oppression that privileges cisgender (not transgender) people.

Heterosexism: An axis of oppression that privileges heterosexual people.

Intersectionality: The study of the interactions of multiple systems of oppression (e.g., transgender status and race/ethnicity).

Genital essentialism: The belief that bodies are gendered based on their genitals or “biological” sex (e.g., male bodies or female bodies).

Cisnormative: The assumption that a person’s gender identity is the same as their sex assigned at birth (i.e., cisgender).

Transsexual: Made by heterosexual cisgender men, this word describes a person with a disordered and unnatural disease for which the only cure is physical transition. Alternatively, transgender is a word created by and for transgender people and doesn’t carry the stigma that transsexual does, nor does it imply physical transition. However, some transgender people still choose to identify with or reclaim this word.

Doing our homework

Many people feel overwhelmed the first time they encounter these words and phrases, and counselors should remember that being an ally means doing their homework. It is important for counselors to understand that heterosexism and cissexism are two very related but still separate axes of oppression. An individual can be any sexual orientation while still identifying as cisgender and being cissexist. Straight transgender people can be heterosexist as well. In fact, the LGB population that is cisgender does not experience cissexism and is often oppressive to transgender people. Cissexism is a massive institutionalized structure that takes work for the privileged to understand, just like more familiar forms of oppression such as racism or sexism. In addition, most media is made by cisgender people and is therefore decades behind in portraying the experiences of transgender people.

To be competent and respectful in working with transgender people, it is helpful to identify their preferred words. This can primarily be done through social media, where transgender people speak loudly and unstifled by the threat of violence that is sometimes posed in face-to-face conversations. Engaging with sites such as blackgirldangerous.org, Twitter and Tumblr, reading blogs, watching YouTube, learning from transgender people themselves, referring to self-identification and being open to listen are all strategies for expanding one’s understanding of transgender issues.

It is imperative that counselors do not make assumptions that dismiss a transgender client’s independence by asking that client to act in accordance with the counselor’s values rather than the client’s own values. Counselors who place their cisnormative value system on transgender clients are committing both invalidation and harm. Likewise, counselors who are aware and understanding of differences without treating the individual as “less than” provide a safe space for the client.

In the spirit of nonmaleficence, the “do no harm” principle, counselors must avoid acting in any way that could potentially inflict harm on a client. If we are to serve and protect such a vulnerable population, we must put an emphasis on understanding the needs of transgender clients. Counselors have a unique opportunity to provide a corrective experience for these clients by giving them an interpersonal exchange with someone who is willing to learn, listen and empathize without insult.

Beyond doing no harm, it is crucial that we act as allies and advocates when working with transgender clients, being proactive in our attempts to provide optimal services. Many transgender clients feel unsafe with “LGBT-friendly” counselors because these practitioners may have competence related only to sexual orientation. Indicating a specific competency with transgender issues and your status as a cisgender individual (if applicable) can be much more welcoming.

How can you make a difference?

It is important for counselors to have familiarity with privilege and oppression as social constructs that create power dynamics within our work. Microaggressions, which are subtle and often unintentional forms of discrimination, remain commonplace even in counseling spaces. Such invalidations, although less obvious or harshly intended as an overtly cissexist or anti-trans remark, still must be understood as assaults that dismiss and denigrate transgender clients. Even the most empathic counselor can make the mistake of misgendering or committing a microaggression toward a transgender client that sends the message, “This is not a safe space.”

Although knowledge of current transgender issues and how to work with this population may be limited, counselors should consider the following suggestions.

1) Always refer to self-identification

“What language do you prefer when referring to your body?”

How do you know when a transgender client walks through your door? You don’t. Many transgender people do not “look transgender.” According to the National Transgender Discrimination Survey, 71 percent of respondents said they hide their gender identity, and this figure only encompasses those who were willing to respond to a survey about being transgender. It is quite possible that many others did not feel comfortable responding because of their “closeted” status.

To facilitate healing in this population, it is important never to assume a person’s gender or pronoun preference. Instead, gender can be thought of as something you learn as you get to know someone, just like their name or hometown. Before you learn someone’s gender or pronoun, use neutral language such as they/their/them pronouns and “that person” to refer to them. In this way, always refer to self-identification and use the language that reflects what your client chooses. Furthermore, counselors must be clear on the fact that a transgender woman is a woman and a transgender man is a man. A transgender woman is not a man who thinks he is a woman, and vice versa.

2) Offer your pronouns

“My name is Stephen. I prefer he/him/his pronouns.”

Especially in the intimate setting of a counseling session, one of the best ways counselors can indicate a safe space to clients is by offering their pronoun preference first. Offer your pronouns by simply sharing them when introducing yourself. Ask the client’s preference and then respect that preference. This sort of initiative is not only an invitation to the client but also a recognition of privilege. It communicates to the client, “I know it is frustrating and exhausting to constantly correct and inform strangers, so I will take the burden for you.”

Furthermore, correcting oneself when misgendering a transgender client is a sign of commitment to inclusivity. Additionally, introductory paperwork that reflects the respect of one’s counseling staff can go a long way toward provision of safety and comfort. By offering your pronouns, you begin to build a safe environment and establish the therapeutic relationship.

3) Recognize more than two genders

“How do you describe your gender identity?”

Some transgender clients, mostly those who are nonbinary, will prefer to use they/them/their pronouns, which take the place of he/him/his or she/her/hers in sentences referring to them. (That’s why we use they/them/their pronouns throughout this article). Others may use pronouns you may never have heard of. Even Facebook, the popular social media outlet, has updated its website to be inclusive of gender diversity by allowing for more choices than the male-female binary and by asking for an individual’s preferred pronouns.

