Ruben Hopwood and lore m. dickey
IN ADDITION TO OUR PHYSICAL HEALTH, we also need to pay attention to our mental and emotional health and well-being. As trans people, we have many reasons to look for support from our friends and family and from mental health professionals. We may feel distressed in some aspect of our lives, or we may wish to have more information about ourselves to make choices about how to express and affirm our gender identities.
When we have good mental health, we may experience relative comfort functioning in society and experience minimal emotional and behavioral problems. We are able to think clearly, access and control our emotions, cope with daily life, meet responsibilities and challenges, and maintain mutual and supportive relationships with others.
While most of us function at a good level of mental health (Dean et al., 2000; Shipherd, Green, & Abramovitz, 2010; Sperber, Landers, & Lawrence, 2005), when there are interruptions or difficulties in our lives, we may begin to feel significantly distressed. Cultural differences can affect how we handle stress. We may be in a state of good mental health at some points in our lives and not at others. It is also possible to have some areas of life that are going well while other areas seem to be falling apart. In many instances, it is possible to regain mental health when it has become unbalanced. At moments when it seems there are more areas of life falling to pieces than operating smoothly, we may seek the services of mental health professionals to help to put things back together again.
For many trans or gender nonconforming people, our first experience with a mental health professional may be when we decide to begin a gender affirmation or transition process and discover that we need someone to help locate providers and write introduction letters to get the services we want or need.
“I’m just starting the actual transition, after more than a decade of yearning. . . I spent my grade[school] and college years burying my feelings, but could not keep doing so when I finally struck out on my own. I spent weeks in soul-searching introspection, then decided to at least give therapy a shot. At that point it was as though the balance of my life had shifted, and I went from a conflicted, confused cisgendered man to a happy, certain woman-to-be (internally, of course) in less than a month.”
Deciding who to see and then finding a knowledgeable professional may be the most challenging aspect of getting support. We may seek the care of a gender specialist, an expert in trans issues, in order to explore our gender or talk about issues in our relationships. Or we may look for a more general mental health provider to talk with about anxiety or depression. Some of us seek out mental health providers because we need an evaluation in order to be referred for gender affirmation treatments (Bockting, Knudson, & Goldberg, 2007; Lev, 2004, 2009; Rachlin, 2002). For those of us seeking gender affirmation, we may not have a choice about whether to see someone but may have some choice about whom to see (Bockting et al., 2007; Ehrbar & Gorton, 2010).
“I didn’t see a gender specialist until I was 20, but I’d gone to therapists and psychiatrists before that for other reasons. When I went to see that therapist when I was 20, it was strange because I felt like I was finally talking about real matters with a therapist. I was only able to see her twice until 7 years later—I have started seeing her again.”
(BEYOND) SUFFERING AS A MEASURING TOOL
Xander (Sly) Sarkisova is a queer and trans person who has been working in mental health and addictions counseling for the past 13 years in Vancouver, British Columbia (occupied Musqueam, Tsleil-Waututh, and Squamish Territories) and Toronto, Ontario (Mississauga and Anishnaabe).
In Ontario, you are required to go to your nearest mental health institution to receive a diagnosis of gender dysphoria in order to get funding for surgeries. Many trans folks experience serious mental health issues and have histories of trauma due to transphobia. Yet if you disclose your trauma history and mental health status, you may be refused access to surgery. Paradoxically, you are required to present your trans narrative as if it is an unbearable burden and admit that your gender identity is a mental illness. It is not simply enough for you to know that you are trans and that access to care would be beneficial to you; in order to qualify for treatment, you are expected to meet a certain subjective threshold of dysphoria, as defined and assessed by cisgender and Eurocentric medical gatekeepers. Trans women of color have spoken out about this idea of the “tragic trans narrative” as the only possible narrative applied to them by mainstream society.
Using suffering as a measurement of “transness” while withholding health care is simply a means by which the state regulates and controls our bodies. If trans people were reared to explore and accept themselves from a young age, many of the sources of their suffering would be absent. The stigma and restricted access to decision making in trans health and trans embodiment is a major cause of suffering for many trans folks. Having trans people measured for degree of suffering is a systemic multiplication of transphobia under the guise of psychiatry.
Trans folks who resist the “tragic trans narrative” or who do not have a definitive “endpoint” of gender in mind, but who nonetheless seek masculinization or feminization, can challenge medical service providers to see us in our full complexity. We do this by authentically presenting our own stories in the manner that fits us, using terms that we choose for ourselves, not altering our histories and understanding of our genders, and by seeking out and demanding medical practitioners and surgeons who will listen to us.
