Working with Transgender Clients

[This is an excerpt from a paper I wrote as a first-year MSW student at NYU in 2017]

Transgender people experience most of the same issues that impact cisgender people, in addition to some that are the result of, or exacerbated by their gender identity and/or expression. Underlying the latter set of issues is a sense of gender incongruence, which is the discord between their personal sense of gender identity and the sex assigned them at birth (Winter, et al., 2016). Gender incongruence is the concept that defines which individuals are transgender (Hughto, Reisner, & Pachankis, 2015).

Understanding the impact of gender incongruence and the emotional impact it can have on a transgender client is vital to working effectively with them. In addition, it is important to recognize that many transgender people, because of their identity, “live on the margins of society, facing stigma, discrimination, exclusion, violence, and poor health” (Winter, et al., 2016).  It is often, in fact, discrimination and other victimization that can lead to physical and mental health issues (McCann & Sharek, 2015).

A valuable starting point for understanding working with transgender clients are the WPATH (World Professional Association for Transgender Health) Standards of Care. WPATH promotes evidence-based care, education, research, advocacy, public policy and respect in transgender health care (Wylie, et al., 2016). The latest edition of the Standards of Care includes the idea that gender non-conformity is not pathological but acknowledges that those who experience gender incongruence may suffer distress and may want to physically transition (Wylie, et al., 2016). This concept is mirrored in the latest edition of the DSM, which de-pathologized transgender identity by removing “Gender Identity Disorder” and adding “Gender Dysphoria” (Parry, 2013), which reflects any emotional or other issues caused by one’s gender incongruence.

At the outset of working with any transgender client it is important to consider their cultural background as a factor. Wylie, et al. (2016) note that gender roles are culturally stereotyped in most societies, with men and women expected to carry out masculine or feminine roles based on their assigned sex at birth. As a result, transgender identity is considered abnormal in many societies because “they transgress the normative sex-gender binary system.” Exploring with the client the emphasis that was placed on gender roles in their culture or other background areas may be helpful in identifying the full impact of their transgender identity.

As discussed by McCann & Sharek (2015), mental health issues for transgender people bear similarity to other minority groups, and like other minority groups may be exacerbated by finding themselves disconnected from mental health and other medical care needs. Mental health issues for transgender people relate to minority stress, which in their case often tracks back to becoming estranged from family, being rejected by peers, and enduring marginalization by society. The impact of those stresses, in terms of mental health, can include stigma, discrimination, depression, suicidality, and concerns about social exclusion. Exacerbating the issue still further, according to McCann & Sharek (2015), is that therapists often lack the skills to work effectively with transgender clients and are often ignorant and insensitive towards transgender issues.

Wylie, et al. (2016) identify five essential tasks related to assessment and referral when working with transgender clients: assessment of gender dysphoria; provision of information about options for gender identity and expression and possible medical interventions; assessment, diagnosis, and discussion of treatment options for coexisting mental health concerns; assessment of eligibility, preparation, and referral for hormone therapy; and assessment of eligibility, preparation, and referral for surgery. The last two items only apply to clients who are interested in physical transition.

Assessment of Gender Dysphoria

Hughto, et al. (2015) define stigma as “the social process of labeling, stereotyping, and rejecting human difference as a form of social control.” This stigma can come from societal norms and institutional policies, direct interpersonal forms such as verbal harassment, physical violence, and sexual assault, and from the feelings people hold about themselves or the beliefs they perceive others to hold about them (“internalization”).

“Gender dysphoria” is essentially the “distress” that can come along with gender incongruence. Some of the distress is internal and can be relieved in large part through the medical

interventions discussed below, but much of it is also caused by the stigma that society imposes on transgender identity. A point that was not recognized by these articles is that the stigma is very likely enhanced by the language used around “gender dysphoria,” which includes, among other things, the “desire” or “preference” to be “the other sex.” This language implicitly dismisses the idea that the person IS “the other sex,” and was misidentified at birth.

Options for Gender Identity, Expression, and Medical Interventions

Transitioning in terms of gender expression and/or medical interventions is a typical option for relieving gender dysphoria. It has been found that delaying one’s transition and concealing one’s transgender identity may cause psychological distress (Hughto, et al., 2015). It is, however, a difficult option for many. It can be prohibitively expensive (for example, the client I discussed earlier is experiencing homelessness, it’s very unlikely that she can afford anything more than the most basic elements of transitioning, if that – when I met with her she was “presenting” as female, wearing a wig and some makeup, but she couldn’t have gone any further than that). It can also, initially and even in the longer term, lead to increased stigma as your presentation begins to change.