Although some counselors may at first find the use of this language a feat of grammatical acrobatics, it is important to keep in mind that your client’s sense of safety is predicated on you respecting their gender identity. In addition, keep in mind how your language excludes those who are not male or female: saying “he or she” when attempting to describe everyone is a very common microaggression in communication that excludes nonbinary individuals.

4) Start de-gendering strangers

“Your body is your own, and you can define it how you like.”

The easiest way to avoid misgendering strangers is simply to not gender strangers. We need to eliminate the coercive attribution of gender based on physical characteristics such as breasts, wide hips or facial hair. If a transgender person identifies as female, then they have a female body. Instead of viewing transgender women as “trapped in male bodies,” we must broaden our definition of “female body” to make room for the bodies of women with wide shoulders, facial hair and external genitalia.

In working with transgender clients, it is important to recognize that there is no such thing as a “biological” gender. Rather, bodies only have a gender when designated by the owner. Another way of describing this phenomenon is to describe sex as a social construct just as much as gender. For example, if most people with type “A” bodies are female, but some are not, we can assume that type “A” bodies are not inherently female or do not inherently cause female-ness.

5) Practice seeing and hearing gendered language

“Women’s rights should include more than individuals with a uterus.”

The role of an ally is not simply to know how to avoid misgendering and committing other microaggressions. An advocate for transgender clients has the responsibility of correcting others who misgender, stereotype, tell inappropriate jokes or oppress transgender communities in any other way, whether overt or subtle. Your courage as an individual of privilege and power can save or, at minimum, improve the life of someone who is all too familiar with being “other.” Systemic changes can eventually happen when they start at the individual level.

Conclusion

This article is meant to serve only as a brief introduction to working with transgender clients. There is no step-by-step formula to providing guidance for any individual of the transgender community. However, the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC) Competencies for Counseling With Transgender Clients (approved by the American Counseling Association Governing Council in November 2009) provides practitioners with a baseline position from which to begin one’s education.

Counselors, and not only those of cisgender privilege, must be pursuing continuing education and self-awareness to provide optimal services to transgender clients. This includes lesbian, gay, bisexual and other nonheterosexual individuals who don’t identify as transgender. Counselors must also remember that the language of oppressed communities is always changing and growing. Therefore, continued education is necessary. Addressing these action steps to change your language is not a simple task. However, your efforts will be catalysts for the healing process and may represent the first time that a client has had a health professional show empathy for their identity.

Continued opportunities for awareness and advocacy may include reading the World Professional Association for Transgender Health Standards of Care (wpath.org/site_page.cfm?pk_association_webpage_menu=1351) and obtaining membership in ALGBTIC, a division
of ACA.

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Stephen P. Hebard (he/him) is a licensed professional counselor associate in North Carolina, a national certified counselor and a doctoral candidate of the Counselor Education Department at the University of North Carolina at Greensboro. Contact him at sphebard@gmail.com.

AJ Hebard (they/them) is a transgender counselor education master’s student at North Carolina State University. They are currently the social advocacy chair of the Nu Sigma Chi chapter of the Chi Sigma Iota honor society and are passionate in their advocacy for transgender communities. Contact them at ajhebard@ncsu.edu.

Letters to the editor: ct@counseling.org

Partners in transition

By Stacy Notaras Murphy January 26, 2015

Robyn Chauvin was happily married in the early 1990s. Having spent time in counseling, she had given up drugs and alcohol, was studying to be a music therapist and was working with patients in a psychiatric hospital. But she knew there was one more change she needed to make. “I got very clear that I was not going to pretend to be male anymore,” Chauvin says.

Born looking like a male, Chauvin had lived her life as a man, fell in love and married a woman — but she knew something was wrong. “The one unhappy thing was my gender identity,” Chauvin says. “I grew up in New Orleans, and my idea of male-to-female transsexuals was strippers and hookers. That was what I thought it would have to be. I never imagined it was a possibility for me, and then I got to a point where it felt like an imperative.”

Chauvin describes going through years of deep self-hatred and low self-esteem, with associated Branding-Box-gender depression and substance abuse, before deciding she could no longer pretend to be someone she was not. But deciding to transition to female also would require enormous sacrifices, including a divorce, the concern of possibly resigning her position at the psychiatric hospital and securing significant financial arrangements to pay for her eventual surgery. After going public with her decision, Chauvin found herself welcomed and accepted by the hospital staff and eventually went on to study counseling at Naropa University in Boulder, Colorado. Today, she is a licensed professional counselor (LPC) and music therapist in private practice with offices in Boulder and Denver. She sees adult clients who are dealing with what she describes as “garden variety neuroses,” including gender identity and divorce. “Not to sound too existential, but I think everybody is dealing with gender identity issues,” Chauvin says. “The idea of a gender identity is false.”

Many in the counseling profession are exploring Chauvin’s assertion. The Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC), a division of the American Counseling Association, approved competencies for counseling transgender clients in 2009. The competencies emphasize a wellness-, resilience- and strength-based approach to working with transgender clients, while also acknowledging the multiple oppressions experienced by many in this population.