SELF-CARE AND WELLNESS
Not every problem requires the help of a therapist or mental health professional. Sometimes we can feel better after doing positive things for ourselves, like reading a book, exercising, taking hot baths, or engaging in creative activities. When going through difficult times, emotional issues, or personal struggles, many of us benefit from talking to someone we trust, such as a friend, relative, or spouse. Sometimes talking, laughing, or crying with friends can be therapeutic. There are many ways we can take care of ourselves and improve our mental health in addition to seeing professionals.
Some of the possibilities include the following:
Self-care. This includes getting enough sleep and sunshine, eating well, exercising, and finding time for personal relaxation. Some of us allot time for ourselves to participate in activities we enjoy like jogging, yoga, getting massages, playing video games, painting, gardening, or listening to music.
Using creative outlets. Many of us sing, play instruments, draw, dance, or write poetry or stories in order to express our inner selves and find ways to channel how we are feeling. For example, keeping a journal can be a very good way to put our thoughts onto paper and process stress.
Religious or spiritual work. Some of us find solace in our spirituality, faith, or faith communities. We may meditate, pray, talk to trans-friendly religious leaders, or get involved in a trans-affirming religious or spiritual community. However, some religious communities may be unfriendly and can be a source of additional stress, so we may want to weigh the pros and cons of being involved in them.
Community service. In order to take our minds off of personal stress and to give back to the community, we may spend our time volunteering at soup kitchens, homeless shelters, community centers, or LGBTQ organizations. Some of us focus on creating social change, especially if it has potential to improve the issues that are causing our stress to begin with.
Building community and support groups. Depending on where we live, it can be hard for us as trans and gender nonconforming individuals to find people who understand what we are going through. Some of us have never met another person who identifies as trans or gender nonconforming and feel alone in the world. For this reason, it can be especially helpful to seek support groups or create one of your own. Some community or LGBTQ centers have existing support groups. Some are geared specifically for people of color, youth, the elderly, or other groups. There are also social scenes that are traditionally more trans-friendly. The Ball scene and drag communities are both great places to find trans-friendly spaces. For those of us who live in rural areas that do not have local trans-friendly community centers, we may have to look online.
ACCESSING PROFESSIONAL SUPPORTS AND SERVICES
Should we decide we would like to find a mental health provider, there are resources at our disposal. Many of us go to a local county or community mental health agency. The staff at state or local agencies may include psychologists, counselors, social workers, and psychiatrists. One advantage to a county or community mental health agency is that it is usually possible to get most of our mental health needs addressed at the same agency. Be aware, though, that gender identity support and services may not be available at such agencies. Another feature of some county or community agencies is that they are likely to have sliding fee scales that are based on income. While figuring out if you qualify for services on a sliding scale may be time consuming, it can be worthwhile for those of us who are underinsured or uninsured and have little to no extra income to pay out-of-pocket expenses for mental health support.
For college students, a good source for short-term mental health services is the counseling center that is affiliated with your college or university. Typically, these services are covered through student fees, though there may be a small copayment depending on the school you attend.
Another resource, not just for college students, is university-based clinics that provide therapist training programs. For example, a university psychology or social work department may provide low-cost counseling and testing services in a clinic where the therapists are student trainees who are closely supervised by licensed providers. A disadvantage to this type of counseling center is that the trainees are likely to have less experience working with clients than a licensed mental health provider. Advantages to these clinics are that they typically have appointments outside “normal business hours” (i.e., after 5:00 p.m.) and may offer very low-cost services.
Some major cities have LGBTQ-focused medical and mental health centers. While these centers can be good sources for counselors with experience with LGB-related issues, there is no guarantee that these providers have experience with concerns within trans or gender nonconforming communities. Even so, we may have a better chance at finding a trans-friendly provider at one of these centers than we would at a general mental health agency or private practitioner’s office.
Many of the mental health professionals who specialize in LGBTQ or trans care have private practices outside of clinics. In a clinic, a provider typically sees whoever comes through the door, while in private practice, the provider may specialize in a certain area. Private practice providers may be harder to locate, but finding them can be rewarding.
Locating Care
Overall, there are usually more resources for trans and gender nonconforming people in larger urban areas than in rural and sparsely populated areas. Additionally, it is common in many geographic areas for there to be mental health professionals, but no medical providers, who treat trans people. Some of us find that we need to travel to a nearby larger city for trans-specific, competent care. This may increase the burden on some of us who do not live in or near a large city while seeking support or gender affirmation treatments.
WHY WE NEED MENTAL HEALTH CARE
Jack Pula, MD, is a psychiatrist and therapist in New York City on faculty in the Department of Psychiatry at the Columbia University New York Presbyterian Hospital. He is chairperson of the transgender committee of the Association of Gay and Lesbian Psychiatrists (AGLP) and is himself a transgender male.
Transgender people have not always benefited from mental health “treatment.” Due to misunderstanding by professionals and the creation of a gateway system, an unhealthy relationship developed between the transgender community and the psychiatric profession. Unfortunately, the tension of these controversies has raised doubts about the role of mental health professionals in the lives of transgender people.
