Special Section: Transgender Individuals in Communities

Introduction

Eric Herschman, PsyD

The aim of this special section is to explore a variety of psychological issues faced by transgender individuals and communities, through the work of several professionals representing fields of study ranging from psychology to law. We believe it is paramount for professional psychologists to have knowledge surrounding the unique set of issues faced by the transgender community, and relevant pre/ post-doctoral training and continuing education are, unfortunately, rare. This section features articles from the following authors: Carmon Lalonde, PsyD who contributed the article titled, Toward Gender Affirming Care for the Trans and Gender Diverse Community; Peter Economou, PhD who contributed, Transgender Health Care: Integrating CBT with a Transgender Client; and Jodi Argentino, Esq. and Celeste Fiore, Esq. who co-authored, The Convergence of the Legal Rights With Educational and Psychological Well-Being of Transgender Students in New Jersey. We would like to extend additional thanks to Celeste Fiore for their review of the entire section for accuracy and culturally appropriate language.

Instructions for obtaining CE credit: Visit <www.psychologynj.org> and find the CE Homestudy Library link under the Learn Tab. This will take you to the online library where you will find the article and evaluation.

Toward Gender Affirming Care for the Trans and Gender Diverse Community (3 CE Credits)

Carmen Lalonde, PsyD Ferkauf Graduate School of Psychology

Abstract

“Fewer than 30% of psychologists report familiarity with transgender and gender diverse (TGD) clients’ needs. The clients, in turn, report a lack of support in their gender journeys, illustrating a significant gap in knowledge, skill, and competence in this area of practice (Singh & dickey, 2017).” The 2015 US Transgender Survey (USTS) (N = 27,715) reported that almost half of the respondents had attempted suicide during their lifetime. Given this startling data, clinicians need to make every effort to increase their ability to deliver gender affirming care. Sadly, gender affirming care is not included in many clinicians’ training. This article addresses the disparities that exist between the current state of knowledge about transgender individuals and current clinical practice. The goal of the article is to contribute to improving clinical practice. After reading this article, clinicians will a) be provided with suggestions for addressing personal biases related to gender; b) become aware of the basics of gender-affirming care; c) learn of recent gender affirming resources for treating adults and children.

Toward Gender Affirming Care for the Trans and Gender Diverse Community

Few aspects of human development have undergone such radical exploration and change in the early 21st century as gender. In the last two decades, the visibility of Transgender and Gender Diverse (TGD) people has increased exponentially (Edwards-Leeper & Spack, 2012). More and more are seeking care with confidence and strength in asserting their authentic identities. “Transgender and Gender Diverse people” (TGD) is an umbrella term that describes individuals whose gender identity does not align with their sex assigned at birth. TGD includes both transgender individuals such as trans women and trans men who align with the gender binary, as well as individuals who do not align or conform to the binary. These include individuals who identify as agender, non-binary, genderqueer, and gender fluid (Chang, Singh, & dickey, 2019; Puckett, Cleary, Rossman, Mustanski, & Newcomb, 2018). This list is not exhaustive and is continuously evolving. For this article, TGD will be used to denote the vast array of individuals who identify with diverse gender identities.

Knowing which TGD resources are affirming, as well as understanding the core elements of providing gender affirming care are essential to developing humility and skill in providing affirmative care for TGD clients. In the following section of this special edition, the author (she/her/hers) will provide a brief introduction to the core elements of gender affirming care as understood through the lens of a White privileged cisgender gay woman. The author draws on current research in the field, her own research, and her clinical work with TGD adults and youth.

Gatekeeping

A core element of gender affirming care is understanding, a) the history of gatekeeping that has occurred in the mental health field, and b) the current political climate. Both of these contexts affect access to care, physical safety, and the mental health of TGD clients (American Psychological Association, 2015; Chang et al., 2019; Erickson-Schroth, 2014). Before the 2016 election, a great deal of progress in transgender rights had been achieved. The Obama administration expanded the interpretation of Title IX to include transgender discrimination, and transgender youth saw progress in being

able to use bathrooms and locker rooms that aligned with their gender identity, rather than their assigned sex at birth (The National Center for Transgender Equality, 2018). Moreover, transgender affirming services, and the clinical modality of gender affirming care started to gain traction.

The American Psychological Association (APA) published comprehensive guidelines for working with Transgender and Gender Non-Conforming people (TGNC). Moreover, the Diagnostic and Statistical Manuel, Fifth Edition (2013) revised the diagnosis of Gender Identity Disorder to Gender Dysphoria. This event signified a shift from pathologizing and medicalizing non-binary identities (Lev, 2013). Researchers began to explore the subjective experiences of people with diverse identities by focusing on lived experiences, quality of life, and resilience (Bockting et al., 2016; dickey, 2017).