An April 2011 research brief published by the Williams Institute on Sexual Orientation and Gender Identity Law and Public Policy at the UCLA School of Law said an estimated 3.5 percent of U.S. adults identify as lesbian, gay or bisexual, whereas an estimated 0.3 percent of U.S. adults — or about 700,000 people — are transgender. Meanwhile, a February 2011 study by the National Center for Transgender Equality and the National Gay and Lesbian Task Force (NCTE/NGLTF), titled “Injustice at Every Turn,” revealed that trans people face pervasive discrimination and report staggering rates of attempted suicide.

These findings suggest that you are quite likely to meet a transgender person in your lifetime, and if they turn up in your counseling office, they are likely to have experienced significant ostracism and pain. The good news is that healing can start within the therapeutic alliance. But counselors must be aware of the uncommon factors that might affect these clients, as well as the ways they experience common mental health issues, just like any other client.

Thomas Coughlin, an LPC and ACA member at Whitman-Walker Health (formerly Whitman-Walker Clinic) in Washington, D.C., explains this further. “The needs of this community range from the very basic — i.e., adequate and safe shelter, food, personal safety and protection against discrimination and violence, sometimes from the very agencies in place to protect us — to gender consolidation, navigating romantic relationships and/or ‘coming out’ concerns.”

Pointing to the recent NCTE/NGLTF report, Coughlin notes that individuals in this community often experience “cumulative discrimination” in which they are personally affected by at least three events rooted in bias and discrimination. “It is clear to see how one’s mental health may be impacted,” he adds.

Heather L. Chamberlain agrees. A licensed mental health counselor and self-described “gender specialist” in private practice in Seattle, she applies narrative and feminist theory to her work with transgender clients. “Anyone who is transitioning their gender identity is necessarily involved in rewriting their story and evaluating the impact of systemic obstacles on their past, present and future development,” she explains, noting that she has focused her education and training on gender issues from the outset.

Chamberlain has found that these clients initially present to counseling with marked depression and anxiety. “It is a terrifying prospect to disclose the self-discovery that one’s anatomy and inner experience do not align,” she says. “People fear rejection, loss of employment [and] loss of family, friends and intimate relationships. Initial goals for treatment often include support in coming out, strategizing about how to manage the obstacles and challenges they anticipate in their transition experience and mitigating depressive and anxiety-related symptoms.”

“Often, there are issues surrounding low self-esteem, as many people have spent years living with a gender presentation that they know to be wrong for them and have developed significant self-loathing as a result,” Chamberlain continues. “People who are further along in their transition sometimes have trauma issues to process, perhaps as a result of hate crimes, rejection from family or termination of employment. The risk of suicide for these clients cannot be overstated. The challenges they face are immense and, sometimes, quite overwhelming.”

Chamberlain cautions that one challenge in working with the transgender population comes in the form of witnessing the extreme injustice and marginalization these clients are forced to endure. However, she notes that the work is highly gratifying as well. “I have yet to work with a transgender or gender-variant client who is not intelligent, insightful, creative and incredibly tenacious in one way or another,” she says. “There aren’t words to describe how incredible it is to witness the transformation of a person who comes to you sad, fearful and overwhelmed into a confident, beautiful, successful human being whose outer self aligns with their inner experience.”

Thomas Tsakounis reports a similar experience. An ACA member in private practice, Tsakounis is the executive director of A Quiet Journey Counseling & Associates in Silver Spring, Maryland, where he works with a variety of clients, including lesbian, gay, bisexual and transgender (LGBT) individuals, same-sex couples and families. “Witnessing the shift from nonacceptance to acceptance is one of the most rewarding experiences,” he says. “[Although] oftentimes it doesn’t happen in one session but is more a transition, the work is life altering.”

Tsakounis finds that working through deeply embedded social, cultural and religious views often presents the most daunting challenge. “It is my belief that since many of these views are imparted to youngsters early in life, deviating or breaking free from these belief systems is more challenging as a young adult or adult,” he says. “These deeply steeped views result in challenges in empowering the client to see themselves in a different light.”

Counselor as gatekeeper

Transgender clients present to counseling for a variety of reasons. Counselors may find themselves working with someone who is fully confident at the end of her transition or a person for whom even speaking the word “transgender” may be a new experience.

When a trans person decides to pursue gender reassignment surgery, they are often required to have a mental health evaluation and a letter of support written before receiving hormones or being evaluated for surgery. Coughlin describes this as playing the role of gatekeeper, or being the one with the power to determine if the client gets to live an authentic life.

“When I was doing intakes, I would sometimes be the first person [the client had] ever shared their feelings with. They come in with symptoms of depression or anxiety, and it takes a while to get to the gender stuff,” he says, adding that, as a health center, Whitman-Walker Health addresses the mental health factors alongside the physical health issues that clients are facing.

Coughlin says it is critical that counselors educate themselves on gender identity topics because they are often on the front lines of helping trans people find resources. “We are put in a tremendous position of power to say if [these individuals] can get ‘the surgery’ [gender reassignment surgery],” he says. “They can come in skeptical or unsure. This has been a marginalized community that has dealt with marginalization and discrimination by health care providers, [so they] may come in very distrustful of us.”

Chauvin suggests that counselors attune themselves to situations in which a trans client enters treatment with resentment toward the medical establishment and use that as a way to explore similar resentments and frustrations the client has experienced over a lifetime. She also recommends that counselors be prepared to help these clients if they are facing financial crisis as a result of losing a job or career when they begin to transition. She notes the example of one of her clients who had been running an engineering firm but lost her job and had to become a massage therapist after making the transition to female. But at the center of this process, Chauvin emphasizes, is the same existential question that any other client may face: Who am I in the world?