When someone decides to transition using hormonal and surgical treatment, standard protocols in the medical community have dictated that the person first undergo psychotherapy treatment. Over the years, clinical consensus about psychotherapy has evolved, taking into consideration criticisms by transgender people who were harmed by rigid standards that made them wait too long, obtain expensive therapy they could not afford, or jump through unnecessary hoops.
Today, many transgender people go to mental health providers to understand their gender identity, seek transition, and explore how to live comfortably in their body and gender. Some transgender people struggle immensely. Current controversy over the psychiatric diagnosis of gender dysphoria represents long-standing distrust and hostility among activists toward the psychiatric profession, and it can deter transgender people from seeking treatment. Yet we know that transgender people struggling with gender can suffer so severely that they stop functioning, become unable to live healthy lives, and sometimes kill themselves. We also know that with good treatment, distressful feelings and patterns of behavior improve and help people live productive and meaningful lives.
Transgender people struggling with dysphoria may or may not choose to transition. There is evidence that those who do transition have better outcomes if they have undergone psychotherapy in preparation for their transition. In the best-case scenarios those who transition experience resolution of their dysphoria. However, this is not always the case. Even those who transition remain at higher risk for depression, anxiety, substance abuse, and suicidality than the general population.
Many transgender people need no psychiatric care. They have embraced their gender identity and navigated their lives with success and few symptoms. Some of these folks may see a therapist to help with the process of transitioning and integrating life goals. Some feel offended at the suggestion of seeing a mental health professional, feel no conflict, are certain about their path, and fully understand the risks and benefits of transition.
Some transgender people suffer from serious mental illness such as schizophrenia, bipolar disorder, major depression, or major personality disorders that lead to self-injury. To struggle with a major mental illness in addition to the strain of being transgender can be daunting. In this case, quality psychiatric treatment competent in dealing with both major mental illness and the unique aspects of being transgender is necessary.
Despite the unfortunate reality that some practitioners are not knowledgeable about transgender issues and express a transphobic bias, there is now a community of competent psychiatric providers who enjoy working with transgender people and are devoted to improving care. We can take care of our mental and emotional lives with help from skilled professionals when we need it. We deserve nothing less.
The best resources for finding local services and supports are usually other trans and gender nonconforming people who live in or near our region. Many regions have online trans community support and information groups. Online trans resource directories often list therapists and medical providers by city or state. There are even a few gender specialists who will work with people online for some aspects of their gender care (Fraser, 2009). It is always important to check any listings or referrals for accuracy. Call to verify that the person is still in practice, is licensed as a mental health professional (or is under the supervision of a licensed professional and working toward obtaining the appropriate clinical license), and that they see people with your specific needs—particularly if you are seeking someone who is experienced working with other trans people.
“I mentioned my gender variance to my psychologist when I was being treated for depression as a young teenager. We didn’t talk about it because I didn’t find it particularly important at the time. As I transitioned in my teens, there got to be a point where that was important. Very important. I sought out therapists specifically for that issue then.”
Affording Mental Health Services
For those of us who are fortunate to have health insurance that covers mental health treatment, the use of that insurance for mental health services can be a complicated decision. Many insurance companies in the United States have a standard exclusion for care related to gender identity and transition-related services, including mental health care.
“I have faced discrimination with my insurance carrier which was covering all my psychotherapies until they found out it was gender related. After that they became non-covered medical care.”
At times, people work around insurance concerns by paying for mental health care out of pocket. If you choose to self-pay for mental health services, you may find that you are able to negotiate a rate that works for your financial situation. Providers and clinics may offer discounted rates based on income (sliding scale). Most agencies have strict requirements to determine who qualifies for a reduced fee. They may also have time limits for services at that lower fee to enable as many people as possible to have access to less expensive services. Talk with the provider about your financial situation or any changes in it, and discuss available options. These options may include referral to a different, more affordable provider or agency, reduction in frequency of visits, or ending treatment until a later time when you are able to afford it.
Even if you have insurance and want to use it, your insurance may or may not cover mental health services. If it does, you may want to contact your insurance company directly to find the names of providers who are “in network” for your coverage, meaning that the insurance company has agreed to pay for those providers’ services, though you may still be responsible for any copayments and deductibles. You may also use what is called “out-of-network” providers if there is no in-network provider with the correct expertise. Many mental health care providers are not affiliated with any insurance companies because some insurance companies have a poor track record of paying for mental health care. If this is the case with the provider you want to see, you may end up paying out of pocket and submitting claims for reimbursements, or you may negotiate a self-pay rate you can manage. At times, insurance companies may cover out-of-network services it there are no in-network providers who offer the specialized treatment or service you need.
