May 3, 2022
By: Dr. Lisa Linardatos, Clinical Psychologist
For some people, their gender identity is not something they think much about. For others, the gender they are assigned at birth doesn’t fit with their gender identity. These individuals may identify as transgender, non-binary, gender-diverse, or gender nonconforming persons. The term transgender is used to refer to “a diverse group of individuals who cross or transcend culturally defined categories of gender” (Bockting, 1999). Transgender and gender nonconforming people experience pervasive, systemic discrimination and violence, including in terms of access to healthcare, education, housing, and employment (for a review, see Kcomt, 2019).
The discrimination and stigma trans and gender nonconforming folks face negatively impact their health and well-being, and they experience disproportionately higher rates of mental health concerns, including higher rates of anxiety, depression, and eating disorders (Kcomt, Gorey, Barrett, & McCabe, 2020; Lin et al, 2021; Reisner et al., 2015; Witcomb et al. 2015). Transgender and gender nonconforming folks also often experience gender dysphoria, which is defined as the suffering that arises from the incongruency between a person’s assigned gender at birth and their gender identity. People with gender dysphoria experience higher levels of suicidal ideation and suicide attempts than the general population, largely due to discrimination that extends to the challenges of accessing gender-affirming medical care (García-Vega, Camero, Fernández, & Villaverde, 2018).
Given the multitude of challenges transgender and gender nonconforming individuals face, including systemic discrimination, mental health issues, gender dysphoria, and suicidality, how can we, as practitioners and allies, ensure that we are best supporting these individuals? What are the different aspects of gender-affirming care? Below are some suggestions.
Some tips for gender-affirming care:
1. Listen, believe, and don’t assume you know what is best for trans, non-binary and gender diverse folks. Their voices are often dismissed, or even completely silenced. Part of our therapeutic work is to provide a safe space to have their voices heard; and more specifically, to have their needs identified and taken seriously, and their emotions validated. If you fall into the category of cisgender, like myself, it is especially important to be aware of our biases (see point #4) and adopt a posture of openness and cultural humility. When we’re coming from a privileged position, we won’t be able to fully appreciate the challenges face by a more marginalized group. Check out this Cisgender Privilege Checklist for a list of some cisgender privileges you may not be aware you have.
2. Use your client’s chosen name and pronouns. If you’re not sure what these are, ask. Apologize if you use the wrong name or misgender them and move on. Don’t make it about your feelings. This can be an extremely distressing experience for folks and being misgendered might be associated with a long history of not being seen. Research shows that chosen name use in more contexts predicts fewer symptoms of depression, and less suicidal ideation and suicidal behaviour (Russell, Pollitt, Li, & Grossman, 2018)
Make it a priority to use your client’s correct name and pronouns and find tricks for yourself so you don’t forget. You may feel intimidated by having to remember chosen pronouns when your brain automatically conjures up a different pronoun. The more you work in this field, the more your conditioning of seeing gender as a binary construct will be undone. Check out this article, “Why Pronouns are Important” for a helpful discussion on this topic.
3. Educate yourself. They are many ways to do this. I did a training in trans health with Dr. Françoise Susset, and continue to take part in a supervision group in trans health by the Institute for Sexual Minority Health, and have found this to be an extremely rewarding experience. I have met some great people, learned a lot, and have felt supported and inspired.
If you’re interested in working with trans, non-binary and gender nonconforming folks in a clinical setting, familiarize yourself with WPATH (World Professional Association for Transgender Health) and their Standards of Care. The WPATH Standards of Care is a handy, free, science-based document with the purpose of promoting the highest standards of care for transgender and gender nonconforming people. It outlines the therapeutic approaches for gender dysphoria, and describes the various gender-affirming medical procedures, the changes one might experience with each procedure, the associated risks, and what to consider when it comes to postoperative care, among other things. The 8th version is expected to be published in the coming months. It is important to check how these guidelines are applied in your country and region, as they are interpreted differently depending on where you live.