Rebecca Ouer, a social worker in Dallas, is currently writing a book titled Solution-Focused Brief Therapy With the LGBT Community: Creating Futures Through Hope and Resilience to help educate clinicians. Her philosophy is to make room for the client to fully define himself or herself. “If a client looks to you like a typical male and sounds like what you have always known as a male but wants to be called ‘Nicole’ and referred to by female pronouns, as their therapist, you must get past any and all reservations you have about societal norms and completely respect your client’s definition of themselves. If you cannot do that, you should not be working with this community,” Ouer states. “Do not question their definitions; just respect them and ask them questions about the hopes that they have for their lives.”

Coughlin himself transitioned around 2000, when he says the medical community still struggled with how to help trans people. “The field around transgender people has just totally transformed [since then],” he says. “Way back then, we were still considered to be in this pathology that needs to be corrected. Still [today] people see it as an affliction, a disorder, a tragedy — and it’s not. I come at it from a strengths-based place. Coming into my office is an amazing feat [for these clients]. Trying to become more authentic and more themselves … it’s not a horrible thing. With some family members, this is a courageous thing to go through, so my focus is on how can I help and be of support to you?”

Counselors who are not transgender themselves still can be helpful to clients facing gender identity issues. Tsakounis suggests that counselors consider exploring sensitivity training to help them “separate the myth from the truth.” He adds that coming out often is a long, painful and confusing process. “Seeking support may seem simple and straightforward, but there is a certain degree of courage involved,” he says. “Clients who present to counseling have reached a point where they simply don’t have the answers they seek, and despite their concern about judgment and anonymity, they make the decision to engage professional help.”

For counselors looking for a starting point in their work with these clients, Tsakounis recommends recalling Carl Rogers and the concept of unconditional positive regard. “I am always reminded that whether it is an LGBTQ client or anyone else seeking a counselor/therapist, the bottom line is that when you erase all the labels, what sits before you is a peer — a person who wants to be accepted, listened to and supported. In the end, their sexual identity is a small, very small, part of that human being,” he says. “Offering a safe space where there is no judgment and providing unconditional positive regard [are two] of the most valuable gifts you can give to someone who has known nothing but the contrary their entire life.”

A host of interventions

The diversity of ways a transgender client presents to counseling may be equaled only by the variety of interventions used with this population. Caroline Gibbs, an ACA member, is the founder and director of the Transgender Institute in Kansas City, Missouri, where the model of treatment extends beyond talk therapy. Gibbs explains that the institute’s offerings are multifaceted to truly support transgender people through all phases of their transition. Services include individual and group therapy, one-on-one vocal coaching, mentoring programs, insurance navigation assistance and physician referral, as well as clinical consultation for therapists desiring support as they help transitioning clients. The institute also offers classes on makeup application and hairstyling, Gibbs says, because many trans women are highly interested in learning about these skills and need a safe space to explore them.

“We have a fashion stylist … [and] we have a finishing school for people who want to learn how to sit properly at a table and how to make their way around society. We do vocal feminization, and, of course, we do therapy,” she explains. “99.9 percent of the patients who come here say, ‘I want to blend in. I want to be a woman in this society, and I want to live my life.’ They may choose to be an advocate for their community in the future, but most often they are very sure they just want to blend in.” Gibbs adds that female-to-male transsexual clients may find it easier to blend in faster because testosterone treatments provide physical and vocal changes within three to six months.

Gibbs often starts by inviting clients to write an autobiography, which, she explains, can feel easier than having to vocalize their feelings. “Sometimes people are so anxious they will not talk in therapy,” she says. “They are so afraid to say ‘I’m transsexual,’ so they write out their sessions.”

Gibbs mentions the example of a male-to-female transsexual client who grew up in a household of brothers and with a masculine father who profoundly discouraged her from doing anything feminine. “All she wanted was to play with Barbies,” Gibbs recalls. “So what she did was take her GI Joes and, at 4 or 5 years old, cut out paper dresses and pinned them to the GI Joes. She remembered that when writing the autobiography.”

At the same time, Gibbs says, “I think that the power of a future-focused conversation with this community cannot be overstated. I never spend time talking about my clients’ childhood or delving into the details of their dysphoria unless they ask me to or bring those things up on their own.”

Gibbs says she believes clinicians can sometimes become curious about the wrong things with this community, such as the details of transition that might make clients uncomfortable. “I think that these clients need to be able to be in the driver’s seat of these therapeutic conversations,” she says. “They need to know that they are the empowered ones in our therapy rooms. They are the experts of their lives and of who they are. We are just the experts of the question-asking process to help them get to their preferred future.”

Other clinicians apply their own preferred treatment modalities when working with trans clients. Tsakounis says he frequently uses the Emotional Freedom Technique (EFT) with clients working through feelings of fear, disappointment, guilt, sadness, low self-esteem, anger, anxiety and frustration. A self-administered energy technique that draws on approaches rooted in alternative medicine, EFT helps clients release distress by tapping on various parts of their bodies. “EFT is very effective in helping a client process through feelings more efficiently, while at the same time bringing out some of the more deeply seated feelings,” Tsakounis says. “EFT empowers the client by giving them a simple, easy-to-access tool which they can use at any time.”

Chamberlain, meanwhile, has found success using acceptance and commitment therapy and dialectical behavior therapy techniques to help clients manage anxiety and enhance their coping and containment skills. She also recommends journaling and art therapy techniques to engage the creative mind and bibliotherapy and media therapy (in which counselors use movies and TV clips) to help clients feel less alone.