In seeking a mental health professional for support with gender-related issues, some people specifically choose to use an out-of-network therapist for complex reasons. These reasons may include privacy or concerns about what might be reported to the insurance company or to our family members if they receive our insurance statements. Additionally, some people do not wish to let insurance companies have access to details of their mental health care, or they may work in jobs where accessing some mental health treatments may be reason to be terminated. Some people are also reluctant to utilize insurance for fear that they will not be able to access other services or benefits in the future if the reason they needed care is revealed or recorded in insurance records as gender related.
Advocating for Ourselves in Accessing Care
Each person who accesses mental health care has a different reason for doing so. There is no one perfect process to follow to assure that you are able to find a provider who meets your needs. However, there are some things to consider that might help in the process. In some ways, finding a therapist is similar to interviewing and hiring an employee. It is not uncommon to have a phone interview with a therapist before arranging an appointment to meet that person. When interviewing a therapist, ask about the professional qualifications of the provider, type of licensure (e.g., psychologist, psychiatrist, clinical social worker, counselor, etc.), and type of services provided. Mental health professionals work from a number of theoretical models to address the same client concerns.
Talk with trusted friends and members of the trans community in your area about who they recommend as a mental health provider. There may not be official lists to refer to, but it is common for community members to have unofficial lists that include the names of people with both good and not-so-good reputations for their work with trans communities. There are also growing numbers of online lists of therapists who are competent in working with trans communities. Be aware that simply having one’s name listed on a Web site, even a reputable or prominent Web site, does not necessarily mean that the person is professionally licensed as a mental health provider. It is okay to ask about and check out a person’s licensure before scheduling a visit. Being listed on a site or being a trans or trans-friendly therapist also does not mean that you will work well with that person, that the therapist will know everything about all the variety of gender expressions and identities in the community, or that the therapist will have the same goals and objectives you have. Always check out a mental health provider before committing yourself.
Types of Mental Health Professionals
Mental health professionals may include psychiatrists, psychologists, social workers, counselors, therapists, psychotherapists, coaches, and others. Nonprescribing mental health professionals use talk and behavioral activities to treat difficulties in mental, emotional, and behavioral functioning. A small set of professionals (e.g., psychiatrists, psychiatric nurse practitioners, and prescribing psychologists in Louisiana and New Mexico) may also prescribe specific medications to help treat conditions causing significant mental, emotional, and life distress.
Some providers have areas in which they specialize and areas in which they have little to no training. Some providers are considered generalists. A generalist has basic training and experience in a variety of mental health concerns. It is important to ask providers whether they have training or experience in treating the type of issue you would like to address. Most professionals will admit when they do not have enough experience in the area you need assistance with and may be able to help direct you to another colleague who might be more qualified to help. People may change types of providers or individual therapists during their treatment and may engage in more than one style of therapy at once or over time. For example, one person may have an individual therapist and psychiatrist as well as being part of a group therapy program. Over time, individual therapy may shift from one modality of treatment to another.
General Mental Health Professionals
Most mental health professionals provide face-to-face counseling or talk therapy services that focus on thoughts, feelings, behaviors, and systems (e.g., family, culture) in order to improve a person’s development, health, and wellness. It is common for a mental health professional to see a client for a set time on a recurrent schedule (i.e., 45 minutes once weekly). Some providers offer time-limited treatment, meaning they may see a client for a preset number of visits. This is especially true with some agencies and with some specific types of treatment. It is also possible to find a provider who will work with people on an open-ended basis, meaning there is no preset or expected time limit to how many visits you will need for your particular situation or before stopping care. Generally, mental health professionals will stop seeing a client when the initial reason for treatment is resolved, the person’s goals have been reached, or because the client is not benefitting from services.
As clients, it is up to each of us to choose to participate in therapy. Like everyone, mental health professionals are unique, with their own values and goals shaped by training and life experience. It can be helpful to speak to potential providers on the phone before scheduling any appointments. When seeking care, it can be hard to know whether we will click with a therapist until we meet for one or more sessions. Therapy may feel awkward or uncomfortable at first because it is new or you have never spoken about some things with another person before. It takes time to know and experience feelings of comfort and safety in therapy.
“I still see the therapist I started going to when I was about 16 or 17. He’s helped tremendously and nobody else has ever made me feel as normal, as loved, and as whole as he has. I mean this platonically, of course, he’s just good at making you understand that you are important even if the things you do don’t make sense to the majority of people.”
It is important, when and where possible, to find someone who fits reasonably well with you, can meet your needs for treatment, and supports your goals. Many of us meet with more than one therapist before deciding on which is the best fit. A word of caution, however, is that changing therapists repeatedly or after only one or two visits may prove to be more problematic than helpful in receiving support and relief from distress.
