Tag Archives: gender

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.


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.


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.”


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


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.


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


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


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.





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




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.




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




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


Follow Counseling Today on Twitter @ACA_CTonline and on Facebook: facebook.com/CounselingToday


Men are not exempt from eating disorders

By Heather Rudow April 6, 2012


Statistics from the National Association for Anorexia and Associated Disorders reveal that up to 24 million people suffer from an eating disorder in the United States, and an estimated 10 to 15 percent of those cases are men.

Although the number of men with eating disorders is higher now than it’s ever been, writes Rebecca Wagner, the eating disorder coordinator at the Menninger Clinic, in The Atlantic, they are less likely to seek treatment.

And part of the reason, Wagner says, is shame.

“Many men find it particularly difficult to seek help because they feel uncomfortable, embarrassed or ashamed about identifying themselves as having an eating disorder,” Wagner writes. “In a society where men are always expected to be strong, they may feel weak for admitting that they have the disease, which may preclude them from seeking help.”

This idea of strength and toughness can date all the way back to childhood.

“Men, in turn, want to strive to appear more muscular, athletic and attractive,” Wagner writes, citing G.I. Joe action figures as having a potentially negative impact on young boys in the same way Barbie dolls can impact girls. G.I. Joe action figures, she says, can promote “a hyper-muscular physique that is associated with supreme masculinity. Additionally, some men’s sports, such as gymnastics and diving, expect a particular body type.”

“Research shows that these feelings have led many young men to begin using external agents like steroids and over-the-counter supplements to fix an internal problem — body dissatisfaction. These men are also over-exercising and engaging in other maladaptive behaviors to manage their weight, including restricting, binge eating and purging.”

Read the rest of the article

Heather Rudow is a staff writer for Counseling Today. Email her at hrudow@counseling.org.

Follow Counseling Today on Twitter.