Coughlin notes that he doesn’t believe therapy is an absolute requirement for trans people. “I think there are people who are high functioning, and this is just a path of self-actualization. They know who they are and have to go this track to be connected to the medical options,” he says. “[For] others, I think really it’s about support in dealing with the other people in their lives, dealing with the coming-out process, societal pressure, loss of family support, being isolated [and] just how to connect. Trans folks are human. You can be trans and be depressed. It’s not necessarily causal.”

How to become a resource

Working with the trans population may demand more than conventional counseling skills. Coughlin, for example, sees much of his calling in this community revolving around advocacy and education for people outside the clinic. He notes that he often does a substantial amount of footwork to help clients find competent providers for mental health and other health care needs.

“It’s more than hanging a shingle and saying, ‘Sure, I’ll work with trans folks.’ We need to refer to people with experience,” he says, adding that word-of-mouth is often how he becomes aware of providers with skills in this area. “I just went to a workshop this morning about transsexuality, and it’s so much more than just ‘read these two books and start taking clients,’” Coughlin says. “You really have to dive in, talk to providers, join a peer group, go to a conference, go to Gay Pride [events and] find out all the resources. You have to have a wealth of information to do this work well.”

Chamberlain agrees and takes issue with how counseling education programs address work with the transgender community, charging that if and when the topic is even discussed, it barely scratches the surface of what is needed. She recommends that counselors attend conferences specific to gender issues, including the Philadelphia Trans-Health Conference and Seattle’s Gender Odyssey conference. She also suggests joining the World Professional Association for Transgender Health and becoming familiar with its most recent standards of care. “Beware of offerings that promise you certification as a ‘gender expert’ in a short amount of time,” she says. “No such certification yet exists. We become gender specialists through years of education, training, reading, involvement in the communities and working with our clients.”

Although Whitman-Walker Health specializes in serving LGBT clients, Coughlin admits that the emphasis often is on the lesbian and gay clients rather than the transgender population. “A transgender person’s experience is going to be very different from a gay man’s experience. It’s important to do the work to see what the community is and who trans people are [to get] a sense of the complexity and diversity in that community, because it’s certainly not ‘one size fits all,’” he explains.

Coughlin’s advice for counselors is to stop thinking about gender the way they have in the past. “It’s a paradigm shift,” he says. “Gender is this fluid thing … more like a soup. … People are everywhere and anywhere in there, and that’s their right as people and human beings. And that’s our role as therapists — to allow them to be seen as they are and to know that when they aren’t able to present as themselves, to meet them where they are.”

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Contributing writer Stacy Notaras Murphy is a licensed professional counselor and certified Imago relationship therapist practicing in Washington, D.C. To contact her, visit stacymurphyLPC.com.

Letters to the editor: ct@counseling.org

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Entering the danger zone

By John Sommers-Flanagan October 28, 2014

For the most part, the United States lacks a coherent and systematic approach to sexual education. Instead, as lampooned in an online issue of The Onion, sex education is typically informal, unorganized and inaccurate. The Onion article describes a scene in which a 10-year-old boy takes his 8-year-old cousin behind his parents’ garage with a page ripped out of a magazine and shares “the vast misguided knowledge of human sexuality he had gleaned from classmates’ hearsay as well as 12 minutes of a Real Sex episode he watched in a hotel room once.” The older boy recounts his rationale: “Every time people have sex the woman has a baby, and I just want [my younger cousin] to be completely prepared before getting naked with a girl.”

The good news is that The Onion deals in news satire. The bad news is that the current state of sex education in our country isn’t much better than the fictional version portrayed in The Onion.

Image of youth looking at laptop computerConsider that a report this past April from the Centers for Disease Control and Prevention indicated that more than 80 percent of adolescents between the ages of 15 and 17 have no formal sexual education before actually having sex. If teenagers have no formal sex education, then what informal sex education do you suppose they take with them into their first sexual experiences?

One such source of informal sex education is pornography. In 2009, University of Montreal professor Simon Louis Lajeunesse designed a study to evaluate how pornography use affects male sexual development. He planned to interview 20 males who had viewed pornography, then compare their responses with those of 20 males who had never viewed porn. Remarkably, Lajeunesse had to abandon his project because he couldn’t find any college-aged males who hadn’t already viewed porn.

Other researchers report similar experiences. It appears that most boys, rather than learning about sex from a well-meaning, albeit uninformed cousin, get their information from the pornography industry … and my best guess is that the porn industry isn’t focusing on the best interests of American youth. This is one way in which reality may be worse than The Onion’s satiric version of events.

The absence of formal and accurate sexual education is a particularly American problem that may find its way into the offices of professional counselors. Many young males probably have little basic knowledge about sex and sexuality, or hold unhelpful ideas. Some will have porn addictions. Others will want to talk about how pornography may be affecting their real sex lives. You may also have clients who are concerned about their partner’s or potential partner’s porn viewing behaviors. Working with young (and older) males (and females) who want to talk about their sexual knowledge, beliefs and behaviors, including watching pornography, is both a challenge and an opportunity for professional counselors.

Counselors have an ethical mandate to strive toward competence. As articulated in the multicultural counseling literature, this requires cultivating personal awareness, gathering knowledge and developing skills.

Awareness: Expanding your comfort zone

Talking about sex, sexuality and sexual attraction can be difficult at every level. Think about yourself: How easy is it to talk about sex with your supervisor, colleagues, students or clients? Your own experience may give you a glimpse into how challenging it can be to broach the topic of sex — even for professionals.