In addition to face-to-face therapy services provided in office settings, a few counselors may provide therapy over the Internet, telephone, e-mail, or in real-time online visual and talk programs. This is called e-therapy or tele-mental health. The difference between face-to-face and e-therapy is in the method of delivery, not in the therapy that is provided or in the credentials of the therapist (Fraser, 2009). There may be problems with payment or reimbursement for treatment through insurance if the mental health clinician is not licensed in the state the client is in. Some advantages to e-therapy are the ability to keep our mental health treatment relatively anonymous in our local communities, and the ability to find care while living in isolated locations where there may be no other resources available (Fraser, 2009; Israel & Tarver, 1997).
Gender Specialists
Some mental health professionals specifically focus on gender issues or work primarily with gender nonconforming clients. These gender specialists or gender therapists may assist people who are experiencing questions or confusion about their gender, write letters recommending hormones or surgery, or assist people in mental health issues unrelated to their gender. There is no specific training required for therapists to call themselves gender specialists, so their backgrounds and experience vary.
“I as of this writing have gone to see a therapist who specializes in transgender issues. The best part of that experience was the therapist has a wealth of knowledge and was extremely easy to talk to. I think one of the big issues that transgender people face is just being able to find someone to talk to. I found the experience to be very uplifting and plan on seeing her again soon.”
We may seek mental health services to get into gender transition services or to process the changes or difficulties that result from transitioning. Gender therapists can help us to find a place of comfort in whatever gender or body fits best. This complex process encourages us to make informed choices about our care while reducing the potential for nonproductive or harmful coping behaviors, along with attending to and treating other mental health needs, if present (Lev, 2009).
BOOKS FOR THERAPISTS TREATING TRANSGENDER CLIENTS
True Selves: Understanding Transsexualism—For Families, Friends, Coworkers, and Helping Professionals by Mildred L. Brown
Casebook for Counseling Lesbian, Gay, Bisexual, and Transgender Clients and Their Families by Sari H. Dworkin and Mark Pope
Counseling LGBTI Clients by Kevin G. Alderson
Counseling Sexual and Gender Minorities by Lynne Carroll
Handbook of Counseling and Psychotherapy for Lesbian, Gay, Bisexual, and Transgender Clients by Kathleen J. Bieschke, Ruperto M. Perez, and Kurt A. DeBord
Handbook of LGBT-Affirmative Couple and Family Therapy by Jerry J. Bigner and Joseph J. Wetchler
The LGBT Casebook edited by Petros Levounis, Jack Drescher, and Mary E. Barber
Transgender Emergence: Therapeutic Guidelines for Working With Gender-Variant People and Their Families by Arlene Istar Lev
Transition & Beyond: Observations of Gender Identity by Reid Vanderburgh
In the past, gender therapists were charged with assessing our eligibility and readiness to successfully make use of gender-affirming treatments such as hormones and surgery, and with evaluating whether there were other mental health issues masking as gender dysphoria (Coleman et al., 2011). At times, this is still a necessary step. However, this gatekeeper model, or withholding of treatments until the provider deems it is appropriate, is gradually falling to the wayside, especially in light of the new transgender treatment guidelines, published by the World Professional Association for Transgender Health (WPATH). WPATH is an international group of mental health, medical, and other professionals who work with trans people and who utilize research and accepted clinical practice to develop guidelines for the treatment and care of mental and physical health needs of the trans community. Generally, surgeons require a referral letter from a mental health professional that is based on the WPATH Standards of Care. Letters are sometimes also required for hormone treatment, although this practice is decreasing as many medical providers now prescribe hormones based on an informed consent model.
Mental health professionals who work with trans communities listen to, support, and make suggestions or offer feedback, while helping us explore our inner conflicts, ideas, fears, coping skills, strengths, and resilience. Gender specialists work with us to create realistic treatment goals for any mental health issues and help to support and enable any plans we may have for gender transition. Each person’s transition experience and path is unique. It is important to recognize that a gender specialist’s role is not to mold people to a gender binary or make everyone follow the same path. Instead, they collaborate with us to foster expression of our gender identities in the most accurate and authentic way possible for each of us (Rachlin, 2002). As part of therapy, gender specialists will focus on how we feel about our current experience of ourselves physically and emotionally, and explore what supports are in place in our lives to meet our future goals. They may review with us our gender identity development and expression, level of distress, current gender presentation, safety, and plans.
Throughout transition, gender therapists can help us to assess our safety and living situation. They may assist us in exploring options that we might not have been aware of or may have had unrealistic expectations about, such as living cross-gendered without hormonal or surgical body alterations (Rachlin, 2002). For those of us working toward physically changing our bodies with hormone treatments or surgery, a gender specialist may discuss our plans for affording hormones or surgeries, expectations around the physical changes, and anticipated and unanticipated outcomes.
HOW TO WRITE A LETTER FOR HORMONES OR SURGERY
Kit Rachlin, PhD, a clinical psychologist and gender specialist in private practice in New York City, provides tools for mental health providers asked to write letters recommending clients for hormones or surgery.