Following the 2016 election, however, the TGD community has experienced severe backlash from the Trump-Pence Administration. This backlash includes: limiting gender diverse people from serving in the military, as well as proposing an outdated redefinition of “sex” with the Affordable Care Act that would allow providers to discriminate against the TGD community (Burns, 2019). Despite these devastating blows, advocates of the transgender population have continued to demand that clinicians and medical providers develop affirmative gender practices.

Cultural Humility

In addition to learning about gender affirming terminology and clinical practices, clinicians aspiring to work with the TGD community must develop cultural humility (Tervalon & Murray-García, 1998). This concept has become the center piece of multicultural education in general, but is particularly essential when working with diverse identities. Cultural humility is a commitment to lifelong examination and reflection of one’s power and privilege. Providers must reflect on how power inevitably enters caregiving relationships with marginalized clients. Cultural humility requires that clinicians and medical providers become more familiar with the content of diverse cultures. Cultural humility requires a commitment to become a lifelong learner with, not of, members of marginalized communities (Tervalon & Murray-García, 1998).

Another critical element to developing a gender affirming stance is a commitment to relearning and revising one’s own beliefs about gender development (American Psychological Association, 2015). Research now demonstrates that for many people, gender can be fluid and non-binary (Bockting et al., 2016; Chang et al., 2019; Keo-Meier & Ehrensaft, 2018). This realization is freeing for members of many groups who have expressed identities outside of the gender binary. In contrast, this can be anxiety producing for people who adhere firmly to the gender binary. Understanding the history of diverse gender identities in different cultures and during different historical time periods can help clinicians begin to see that gender diversity has existed since human beings have existed (Herdt, 1996). Some examples include the Two-spirit people of North America, the Hijra of South East Asia, the Mahu people of what is now known as Hawai’i, and the Kathoey people of Thailand. These groups are but the tip of the iceberg illustrating the diversity of genders historically and cross cultures (Erickson-Schroth, 2014).

Becoming aware of these groups can help professionals begin to revise their views of gender.

Examining One’s Own Beliefs about Gender

In addition to learning about the diversity of genders that have existed throughout history, the process of becoming a gender affirming clinician requires that one interrogate one’s own gender socialization and beliefs about gender (American Psychological Association, 2015; Chang et al., 2019). As listed in the APA guidelines and discussed extensively in A Clinician’s Guide to Gender Affirming Care, clinicians need to reflect on their belief system about gender. Clinicians must explore their understanding of gender development, as well as examine any anxiety that they might feel when their unconscious biases about gender are challenged (American Psychological Association, 2015; Chang et al., 2019).

Clinicians who are operating from outdated and harmful belief systems rooted in the binary too often believe that they are competent in providing gender affirming care (Chang et al., 2019). According to the APA guidelines for working with TGD clients, mental health providers first and foremost need to reflect on and evaluate their own gender identity and beliefs about gender before working with TGD clients. Without this process of selfreflection, mental health providers run the risk of imposing their belief systems on their clients (American Psychological Association, 2015).

It is the ability to relearn and challenge our own gender socialization that truly begins the development of cultural humility and the ability to provide gender affirming care. In order to do this, clinicians must first address their conscious and unconscious biases about gender by asking reflective questions such as; “Do I believe gender can be fluid?,” “Do I believe that gender identities can evolve and change over time?,” “What was my gender socialization like?,” “What was my gender socialization like, and what is my gender identity?,” and “If I were to treat and work with TGD people, what personal challenges would I face?” These questions can help clinicians begin to unpack, interrogate, and relearn their biases and is a core element of becoming a gender affirming clinician. Having made a commitment to self-reflection and relearning, one is now more ready to receive information about gender affirming resources and best practices in clinical care.

Gender Affirming Resources

The updated Standards of Care (Coleman et al., 2012) and the National Trans Health Survey (James et al. 2016) provide a solid foundation from which clinicians and medical providers can access accurate information. These resources have made it possible for all practitioners to achieve at least a minimal level of gender affirmative care. However, it is sometimes difficult for providers to know which additional resources are actually affirming and up-to-date. Being able to select the best resources is essential to providing care that is affirming and culturally informed. The following list of resources is by no means exhaustive. However, they provide a strong base for accessing accurate and affirming information.

A Clinician’s Guide to Gender Affirming Care (2018) (Chang et al., 2019) is the first manual of its type to outline a solid foundation for providing comprehensive Gender Affirming Care. In 2017, Singh and dickey published the Affirmative Counseling and Psychological Practice With Transgender and Gender Nonconforming Clients, (Singh & dickey, 2017) one of the first clinical books to outline different forms of clinical

modalities with TGD people. In 2014, Trans Bodies Trans Selves was also one of the first comprehensive and accessible resources appropriate for both providers, TGD clients, and parents of GDE youth (Erickson-Schroth, 2014).