Additionally, The Trevor Project has excellent resources for trans and gender nonconforming folks and allies. For a handy breakdown and visual reminder of the differences among gender identity, gender expression, sex assigned at birth, and physical and emotional attraction, check out the Gender Unicorn.
4. Check your biases. This can be a hard one. Most of us like to think we don’t engage in stereotyping, we don’t hold onto prejudices, and we wouldn’t discriminate against others. However, it’s important to remember that the socialization to see gender as a binary construct is pervasive; and trans and gender nonconforming folks are not often portrayed in the media, and if they are, it’s in a negative and simplistic light (McLaren, J. T., 2018). Moreover, because of stigma and discrimination, many gender nonconforming and trans folks are not “out” and so we don’t get the wide personal contact with these individuals that would help undo these biases (Lai et al., 2014).
There is a lot of research that shows that our implicit biases, biases outside of our conscious awareness, are strong (e.g., Greenwald & Banaji, 1995) and exist even if we consciously are committed to not be discriminatory to marginalized people. These implicit biases can affect our behaviour (e.g., Green et al., 2007). To become more aware of your biases, you could start by asking yourself questions like, “would my opinion of this trans/gender nonconforming person be different if they were cisgender?” You might even take the Implicit Association Test, a test designed to measure implicit biases. They even have one measuring preferences for trans and cisgender faces.
5. Adopt an informed consent approach, and make sure your clients know what this means. In my practice, an informed consent approach means that part of my job as a clinical psychologist is to help clients assess their needs, gather and understand the information relevant to any considered medical procedures, and clearly understand the risks. My job is NOT to make decisions for them, but to empower them to make the best decisions for themselves. An important part of informed consent is recognizing that being transgender or gender nonconforming is “a matter of diversity, not pathology” (p. 4, Standards of Care version 7), and the “treatment” for gender dysphoria is social and medical transition, not psychotherapy (Susset, 2018). I also let my clients know that I follow the WPATH Standards of Care and we will read over relevant parts of this document together.
6. Understand that being transgender and gender diverse are not a trend. There are countless examples throughout human history of gender diverse individuals, and in some cultures these individuals were seen as superior. For example, the Sumerian goddess Inanna, goddess of love, sensuality, fertility and war, was said to have a sacred role in changing men into women and women into men, and her devotees were people assigned male at birth who identified as and lived as women, and were accepted as such by society (Barret, 2007; Harris 1991). Sumer is one of the first known civilizations in the world, and existed between 4500 – 1900 BC.
Additionally, there are numerous examples of gender diverse people in indigenous cultures across the world. In Native Hawaiian culture, the term “māhū” is used to describe the expression of the third self that evolves from acknowledging and embracing both male and female aspects of the self (Kanaka‘ole, 2015). Māhū people were thought to be particularly respected as teachers and keepers of cultural traditions (Matzner, 2001).
There are countless other examples. In Cree, “aayahkwew” means “neither man or woman”; In Inuktitut, “sipiniq” means “infant whose sex changes at birth.” In Kanien’keha, or Mohawk language, “onón:wat” means “I have the pattern of two spirits inside my body” (Susset, 2018).
7. Understand that there is lots of evidence demonstrating that the gender binary is false. There is more and more research in neurology, endocrinology, and cellular biology that points to the brain as playing an important role in one’s experience of gender, and as Dr. Murat Altinay, psychiatrist and researcher puts it, “the brain and the body can go in different directions.” Genetics and hormones are thought to contribute to sex/gender differences in brain development, leading to more male- or female-typical characteristics (Ristori et al., 2020; Swaab, 2007). Some research shows that the transgender brain looks and functions more like the brain of the gender they identify with than the one they were assigned at birth (Bakker, 2018; Berglund, Lindström, Dhejne-Helmy, & Savic, 2008; Garcia-Falgueras & Swaab, 2008).
Moreover MRIs of more than 1400 human brains reveal a great deal of overlap between features that are thought to represent a more “male” brain and features that are thought to represent a more “female” brain, demonstrating that human brains do not neatly fit into categories of male and female (Joel et al., 2015).
