COUNSELLING AND SUPPORT SERVICES FOR TRANSGENDER PERSONS AND THEIR FAMILIES
A personís gender typically is assigned at birth and is determined primarily by external genitalia but also can be confirmed by gonads, chromosomes, hormones and internal organs. Newborns are usually designated male or female and, on rare occasions, intersex. Gender identity refers to the subjective sense of who one is as far as male, female or other. Gender identity is determined more by the brain than by sexual anatomy. Most people have a sense of their gender identity by age 4, although this sometimes happens earlier and sometimes later in life.
Different Gender Categories
Cisgender persons are those whose gender identity and expression are aligned with the cultural and social expectations of the gender they were assigned at birth. The majority of persons are cisgender. Gender-nonconforming persons are those whose gender identity or expression are inconsistent with societal expectations typically associated with males and females. Some gender-nonconforming persons do not fit into the gender binary (male or female) as others do and may consider themselves to be gender fluid, gender queer or gender non-binary. Transgender persons have a strong inner sense that their bodies and the gender assigned to them at birth are incongruent with their gender identity. They may be assigned-at-birth males who identify as female (male to female or MTF) or assigned-at-birth females who identify as male (female to male or FTM).
It is important for counsellors to understand how their transgender and gender-nonconforming clients identify, especially given that gender identity is now considered to be more a spectrum between male and female and may indeed be a galaxy of possibilities. With some exceptions, transgender persons desire and, if at all possible, pursue hormone and surgical treatment to experience congruity between their bodies and their minds. In other words, most transgender persons desire and pursue transition to the gender with which they identify. Counsellors and the general public need to understand that there is a difference between gender identity and sexual orientation. Some people make the erroneous assumption that transgender and gender-nonconforming persons are gay. The truth is that they, just like cisgender persons, may be gay, straight, bisexual, pansexual or asexual. Stated simply, sexual orientation refers to who one wants to sleep with, whereas gender identity refers to who one wants to sleep as, meaning as male, female or some other gender identity in that galaxy of possibilities.
Etiology of transgender
Family members and the general public often want to know how this happens or why some people are transgender. The etiology of transgender may be understood as a complex interaction of social/cultural, cognitive and primarily biological factors, consistent with explanations of gender identity in general.
A growing body of evidence suggests that being transgender is a congenital condition caused by varying degrees of testosterone exposure in utero. Research also suggests that transgender persons possess brain characteristics more like the gender with which they identify than the gender they were assigned at birth. Furthermore, some genetic studies show a high concordance rate among identical twins, thereby adding further credence to a primarily biological explanation. Rather than playing a role in the etiology of being transgender, socialization tends to stifle transgender and gender-nonconforming identities. Besides, most transgender persons are less concerned with why they are and much more focused on being who they are. Contrary to prejudicial views held by some in the general public that transgender persons are mentally ill or merely pretending to be the opposite sex, being transgender is best considered a medical condition that can be treated successfully with hormonal and surgical treatments and psychosocial support.
Although being transgender is not a mental illness, most transgender persons experience dysphoria at various times in their lives. The dysphoria experienced by transgender persons is likely attributable to having to live in a body (and social role) that does not feel congruent with their sense of self in a society that misunderstands and discriminates against them. The gender dysphoria diagnosis indicates that it may include symptoms of depression, anxiety, fear, guilt, low self-esteem, shame and self-hatred. For some transgender persons, these negative emotional experiences may lead to self-harm, substance abuse and eating disorders. It is the job of mental health professionals to treat the dysphoria and associated symptoms, not the personís gender identity. Many view the diagnosis as stigmatizing, even if it was included to support access to and insurance coverage for mental health and medical services.
The effects of dysphoria are concerning. One statistic that is particularly startling is that 41 percent of transgender persons attempt suicide, compared with less than 2 percent of the general population. Other statistics derived from the 2011 National Transgender Discrimination Study of 6,456 transgender and gender-nonconforming adults:
One encouraging statistic from this study is that 78 percent of those who completed their transition felt more comfortable at work and improved their job performance, despite mistreatment at work. This suggests that completing transition engenders greater confidence and comfort with self and may strengthen the transgender personís ability to cope with stressful environments.
The World Professional Association for Transgender Health (WPATH) Standards of Care (currently SOC-7) provides state-of-the-art guidelines for the proper treatment of transgender adults and children. Treatment involves an integration of medical interventions, social support and community building, and mental health care. Treatment is integrative and collaborative with other professionals and is most effective when it includes advocacy and education within family, school, work and community contexts.