In comparison, it’s probably an understatement to say that it is especially difficult for boys to initiate a conversation about sex or sexuality with a professional counselor. This is why counselors who work with boys should become comfortable initiating conversations about sex. If you don’t ask at least a few gentle, polite, yet direct questions, you may be waiting a long time for the boy in your office to bring up the subject.

On the opposite extreme, some young clients will jump right into talking about sexuality and push us straight out of our comfort zones. Recently, I was working with a 16-year-old boy who described himself as a polyamorous “furry” (which I later learned involved sexualized role-playing as various animals). Admittedly, it was a challenge to maintain a nonjudgmental attitude. But without such an attitude, we wouldn’t have been able to have repeated open and useful conversations about his sexuality and sexual identity development.

Knowledge: The effects of pornography on boys and men

Many potential areas related to sexuality deserve attention, focus and discussion in counseling. But because pornography and mixed messages about pornography are everywhere, it can be an especially important subject.

Most counselors probably believe that repeated exposure to pornography has a negative impact on male sexual development. This negative impact is likely exacerbated by the fact that most boys aren’t getting any organized, balanced and scientific sexual information. Nevertheless, within the dominant American culture, there remains strong resistance to both sex education and pornography regulation. Even in a recent issue of Monitor on Psychology, the authors of an article questioned whether porn is addictive and blithely noted that “people like porn.”

It’s not surprising that porn has advocates. After all, it’s estimated to be a $6 billion-plus industry. In addition, media outlets explicitly and implicitly use pornlike sexuality to attract an audience and sell products. Recently we’ve seen the increased use of hypermasculine male body types in the media, but most of the rampant sexual objectification still focuses on young female bodies.

Given that sexual development includes a complex mix of culture, biology and life experience, it’s not surprising that researchers have had difficulty isolating pornography as a single causal factor in male sexual developmental outcomes. However, a summary of the research indicates that as the viewing of pornography increases, so does an array of negative attitudes, behaviors and symptoms. Generally, increased exposure to pornography is correlated with:

  • More positive attitudes toward sexual aggression, increases in sexual aggression, multiple sexual partners and engaging in paid sex
  • Increased depression, anxiety and stress, and poorer social functioning
  • Positive attitudes toward teen sex, adult premarital sex and extramarital sex
  • More positive attitudes toward pornography and more viewing of violent or hypersexual pornography
  • Higher alcohol consumption, greater self-reported sexual desire and increased rates of boys selling sexual acts

In contrast to these findings, a 2002 Kinsey Institute survey indicated that 72 percent of respondents considered pornography to be a relatively harmless outlet. This might be true for adults. I recall listening to B.F. Skinner talk about how older adults could use pornography as a sexual stimulant in ways similar to how they use hearing aids and glasses.

But the point isn’t whether people like porn or whether porn can be relatively harmless for some adults. The point is that pornography is a bad primary source of sexual information for developing boys and young men. As a consequence, it’s crucial for counselors who work with males to be knowledgeable about the potential negative effects of pornography.

Skills: How can counselors help?

A big responsibility for professional counselors who work with boys is to consistently keep sex and sexuality issues on the educational and therapeutic radar. This doesn’t mean counselors should be preoccupied with asking about sex. Rather, we should be open to asking about it, as needed, in a matter-of-fact and respectful manner.

As with most skills, asking about sex and talking comfortably about sexuality requires practice and supervision. But as Carl Rogers often emphasized, having an accepting attitude may be even more important than using specific skills. This implies that finding your own way to listen respectfully to boys (and all clients) about their sexual views and practices is essential. It also requires openness to listening respectfully even when our clients’ sexual views and practices are inconsistent with our personal values. As with other topics, if we ask about it, we should be ready to skillfully listen to whatever our clients are inclined to say next.

Case example

Some years ago, I had a young client named Ben who was in foster care. We started working together when he was 10 and continued doing so intermittently until he was 17.

When Ben was approximately 13, I routinely started asking him about possible romance in his life. He typically redirected the conversation. Occasionally he gave me a few hints that he wanted a girlfriend, but he mostly still seemed frightened of girls. As my counseling with Ben continued, I became aware that I had been conspiring with him to avoid talking directly about sex, possibly because I was afraid to bring it up.

I finally faced the issue when I realized (far too slowly) that Ben had no father figure in his life and, thus, I was one of his best chances at having a positive male role model. With encouragement from my supervision group, I was able to face my anxieties, do some reading about male sexual development and finally broach the subject of having a sex talk with Ben.

Toward the end of a session I said, “Hey, I’ve been thinking. We’ve never really talked directly about sex. And I realized that maybe you don’t have any men in your life who have talked with you about sex. So, here’s my plan. Next week we’re going to have the sex talk. OK?”

Ben’s face reddened and his eyes widened. He mumbled, “OK, fine with me.”

The next session I plowed right in, starting with a nervous monologue about why talking directly about sex was important. I then asked Ben where he’d learned whatever he knew about sex. He answered, “Sex ed at school, some magazines, a little Internet porn and my friends.”

I felt a sense of gratitude that he was listening and being open, even if we were both feeling awkward. We talked about homosexuality, pornography, sexually transmitted diseases, pregnancy, contraception and emotions. I tried to gently warn him that too much porn could become way too much porn. He agreed. He told me that he didn’t feel like he was gay but that he didn’t have anything against gays and lesbians. At the end of the conversation, we were both flushed. We had stared down our mutual discomfort and navigated our way through a difficult topic.