Another false binary that we can learn from is that of biological sex. There is lots of diversity in someone’s sex; it isn’t always one or the other. Intersex individuals have anatomical differences in their sexual organs that differ from individuals that are typically male or female (Zucker, 2002). An intersex person can be born with any of several variations in genitals, hormones, chromosomes, or internal sex organs like the uterus, fallopian tubes, and prostate. One to two in 100 people born in the U.S. are intersex, and the person may never know (Planned Parenthood). Check out evolutionary biologist Joan Roughgarden’s book Evolution’s Rainbow. This informative and eye-opening book is a “celebration of diversity and affirmation of individuality in animals and humans” and “challenges accepted wisdom about gender identity and sexual orientation.”
8. React constructively if you feel like your trans or gender nonconforming client doesn’t trust you. Remember, transgender and gender nonconforming folks are consistently discriminated against, and they may have had more than one negative experience with other health care professionals. Ask them if there is anything else you can do to make them feel more comfortable.
9. Connect to the community. If you are personally not connected to the LGBTQIA2+ community, you may want to find a way to become involved. You will understand people’s experiences better the more involved you are, and it is important to be aware that the community is a huge source of knowledge and resources.
In case it’s helpful to anyone reading this, I had no idea what I was doing when I first starting working in trans health, and I still have a lot to learn. I value this work because I care about mental health, and particularly the mental health of marginalized groups. I also care about doing what I can to change societal norms that are based on false truths and are detrimental to people’s well-being. If you’re interested in joining me on this journey or learning more, please don’t hesitate to reach out or check out the resources below.
We all have implicit biases. So what can we do about it? Dushaw Hockett. TEDxMidAtlanticSalon
(1) Amodio, D. M., & Mendoza, S. A. (2010). Implicit intergroup bias: Cognitive, affective, and motivational underpinnings. In B. Gawronski & B. K. Payne (Eds.), Handbook of implicit social cognition (pp. 353–374). New York: Guilford.
(2) Bakker, J. (2018, May). Brain structure and function in gender dysphoria. In Endocrine Abstracts (Vol. 56). Bioscientifica.
(3) Barret, C. E. 2007. “Was dust their food and clay their bread? Grave goods, the Mesopotamian afterlife, and the liminal role of Inana/Ištar.” Journal of Ancient Near Eastern Religions 7: 7-65.
(4) Berglund, H., Lindström, P., Dhejne-Helmy, C., & Savic, I. (2008). Male-to-female transsexuals show sex-atypical hypothalamus activation when smelling odorous steroids. Cerebral Cortex, 18(8), 1900-1908.
(5) Bockting, W. O. (1999). From construction to context: Gender through the eyes of the transgendered. SIECUS report, 28(1), 3.
(6) Brandes, A. (2014). The negative effect of stigma, discrimination, and the health care system on the health of gender and sexual minorities. Law & Sexuality, 23, 155–178.
(7) García Vega, E., Camero García, A., Fernández Rodríguez, M., & Villaverde González, A. (2018). Suicidal ideation and suicide attempts in persons with gender dysphoria. Psicothema.
(8) Garcia-Falgueras, A., & Swaab, D. F. (2008). A sex difference in the hypothalamic uncinate nucleus: relationship to gender identity. Brain, 131(12), 3132-3146.
(9) “The Gender Unicorn.” Trans Student Educational Resources, 2015. http://www.transstudent.org/gender.
(10) Green, A. R., Carney, D. R., Pallin, D. J., Ngo, L. H., Raymond, K. L., Iezzoni, L. I., & Banaji, M. R. (2007). Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. Journal of general internal medicine, 22(9), 1231-1238.
(11) Greenwald, A. G., & Banaji, M. R. (1995). Implicit social cognition: attitudes, self-esteem, and stereotypes. Psychological review, 102(1), 4.
(12) Harris, R. 1991. “Inana-Ištar as paradox and a coincidence of opposites.” History of Religions 30: 261-78.