Coexisting Mental Health Concerns

When working with any client experiencing depression it is clear that treatment for that depression should be addressed. For transgender clients, addressing depression and other coexisting mental health concerns is also a predicate for the medical interventions discussed below, as many cannot be started until the coexisting mental health issue is under “reasonably good control” (Wylie, et al., 2016).  Wylie, et al. (2016) identify the following conditions that are often related to the oppression and stigmatization that transgender people experience: high-risk sexual behavior (particularly for youth); depression (with or without suicidal ideation); anxiety-related conditions; substance abuse; and being victims of violence.

Hormone Therapy and Surgery

For those transgender clients who desire physical transitioning, the next steps include hormone therapy and possibly surgery. As described by Wylie, et al. (2016) drugs are used to suppress natal hormones (testosterone in transgender women, estrogen in transgender men). Transgender woman then receive feminizing hormones (estrogen tablets, transdermal patches or injections) and transgender men receive testosterone therapy. In all cases, it’s important for the client to understand the limitations of hormone therapy, and the possible complications of stopping the therapy (some changes caused by hormone therapy may not be reversible).

Wylie, et al. (2016) go on to discuss possible surgical interventions that can help resolve a mismatch between the body and self-identity. These include non-genital surgeries that can change physical appearance to allow a person to better assimilate based on their correct gender (facial feminization surgery, tracheal shave, breast or chest reconstruction, etc.). Genital reconstruction surgery is typically seen as the final stage in transition (for transgender men this comprises hysterectomy, oophorectomy, vaginectomy, phallic construction, and scrotoplasty; for transgender women it comprises orchiectomy, penectomy, urethral meatus reconstruction, vaginoplasty, labiaplasty, and clitoroplasty). 

Strengths-Based Considerations

When working with a transgender client, particularly from a strengths-based perspective, it can be helpful to be aware of resilient traits that may actually emerge because of the person’s transgender identity. McCann & Sharek (2015) report on a study from the United Kingdom that indicated 80% of participants felt that they had gained something positive as a result of their experience of being transgender, transitioning, and expressing their gender identity. These positive traits include increased confidence, new friends, better quality relationships, community and a sense of belonging, self-expression and acceptance, knowledge and insight, and increased happiness and contentment. From my own experience I would add that most of those positive gains are a result of living and “authentic” life.

“Post-Transition” Care

“Transitioning” is the process by which an individual begins to live as a member of another gender (Raypole, 2016). It is a social construct and one that is very specific to the person. As such, suggesting that there is a “post transition” period is technically inaccurate. For most transgender people transitioning might never really end.  For purposes of this discussion I am referring to the period when medical transitioning is “complete” – i.e., the person has been on hormone therapy and has completed the surgeries that they desire. It is important to recognize that this does not mean that the need for treatment is over.

Wylie, et al. (2016) observe that mental health of individuals undergoing medical transition deteriorates in about 10% of cases. They identify some possible reasons for this, including diagnostic errors, poor coping abilities, employment difficulties, lack of support, and surgical complications. They also note that postoperative regret is transient in 1-8% of people undergoing surgical transition, and permanent in 1-2%.

I feel secure in saying that the emotional impact of permanently regretting surgery, irreversible genital surgery in particular, would in most cases significant. Indeed, transgender people continue to have an increased risk of death, including death by suicide, even after transition (Winter, et al., 2016). Therefore, the health care that aims to help transgender people live in their affirmed gender, widely regarded as the most effective in ensuring their health and wellbeing (Winter, et al., 2016), continues to be important even after transition.

Summary/Take-Aways

These articles collectively provided a great deal of valuable information for working with transgender clients. They are all fairly current, having been published in 2015 and 2016, which is significant. Understanding of transgender issues, and terminology around those issues, is constantly evolving making the use of even three or four year old articles potentially problematic. As such, when working with transgender clients it is very important to stay up-to-date.

The articles were fairly heavy in terms of medical procedures and terminology, particularly for a social worker working in a non-medical setting. I also found that they didn’t generally use medical terminology that clients would be more familiar with, which could be problematic when working with clients. For example, genital surgeries are typically referred to as “SRS” (sex reassignment surgery), “GRS” (gender reassignment surgery) or simply “bottom surgery.” Those are terms that clients are more likely to be familiar with (those who are actually approaching the surgery will likely be familiar with the technical medical terminology).

An area where these articles were also weak was in terms of addressing client resources. Almost every step of gender expression and medical transition is potentially costly, beyond the reach of many clients. A related concern is the treatment of WPATH and their Standards of Care. While the organization is very thorough and no doubt well-meaning in what they are trying to do, they are not without controversy within the transgender community. Many of the requirements they impose for medical transitioning, while reasonable on the surface, make transitioning inaccessible for many clients.

Notwithstanding these weaknesses and the medical terminology, these articles would be very useful for working with transgender clients. Collectively they provided a broad and detailed explanation of the many ways in which transgender identity impacts an individual. This includes stigmatization, the impact on home and work life, the ways in which a person can “transition” and the obstacles to doing so, and much more. But they also covered the very positive impact that “coming out” as transgender and “transitioning can have for the individual.