Working with Transgender/Non-Binary Client and Transphobia

Below is some information that it is essential to understand if you’re working with transgender and non-binary (T/NB) individuals, drawn from my professional and personal experience. It is not an exhaustive discussion, and of course you shouldn’t assume what any individual client has experienced, but I think it’s a good starting point.

Before getting to that I want to make a general point – “coming out” and exploring your gender identity can be a very exciting and fulfilling experience, and it can be very confusing and scary, even without external factors. But external factors are there and can be overwhelming, including bigotry experienced within your family, among friends, at work and in the broader society.  We all need to push back against transphobia, nobody deserves to have their very identity dismissed and to be made to feel invisible (among the many harmful effects of discrimination and oppression).

Working with Transgender/Non-Binary Client and Transphobia/Transmisia

Working with T/NB people will almost inevitably mean having to address transphobia and its impact on the client. In this post I will look briefly at what it is, then at ways that it can impact individuals, and how I try to approach it in therapy sessions.

What is “transphobia/transmisia”?

The most basic definition of “transphobia” is an “irrational fear of, aversion to, or discrimination against transgender people.”  “Transmisia” shifts the language from “fear” to “hate,” and better reflects the oppression that T/NB people experience. You may have heard the term “TERF,” which stands for Trans Exclusionary Radical Feminists – people who have openly and actively worked against transgender rights, and in support of the idea that trans woman “are not women.” That is just one thread of discrimination and oppression experienced by T/NB people.

Going into the full spectrum of attacks on the rights of T/NB people is beyond the scope of this article, but here are summaries by Human Rights Campaign, Human Rights Watch, the ACLU, and Vox.

Clinical Considerations

“Gender Dysphoria” is defined in the DSM as:

“… a marked incongruence between one’s experienced/expressed gender and their assigned gender, lasting at least 6 months, as manifested by at least two of the following:

• A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
• A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
• A strong desire for the primary and/or secondary sex characteristics of the other gender
• A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
• A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
• A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

In order to meet criteria for the diagnosis, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.”

[From Psychiatry.org, Emphasis added]

Note that the diagnosis does NOT reference external factors, including the oppression and discrimination that T/NB people experience. The DSM connects the “distress” to the internal experience rather than the external experience. An individual’s Gender Dysphoria is most certainly negatively impacted by the experience of having their identity denied, dismissed, and even attacked.

Impact on Individuals

Speaking from both professional and personal experience, I can say that it is very hard to explain the impact that transphobia/transmisia has on an individual. There is certainly the direct impact of the political and legal attacks on rights – and even if the person is not directly impacted there can be an emotional toll. There is also the impact of individually experienced transphobia/transmisia – from friends, family, co-workers, neighbors, etc. Whether it’s a direct challenge to the individual’s identity, or expressions of support by those people for the political and legal attacks against them, the emotional impact is significant.

Particularly in cases involving co-workers and family, the T/NB person’s financial and overall security may feel threatened, contributing to feelings of depression and anxiety.

Some examples:

• Family – it is not at all uncommon for T/NB individuals to experience difficulties with their families when coming out, including (at the less extreme end) getting push-back to using the person’s correct name (“deadnaming”) and pronouns (“misgendering”), to having their gender identity rejected by family members, and possibly experiencing abuse (physical and/or emotional) and being disowned.
• Friends – As with family, a T/NB individual might experience difficulties with friends, including deadnaming, misgendering, and being rejected.
• Employment – A T/NB individual might face similar issues in employment settings, and could lose their job entirely (and not all state employment laws cover Gender Identity as a protected class).
• Community – Even in more diverse, liberal communities a T/NB individual might experience discrimination and physical violence, with the possibility increasing in more conservative areas.
• Societal – There is a seemingly endless barrage of public figures and others raging against trans and non-binary identities – even if it’s not experienced directly by a T/NB individual we are seeing the messaging and seeing the support that those messages get.
• Political/Legal – there have been significant advances in rights for T/NB people in recent years (particularly during the Obama administration), and in some states, but there are states where rights for T/NB people are under attack.

Again, this was not meant to be exhaustive, I’ve included links where I could so that you can find more information if you are interested.  Also, recognize that even if a particular individual is not impacted by some of these factors, they might experience “anticipatory” stress or depression around them – not directly experiencing it, but not knowing with certainty that they won’t experience it. They might also experience vicarious stress or depression around these things because they know others who are experiencing them, and can feel more directly how they might be impacted.

It’s also important – as in all cases – to consider intersectionality and how other parts of the person’s identity might make them subject to a greater level of discrimination and oppression.

Working with Clients

What does all this mean in terms of working with individuals?  First, understanding of what types of discrimination and oppression a Trans/Non-Binary person might experience, with a particular focus on the state in which they live and what might be happening there at the legal/political level.  Second, learn from the client what they are experiencing – don’t assume (I think that’s always the best practice but felt it was worth throwing in a reminder here).

A Word about Medical Transitioning

This isn’t the subject of this post, but I did want to add a word about this topic – it’s a good idea to have a general understanding of medical transitioning – what it is, what’s required to pursue it.  But DO NOT assume a client is interested. In practice, when I start with a new trans/non-binary client I might mention that, if they are interested in medical transition, that I can provide letters if they are necessary, but in a way that makes clear that I’m not assuming anything (I might couch it in language about sharing that with all clients who identity as trans or non-binary, or have talked about exploring their gender.)