(13) Swan, J., Phillips, T. M., Sanders, T., Mullens, A. B., Debattista, J., & Brömdal, A. (2021). Mental health and quality of life outcomes of gender-affirming surgery: A systematic literature review. Journal of Gay & Lesbian Mental Health, 1-44.
(14) Joel, D., Berman, Z., Tavor, I., Wexler, N., Gaber, O., Stein, Y., … & Assaf, Y. (2015). Sex beyond the genitalia: The human brain mosaic. Proceedings of the National Academy of Sciences, 112(50), 15468-15473.
(15) Johnson, A. H., Hill, I., Beach-Ferrara, J., Rogers, B. A., & Bradford, A. (2020). Common barriers to healthcare for transgender people in the US Southeast. International Journal of Transgender Health, 21(1), 70-78.
(16) Kanaka‘ole, K. 2015. “The Beautiful Way Hawaiian Culture Embraces a Particular Kind of Transgender Identity,” Huffington Post, April 28, 2015.
(17) Kcomt, L. (2019). Profound health-care discrimination experienced by transgender people: rapid systematic review. Social work in health care, 58(2), 201-219.
(18) Kcomt, L., Gorey, K. M., Barrett, B. J., & McCabe, S. E. (2020). Healthcare avoidance due to anticipated discrimination among transgender people: a call to create trans-affirmative environments. SSM-Population Health, 11, 100608.
(19) Lai, C. K., Marini, M., Lehr, S. A., Cerruti, C., Shin, J. E. L., Joy-Gaba, J. A., . . . Nosek, B. A. (2014). Reducing implicit racial preferences: I. A comparative investigation of 17 interventions. Journal of Experimental Psychology: General, 143, 1765–1785
(20) Lin, Y., Xie, H., Huang, Z., Zhang, Q., Wilson, A., Hou, J., … & Chen, R. (2021). The mental health of transgender and gender non-conforming people in China: a systematic review. The Lancet Public Health, 6(12), e954-e969.
(21) Matzner, A. (2001). ‘Transgender, queens, mahu, whatever’:
An Oral History from Hawai’i. Intersections: Gender, History and Culture in the Asian Context
Issue 6, August 2001.
(23) McLaren, J. T. (2018). “Recognize Me”: An Analysis of Transgender Media Representation.
(24) Reisner, S. L., Vetters, R., Leclerc, M., Zaslow, S., Wolfrum, S., Shumer, D., & Mimiaga, M. J. (2015). Mental health of transgender youth in care at an adolescent urban community health center: a matched retrospective cohort study. Journal of Adolescent Health, 56(3), 274-279.
(25) Ristori, J., Cocchetti, C., Romani, A., Mazzoli, F., Vignozzi, L., Maggi, M., & Fisher, A. D. (2020). Brain Sex Differences Related to Gender Identity Development: Genes or Hormones?. International journal of molecular sciences, 21(6), 2123.
(26) Russell, S. T., Pollitt, A. M., Li, G., & Grossman, A. H. (2018). Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. Journal of Adolescent Health, 63(4), 503-505.
(27) Susset, F. (2018, September 27-29). Vers une approche globale pour la santé et le bien-être des personnes transgenres et transsexuelles [PowerPoint slides]. Institute for Sexual Minority Health/Institut pour La Santé des Minorités Sexuelles.
(28) Swaab, D. (2007). Sexual differentiation of the brain and behavior. Best Practice and Research Clinical Endocrinology & Metabolism, 21(3), 431-444.
(29) Witcomb, G. L., Bouman, W. P., Brewin, N., Richards, C., Fernandez‐Aranda, F., & Arcelus, J. (2015). Body image dissatisfaction and eating‐related psychopathology in trans individuals: A matched control study. European Eating Disorders Review, 23(4), 287-293.
(30) Zucker, K. (2002). Intersexuality and gender identity differentiation. Journal of Pediatric and Adolescent Gynecology, 15, 3-13.