Medical providers may ask a mental health professional for an evaluation of an individual who is requesting gender-affirming hormones or surgery. The evaluation includes information which the medical provider may not have the time or training to obtain. The letter is a statement that the client is ready and able to give informed consent, and it is also intended to give the treating provider a sense of the client as a person, to help support the client’s individualized care.
SECTION I. INTRODUCTION AND OPENING SUMMARY
The client’s general identifying characteristics, age, affirmed identity, and preferred pronoun. The nature of the letter writer’s contact with the client, the name of the person writing the second opinion (if any), and a statement that the letter writers are in agreement. If certain criteria must be met (such as a diagnosis for insurance reimbursement), put it right up here. The statement that the individual is ready and able to consent to treatment can be made in this first paragraph, and the rest of the letter provides support for the statement.
SECTION II. PERSONAL HISTORY
This section contains information standard in any psychosocial evaluation and gives the medical provider a picture of the patient as an individual. A holistic approach calls for the provider to attend to all aspects of the person—physically, emotionally, professionally, and socially. A discussion of gender history includes the client’s history of identity exploration and expression, future goals for expression, and explains why this medical treatment makes sense for this person in the context of their life.
SECTION III. MENTAL HEALTH ASSESSMENT AND ABILITY TO CONSENT TO TREATMENT
The client’s history of psychotherapy, history of mental illness, emotional distress, and current mental status. History of physical or sexual abuse, suicide attempts, and substance use, as relevant to the current treatment. If the client has ongoing mental and emotional problems, make a statement about how these other diagnoses will impact the treatment requested.
SECTION IV. SUMMARY
A statement that the individual is prepared, ready, and able to give informed consent to the requested medical treatment.
A statement that the mental health professional welcomes a phone call to discuss the case further.
Letter writers should be familiar with the WPATH Standards of Care (Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., ... Zucker, K. (2011). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism. 13(4), 165–232.)
DIAGNOSES AND BILLING
During work with a mental health professional, it is typically necessary to use a formal mental health diagnosis for treatment, billing, and referral purposes. The idea of diagnosis is controversial. A diagnosis of a gender-related disorder may cause problems with an insurer that has treatment exclusions for trans care, or at other times, gender-related services may be covered only if there is a gender diagnosis given. Whether a diagnosis is needed, and what diagnosis is appropriate for the care being provided, can and should be a topic of discussion with your provider. See Chapter 15 for more information on diagnoses.
“I do not think there is anything bad or disordered about being trans, but I have no problem with it being categorized as a mental health condition. I feel that those who are outraged by this may need to check their privilege as regards mental health issues. There is also nothing bad about having the brain condition that produces clinical depression—except the distress it causes, much like that often caused by being trans. Much like trans people, those who deal with depression require treatments ranging from positive thinking and healthy habits to therapy and medication in order to live well. As long as trans people experience distress and require medical help as a result of being trans, I think the categorization of transgender feelings as a mental health issue makes sense. When it comes to the specifics of the diagnosis, its section in the DSM, etc., I have some disagreements—but that’s a different question.”
APPROACHES TO GENDER AFFIRMATION TREATMENT
Clinics and providers use different approaches to gender affirmative treatments. Many clinics create their own internal protocols based on research and evidence-based guidelines or standards of care. Having guidelines for ethical care serves to protect trans people from unscrupulous or uninformed providers. These standards of care are usually created and published by groups of medical or mental health providers with experience in research or providing care to trans people. These approaches all follow varying degrees of harm-reduction or client-centered approaches to care that focus on the needs of the trans person over the needs of the provider, and on providing the services that will most quickly help reduce risks of physical and mental health problems. Three of the more prominent formal guidelines for mental health care of gender nonconforming people commonly used in North America are the World Professional Association for Transgender Health’s Standards of Care, Version 7; the Endocrine Society’s Endocrine Treatment of Transsexual Persons; and Vancouver Coastal Health’s Clinical Protocol Guidelines for Transgender Care.
Application of Guidelines and Standards of Care
There have been times in which guidelines and standards of care served as roadblocks for transition-related care with mental health and medical providers as the gatekeepers. Historically, formal standards and guidelines placed mental health professionals in a position of determining access to medical care (Bockting et al., 2007). Today, a growing understanding of the role of the therapist in gender affirmation is moving more toward seeing gender specialists as expert trans health advocates—invaluable assistants who open doors and make introductions to key people who will make a gender transition possible and safer (Bockting et al., 2007; Lev, 2009; Rachlin, 2002).
Ideally, mental health and medical providers work together to empower us to move toward our goals and visions for our lives. Client-centered care, however, does not mean that mental health or medical providers withhold recommendations for additional care and support services that they have assessed and recognize that the individual may need. This approach also does not mean that everyone who presents to a clinic using this model is guaranteed gender-affirming medical treatments (sometimes called “on-demand” care). Situations remain in which a medical transition may be dangerous or life threatening to a person, and health care professionals are obligated to treat the person in their care and help them understand and cope with this situation, or in other words to first and foremost “do no harm.”