Professional sex educators emphasize that parents shouldn’t have just one sex talk with their kids; they should have many sex talks. What I thought was THE talk with Ben turned into something we could revisit. Over the next two years, Ben and I kept talking — off and on, here and there — about sex, sexuality and pornography.

Final thoughts

Boys are a unique counseling population, and sex is a hot topic. Together, the two provide both challenge and opportunity for professional counselors. As counselors, we should work to develop our awareness, knowledge and skills for talking with boys about sex and sexuality. You may not be the perfect sex educator, but when the alternatives for accurate information are pornography or someone’s uninformed older cousin, it becomes obvious that having open conversations about sex with boys is an excellent role for counselors to embrace.

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Readings and resources for working with boys and men

  • A Counselor’s Guide to Working With Men, edited by Matt Englar-Carlson, Marcheta P. Evans & Thelma Duffey, 2014, American Counseling Association
  • “Addressing sexual attraction in supervision,” by Kirsten W. Murray & John Sommers-Flanagan, in Sexual Attraction in Therapy: Clinical Perspectives on Moving Beyond the Taboo — A Guide for Training and Practice, edited by Maria Luca, 2014, Wiley-Blackwell
  • Guyland: The Perilous World Where Boys Become Men, by Michael Kimmel, 2010, Harper Perennial
  • Tough Kids, Cool Counseling: User-Friendly Approaches With Challenging Youth, second edition, by John Sommers-Flanagan & Rita Sommers-Flanagan, 2007, American Counseling Association
  • The Macho Paradox: Why Some Men Hurt Women and How All Men Can Help, by Jackson Katz, 2006, Sourcebooks
  • The Good Men Project: goodmenproject.com

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John Sommers-Flanagan is a counselor educator at the University of Montana and the author of nine books. Get more information on this and other topics related to counseling and parenting at johnsommersflanagan.com.

Letters to the editor: ct@counseling.org

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Behind the book: A Counselor’s Guide to Working with Men

By Bethany Bray August 13, 2014

It is widely acknowledged that men are less likely than women to seek help for mental health issues. At the same time, men’s issues can be misunderstood or overlooked by counselors, the majority of whom are women, say Matt Englar-Carlson, Marcheta Evans and Thelma Duffey, the authors of A Counselor’s Guide to Working with Men, published this past spring by the American Working_w_men_brandingCounseling Association.

“Counselors might not think there is much to know in terms of counseling competency when working with men. By default, counselors might adopt a universalistic perspective that ignores male culture and minimizes the experiences and stresses of growing up male. … Like other dimensions of identity, masculinity wholly influences the well-being of men and therefore must be considered and assessed if counselors wish to create effective therapeutic outcomes,” they write in the preface of their book.

Seventy percent of counselors are female, according to statistics from the U.S. Department of Labor, and roughly 75 percent of American Counseling Association members are female.

With this in mind, there are gender-specific themes that counselors should keep in mind – and be sensitive to – when working with men, say Englar-Carlson, Evans and Duffey.

 

Q+A: A Counselor’s Guide to Working with Men

Responses from co-author Matt Englar-Carlson

 

Men are statistically less likely to seek help for mental health issues. From your perspective, what can counselors do to help this?

The data here is very clear. Referrals for mental health services are about the same for men and women, and across the Diagnostic and Statistical Manual of Mental Disorders, the incidence of disorders are believed to be equivalent for men and women. Yet, regardless of demographic factors, men are less likely to seek help for mental/physical health concerns. So there is something about how men are living their lives and also how the mental health profession operates that maintains this discrepancy.

There is not enough space here to address the question fully, but counselors can recognize that seeking counseling often is stigmatizing for men and violates masculine norms about how many men should live their lives. Seeking help means relying on others, admitting the need for help, recognizing the influence of emotional problems — and if men are invested in a model of masculinity that values being strong, self-reliant and maintaining emotional control, then counseling is a tough sell, as the popular perception of counseling directly conflicts with this.

To address this, counselors can initially address men’s self-stigmatizing beliefs, normalize concerns and encourage expectancy in a positive outcome, reframe masculine-associated negative beliefs, validate the courage to seek help and the ability to overcome obstacles and, most importantly, meet men where they are. And that can mean getting out of the office and into the community to the places where men congregate. Go to gyms and athletic clubs, fraternal organizations (Rotary, Kiwanis, etc.), churches, business organizations and other places where men go and see if there is a way to talk about men’s health.

Often it is better to modify the message to reduce resistance. For example, I often talk about “men’s health” rather than just “mental health,” as I know that mental health is more stigmatizing. Other research indicates using terms like “coach” rather than “counselor” can be helpful. All of this is really about being strategic in knowing the audience you are trying to target. So you can see that counselors might find themselves borrowing tactics from public health to reduce barriers to help-seeking and working to create social norms where men come to recognize their concerns as normal.

The key here is that counselors cannot do this if they do not understand the men they are trying to help. Counselors need to be masculine-sensitive in their work so that that are able to actually help men when they do come.

 

What advice would you give to counselors to prevent gender bias when working with men and to keep away from stereotypes — men are “macho,” unemotional, etc.?

The first answer here is that counselors need to do their own work to address their own barriers to working with men. Men and women alike need to examine their own stereotypes about men and their own past experiences so that they are not limited in how they understand the full range of men’s lives.