Keo-Meier and Ehrensaft (2018) published one of the first affirming models of gender development and included suggestions for working with Gender Expansive Children (GED). This text is pivotal for providers in that it outlines an evidence-based model of gender development and reinforces the fact that diverse gender identities are variations of human expression. The Gender Affirming Model (GAM) outlines a solid basis for revising and challenging one’s beliefs about gender development. Keo-Meier & Ehrensaft (2018) assert that no gender identity or expression is pathological, but is instead a variation of human expression. The authors discuss how gender presentations vary across cultures and are informed by socialization and cultural diversity (see also Herdt, 1996). The authors further report that gender is fluid and not binary, i.e., that it can change over time. They emphasize resilience, coping, and wellness, and the human right to express one’s gender identity (Ehrensaft, Giammattei, Storck, Tishelman, & KeoMeier, 2018; Ehrensaft, Keo-Meier, & Yuen, 2019; Keo-Meier & Ehrensaft, 2018).

GenderSpectrum, <http://www. genderspectrum.org> is an open source online agency whose mission is to create a gender affirming world for children, youth, and families. It offers a plethora of guidelines, resources, and information created by experts in the field that is accessible to both parent and providers. GenderSpectrum is the first organization to publish a complete guide for schools, Schools in Transition (2015). Even more recently, on April 19, 2019, GenderSpectrum published the first ever comprehensive principles for genderinclusive puberty and health education (PHE) that was part of a national call to action for creating inclusive sex education for LGBTQI students. This publication was endorsed by leading national PHE organizations, such as Planned Parenthood and the Sexuality Information and Education Council of the United States.

In addition to texts, affirming terminology is also an important resource (Chang et al., 2019). Language is a form of power, creates visibility, and allows for marginalized communities to create a history and identity for themselves. Many clinicians and trainees’ express anxiety about terminology, reporting that they are worried they will use the wrong terms and offend their TGD clients. TGD clients are very aware of the evolving nature of terminology within their community, and respect clinicians who ask for information in a respectful manner. For example, “What are your pronouns?” and “How do you describe your gender identity?” Ask clients how they identify themselves. If the term is new, honor it, and ask respectful and empathic questions about it. If the terminology is unclear, ask them to explain.

One way to reduce the anxiety of not always knowing the correct terminology is to ensure that time is dedicated to learning about current terminology. Educating oneself on current terminology and reading updated information from resources, such as those listed in the previous paragraphs, are important tasks of the responsible clinician. Seeking consultation from more experienced colleagues, when possible, is also a good strategy. However, it is crucial to be able to differentiate between gaining an understanding that informs treatment and simple curiosity that is unnecessary and unrelated to treatment. A helpful way to know if asking the question is necessary, is to ask oneself whether you would ask a cisgender client the same question. Further, clinicians should not place the burden of educating themselves on the client (American Psychological Association, 2015; Chang et al., 2019).

Defining Gender Affirming Care

In addition to the recent development of a more comprehensive base of resources, clinicians need appropriate training and supervision for working with TGD clients. Research on mental health disparities and TGD clients consistently state a) inadequate training, b) discrimination against clients, and c) outdated practices too often keep TGD people from accessing affirming care (Feldman et al., 2016; Puckett et al., 2018). Given the recent increase in discriminatory governmental laws introduced by the Trump administration, TGD populations require affirming care more than ever.

Gender affirming care is a relatively new term that extends beyond gender affirming surgery. Gender affirming care includes, but is not limited to, a) social gender affirmation that focuses on terminology, b) affirming pronouns, chosen names, and c) support for social transitions. It includes psychological gender affirmation that supports the ability to a) explore one’s internal sense of gender, b) encourage resilience work against transphobia and internalized stigma, and c) urge clinicians to develop affirming mental health counseling skills. Medical and affirming-transition care includes supporting clients in accessing gender affirming surgery, hormones, and medical interventions. Legal gender affirmation relates to understanding the legalities and gatekeeping of name changes and gender markers. Finally, clinicians need to commit to advocacy and increasing visibility and the rights of TGD people (American Psychological Association, 2015; Chang et al., 2019; Reisner, Radix, & Deutsch, 2016).

However, the majority of mental health clinicians are unfamiliar with even the basic needs of TGD people. Moreover, there is often a rigid and inadequate understanding of gender affirming care that over-focuses on genitals, leaving TGD people at risk of experiencing microaggressions. This lack of expertise can contribute to discrimination towards non-binary individuals, who are not seeking medical transition care, and might generate stress in TGD individuals seeking standard medical care. These experiences frequently leave TGD people feeling uncomfortable in accessing medical and mental health care (Feldman et al., 2016; Puckett et al., 2018).

Conclusion: Tasks Toward Becoming a More Gender Affirming Clinician

1. Become aware of the history of gatekeeping and discrimination that the TGD community has faced in the past, and continues to face in some contexts in the present. 2. Strive toward cultural humility: selfreflection and a commitment to relearning personal assumptions about gender if necessary. 3. Become familiar with current resources, terminology and standards of care for both adults and children. 4. Make a commitment to ongoing supervision and/or consultation with experts in the TGD community.