Under any model of care and following any of the formal standards and guidelines, client-centered support and services operate from the belief that most of us are well adjusted and need only realistic information and direction on where to find appropriate care. Client-centered gender specialists emphasize our self-determination in choices. The role of the mental health provider is based on support and guidance with an emphasis on our autonomy. Client-centered care emphasizes the vast differences among people who are gender nonconforming and recognizes that not all of us wish to follow the same pathway to self-expression, move from one end of a gender binary to the other, or medically transition at all. Client-centered approaches recognize at the start that not all gender nonconforming people are dealing with mental health concerns or life situations that require mental health treatment.
FAMILY SERVICES AND COMMON FAMILY CONCERNS
Prior to coming out to partners and families, it may be helpful for us as gender nonconforming and trans people to get support from a mental health professional to help think about how to best come out, set realistic goals and timelines, and prepare for potential reactions and responses. A central issue often revolves around deciding when we disclose our identities or histories to others.
“After much therapy over the years for my depression and getting to a point where it was either come out to my spouse about being trans or die, I came out to her. Fully prepared to lose everything, even my marriage and child and vocation, I told her and, while she didn’t understand it, she did accept that this is who I am. (As an aside, she was actually relieved because she thought I was gay all these years. Funny thing is, I actually do consider myself to be a lesbian. . . it’s complicated.) I also came out to my daughter and she has accepted me without any reservation. I’m in the process now of coming out to other family members. I am still very much ‘stealth’ because of both my (and my spouse’s) vocation. We’re both ordained priests working in the church. Did I mention that it’s ummm. . . complicated?”
Delaying talking to a partner may result in our partner feeling betrayed, lied to, or not trusted. It is common for us to be nervous about coming out. It is also common for our partners to have questions about their own gender or sexual orientation based on our gender nonconformity or gender transition plans and process. Some of us may be concerned that our disclosure or plans to affirm our gender will end the relationship—a realistic fear, yet there are examples of relationships that endure the gender transition of one or both partners. Being trans does not mean that we will lose our partner or never be able to find a partner. Honesty, effective communication, and respect can help relationships survive and thrive during the transition period. Chapter 16 provides more information on mental health in relationships.
Just as some of us who are trans-identified or gender nonconforming travel paths of gender affirmation, or transition, so must our partners and family members, which can be difficult for both our loved ones and for us. Our families’ reactions may include shock and confusion, and they may range from acceptance and celebration to rejection and sometimes violence (Lev, 2004; Xavier, 2000). However, there are increasing numbers of partners and families who accept the revelation with minimal difficulty.
In the past, therapists and medical providers required trans people to leave their families in order to access medical gender affirmation treatments. Though leaving one’s family may still be a common practice in some cultures, it is not recommended. Unfortunately it is still something that a few trans people believe they must do in order to live their lives as their authentic selves. Seek out a mental health professional to talk with before making such a significant life decision.
A mental health professional may be able to assist us and our families in navigating difficult life situations and relationships before, during, and after transition. Some partners and families may be accepting of one type of gender expression or treatment, but not another. For instance, a partner or family member may feel comfortable with a trans loved one’s dressing and grooming themselves as their affirmed gender but may struggle with the idea of gender-affirming hormones or surgeries. These partner and family concerns are issues with which a mental health professional might be able to assist, and they would likely include partners and family members in some of the therapeutic sessions. Partners and families are beginning a sort of gender transition of their own and may also need their own support and counseling to understand what this will mean for their lives and identities, and how to deal with possible changes ahead. Partners and families must also wrestle with the consequences of coming out to other people, just as the trans person does. For instance, some partners may have their sexual identities questioned or made invisible as a partner transitions.
“I used to love going to gay pride parades and events, but after my partner transitioned from female to male and we later had a child, we were no longer welcome at most LGBT events. We were often asked why we were there or told to leave. People won’t talk to us and they stare. No one seemed willing to think we might be a part of that community, because we looked like an average straight couple with a child. It was very hurtful because I still am a lesbian, and my partner identifies as bisexual, but to be welcome now, we have to go alone or wear shirts that say ‘nobody knows I’m a lesbian, ’ ‘trans parent, ’ or something like that. I think it’s sad.”
Some partners, family members, friends, and chosen family may say they suspected or knew about their loved one’s trans identity for a long time and were just waiting for the individual to disclose their gender identity in their own time and on their own terms. Yet whether loved ones are supportive from the start or not, it is common for people to change how they feel over time. When our partners and families are accepting and supportive from the start, there still may be days, months, or even years of challenging conversations and movement forward as everyone transitions together. Some families and their trans or gender nonconforming members may at times withdraw from one another, while others do the exact opposite, turning inward into the family system and withdrawing from others outside the family. Some families may go into denial, trying to forget that the gender identity or transition information was ever shared and pretend everything is as it was before. Others, unfortunately, completely sever ties.