It is important to know that many men are invested in presenting an image and seeing themselves in a manner that matches the dominant masculine norm. Yet research on masculinity indicates that most men are of middling masculinity. It doesn’t matter how it is measured — most men score close to the middle of the scale. Research also tells us that most men think they’re not as masculine as other men they know, and most men don’t think they’re as masculine as they ought to be. So in other words, the average man thinks he ought to be more masculine. He’s likely to believe that he’s the least masculine guy in the group.

From that perspective, it’s no surprise that men make the effort to prove their masculinity again and again — and that it doesn’t take much prodding, even when it involves doing something stupid. As counselors, we have to use this information wisely, and see and experience the full range of the men that we see. We can easily reinforce masculine norms if that is all we expect, or we can be wise and patient enough to understand that there is a duality to how many men present. They will show you the toughness in order to protect their own tenderness, and they may present as stoic and unemotional in order to protect deeply painful and hurtful feelings. I think counselors need to acknowledge the toughness in order to experience the tenderness and understand why the toughness exists.

One of the key concepts here is being aware of the role of shame in men’s lives (see the article on men and shame by David Shepard and Fredric Rabinowitz in the Journal of Counseling & Development special issue on men and counseling). If counselors are sensitive to men, shame and emotions, then they will quickly learn that what you see on the outside is not always what is going on on the inside for many men.

 

Who is your target audience for A Counselor’s Guide to Working with Men?

Our audience is rather broad, knowing that everyone has some contact with boys, adolescent males, men and fathers in their personal and professional lives. The ideas in the book are tailored for clinical work with men, but we think the insights gained about male socialization and men’s health behavior could assist the reader with any of the men in their life. Most people know so little about the socialization and psychology of men, and it is rarely discussed in professional circles or among men themselves. We believe that a little knowledge can go a long way, and we hope the book helps the reader develop more sensitivity to men’s lives.

We also are aware that men may not always follow traditional help-seeking pathways, so this book was aimed to help professionals meet men where they are. If that means in a primary care setting, a school, private practice, community mental health facility … any setting is fine, as any interaction is an opportunity to promote health and wellness.

 

What do you hope counselors take away from the book?

That is a good question, as we considered that idea on many levels. On a basic level, our hope is that counselors learn about the wide range of men and masculinities and how male development can contribute to the difficulties many men experience around living healthy lives. This awareness can shift not only how counselors conceptualize the needs of men, but also how counseling is presented and practiced.

We also believe that ideas in this book will challenge readers to do some self-reflection about their own experiences, beliefs, biases and judgments about men. That process of reflection is critical in being a caring and compassionate counselor who works with men.

At a more technical level, there are many interventions and skills presented that can help counselors create better helping relationships with men and deepen the clinical experience. And I think that is something that our book really highlights — that men crave and can co-create deeper relationships. We put that idea front and center since it is critical to shaping how counselors work with men. You can see that we view working with men through the lens of developing relational cultural competency. Thus, our book looks at knowledge, beliefs and skills.

 

What would you want all counselor practitioners — school counselors, addictions counselors, mental health counselors, etc. — to know about the book’s subject matter?

First of all, we see this as practical book with clear ideas and case examples that illustrate concepts in action. Further, the book has multiple reflective questions embedded in each chapter that are designed to create a dialogue with the reader. We take an inclusive approach to understanding men and recognizing the wide range of identities associated with how men organize their lives.

We also present the book from a social justice perspective, recognizing the conflicts and barriers — intrapersonal, interpersonal, societal — that contribute to many men’s difficulties in being healthy. We present that perspective with the realization that health needs of men are vast and that the health disparities encountered by many men, but particularly men of color, need our immediate attention. It is easy to observe that men do not seek counseling as much as women, but the real question is, what are counselors doing to tailor their work to bring men to address why men might be hesitant?

 

Considering that the majority of counselors are women, do you think men’s issues and gender-specific needs are often overlooked or unrecognized in counseling sessions?

That is somewhat complicated to explore. I think that everyone recognizes sex and gender in a counseling session, but not everyone realizes that gender is salient to many men who are in counseling. I think that is true for almost any counselor. So in that sense, it might get ignored, or it plays out in sessions without any specific attention.

It is true that the most common counseling dyad is female to female, so in many cases, it might just be that counselors are not seeing as many men. But as I mentioned above, that also is a pretty significant issue that we ought be to addressing. Some counselor educators do not think the field should look at men’s issues. Due to many factors, it is also true that few counselors receive any formal training about working specifically with men.

One of the ways that male power and privilege works is that it clouds others — men and women alike — from seeing the pain and suffering of men. It leads many to assume that men do not need, want or will not accept assistance. It also deludes people — again, men and women alike — into not examining the role of gender for men. When gender is addressed in counselor training, it is often referring to women’s issues — take a look at chapters on gender in most multicultural counseling textbooks. So I do see a gap between what many men experience in their lives associated with their mental health needs and the counseling profession’s ability to comprehend and meet those needs effectively.

 

 

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A Counselor’s Guide to Working with Men is available from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-422-2648 x 222

 

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About the authors

Matt Englar-Carlson is a professor of counseling and co-director of the Center for Boys and Men at California State University, Fullerton.

Marcheta Evans is dean of the School of Professional Studies and the Worden School of Social Service at Our Lady of the Lake University in San Antonio, Texas. She served as ACA president for 2010-2011.

Thelma Duffey is ACA president-elect. She is a professor and chair of the Department of Counseling at the University of Texas at San Antonio.

 

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Related reading: See “Men Welcome Here,” Counseling Today‘s cover story from August 2010: ct.counseling.org/2010/08/men-welcome-here/

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

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