Our partners’ and families’ reactions are impossible to predict. Many of us fear complete familial and social rejection, and then are extremely surprised when these dire predictions turn out to be false. As trans and gender nonconforming people, we may find ways to balance our own needs with the demands and needs of our partners and families. Some of us find it easier to appease uncomfortable partners or family members by limiting the amount of time we dress in our affirmed gender or delaying certain aspects of transition. Others of us gain the acceptance of partners and families and will continue to have support from our loved ones as we express ourselves more fully and authentically.
Mental health professionals experienced in working with trans or gender nonconforming clients may be able to assist in working with families. It is helpful for all the people affected directly by a gender transition to have support whenever possible. We should have separate individual therapists from our partners and family members whenever possible, because working individually and as a family with the same therapist may make it very hard for everyone to feel equally supported.
GROUP SUPPORT AND COUNSELING
Besides individual, couples, and family counseling, we may find support groups helpful. Support groups generally come in three types: peer led, therapist led, and online. In peer-led support groups, a member of the trans community leads a face-to-face group at a community location. It is not uncommon for these locations to be undisclosed for the purpose of ensuring privacy of the group members. These groups might meet weekly, every other week, or monthly. There is usually a small, suggested donation for the meeting that is used to cover the cost of the space. Many of these meetings recognize that trans people are often struggling to make ends meet so will offer a reduced fee or no cost until you are able to help support the meeting. Usually the leaders of these groups have been trained or have skills in group management. Additionally, these groups may be open only to certain people in the trans community, such as cross-dressers, trans men, trans women, or people of color. In some cases, the meetings are open to anyone, including friends, family, and loved ones.
Other groups are therapist-led groups, as known as “group therapy.” In these cases, there is usually a screening process for the group to determine whether you are a good group candidate. This is done for a variety of reasons, including the need to assure a sense of balance in the group as well as to be certain that group members will benefit from the experience. Therapist-led groups can be in an open or a closed format. In an open format, group members can come and go. This might be used in a group that is designed to help you understand the transition process and to benefit from the experience of others. In a closed group format, a set number of group members agree to participate in a group experience for a certain number of sessions. Usually, these group experiences last at least six weeks and may go as long as twelve or more weeks. When signing up for a closed group, you are expected to be in attendance at each of the group sessions. In fact, this commitment is often part of the screening process. Closed groups focus on a specific area of concern, such as coming-out experiences, preparing for medical transition, or work or career concerns. It is common for two therapists to lead group sessions together. Unlike peer-led groups, these group sessions almost always have a cost associated with them, although the fee may be negotiable.
The final type of groups is online support groups, such as Yahoo, Google, or Facebook groups. While these groups can be useful for accessing support, they do not take the place of face-to-face meetings. However, for those of us who are unable to access in-person meetings, they can be a great substitute. Online, we can be sure that we will be able to find a group for just about any interest or identity we might have.
CONCLUSION
By taking action and responsibility for locating our own supports and services, we can help to improve our therapeutic relationships and mental health outcomes. We have the right to be treated with dignity and respect in therapy. There are supports and services to assist us in our journeys of self-discovery and expression. Knowledgeable therapists are available in many regions across the country and are becoming trained in working with gender nonconforming and trans populations in increasing numbers. Competent mental health treatment is attainable and can be highly effective in helping us to reach our goals and relieve distress.
REFERENCES AND FURTHER READING
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Bockting, W. O., Knudson, G., & Goldberg, J. M. (2007). Counseling and mental health care for trans adults and loved ones. International Journal of Transgenderism, 9, 35–82.
Coleman, E., Bockting, W., Botzer, M., Cohen-Kittenis, P., DeCuypere, G., Feldman, J., ...Zucker, K. (2011). Standards of care for the health of transsexual, transgender, and gender-non-conforming people, Version 7. International Journal of Transgenderism, 13(4), 165–232.
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Israel, G. E., & Tarver, D. E., II. (1997). Trans care: Recommended guidelines, practical information, and personal accounts. Philadelphia, PA: Temple University Press.
Lev, A. I. (2009). The ten tasks of the mental health provider: Recommendations for revision of the world professional association for trans health’s standards of care. International Journal of Transgenderism, 11(2), 74–99.
Lev, A. I. (2004). Trans emergence: Therapeutic guidelines for working with gender-variant people and their families. Binghamton, NY: Haworth Press.
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Xavier, J. M. (2000). The Washington Transgender Needs Assessment Survey. Us Helping Us, People Into Living. Retrieved January 2014, from http://www.glaa.org/archive/2000/tgneedsassessment1112.shtml