Medical interventions may include any or all of the following, depending on the age and gender identity of the transgender person:
Cosmetic surgeries may also be performed, such as tracheal shave and facial feminization surgery to help feminize facial features in MTF persons. Electrolysis or other hair-removal methods may also be considered by MTF transgender persons to feel and appear more feminine. Androgen blockers and estrogen help to feminize the body in a variety of ways but do not feminize the voice, so MTF transgender persons may seek voice training to feminize their voices. Testosterone will deepen the voice and promote growth of hair on the face and body, so there is typically little need for FTM transgender persons to seek voice training or cosmetic treatments.
Social support and community building
Social support is very important for reducing the sense of isolation that many transgender persons experience. Many report that they first sought information and support for themselves on the internet, describing how comforting it was to find out there were other people like them. The Equality Centre offers several groups in support of transgender and gender-nonconforming persons, along with many other services for LGBTQQIA (lesbian, gay, bisexual, transgender, queer, questioning, intersex, asexual) people. There are support groups for transgender men, women, children and teens, and for parents of transgender children and teens.
Gay-Straight Alliance groups in schools, and support groups and student organizations on college campuses, can serve as safe zones for adolescents and young adults. Such groups for transgender persons and their family members provide useful information about medical, cosmetic and legal steps in the transition process. These groups are also central to the community building that provides hope and support for dealing with unaccepting environments and other challenges that transgender persons may encounter. Fostering the development of support services and participating in community-building efforts are among the ways that professional counsellors can make a positive difference in the lives of transgender persons and their families.
Community building can also be helpful in organizing or participating in efforts to challenge legislation that would be harmful to transgender persons. Under President Obama, the U.S. departments of Justice and Education established guidance and took steps to protect the rights of transgender persons in the workplace and the rights of transgender students in the schools to use restrooms consistent with their gender identity. Several state attorneys general filed suit against the Justice Department in 2016, and some state legislators have succeeded in enacting state laws that restrict the restroom usage rights of transgender persons. In the early weeks of the Trump administration, the Justice Department and the Education Department rescinded the guidance that served to protect the rights of transgender persons and students
Nevertheless, the rights of transgender persons to use restrooms consistent with their gender identity remains both a national- and state-level issue, when all transgender persons want is to feel safe and comfortable using a restroom for the same reason that anyone wants to use a restroom. Counsellors can be helpful to transgender persons by advocating for their rights. Considering that many transgender students report being bullied in schools, counsellors can support anti-bullying state legislation and intervene, as appropriate and with their clientsí consent, in school systems where transgender youth experience harassment. The importance of the counsellorís role as an advocate for social justice is strikingly evident in our efforts to help transgender and gender-nonconforming persons.
Mental health care
Professional counsellors can be helpful to transgender persons by providing informed, competent and compassionate mental health care. Minimum qualifications to provide mental health care to transgender persons include a masterís degree in a clinical behavioural science field; training and competence; documented supervised training and competence in counselling/psychotherapy; and continuing education in the treatment of gender identity issues.
Transgender persons present several common concerns to counsellors and other mental health professionals. They may present with symptoms associated with gender dysphoria, such as depression, anxiety and suicidal ideation. Some may need help with substance abuse or other harmful means of coping with distress. It is also important to attend to any co-occurring mental health issues that may require a referral to a psychiatrist for medication. Be aware that some transgender youth develop eating disorders, and others may be on the autism spectrum, so collaboration with providers with specialized expertise in these areas may be necessary. Counsellors also may need to attend to traumatic experiences and symptoms of minority stress associated with discrimination, stigmatization and harassment.
Other commonly expressed concerns involve:
Regarding ethical responsibilities, it is crucial that counsellors are aware of, confront and alter their own biases, fears (transphobia), discomfort, gender-normative assumptions and lack of information about transgender persons. One of the best ways to do this, as with overcoming any discomfort with people we perceive to be different from us, is to get to know persons who are transgender. This requires openness to learning about their experiences, listening with empathy to their life stories and demonstrating respect. One of the major ways we show respect when working with transgender and gender-nonconforming clients is by asking them about and consistently using their preferred pronoun (she, he, them, etc.), the name by which they prefer to be called and their self-defined gender identity (transgender, gender queer, gender non-binary, etc.).
It is also important that counsellors are respectful of their transgender clientsí sense of timing for coming out to others and the pace and timing for steps they wish to take in their transition. Some transgender persons seek multiple surgeries (top, bottom, cosmetic), whereas others choose not to take all of these steps in their transition or simply cannot afford every surgical intervention that they might desire. Furthermore, passing as the gender with which they identify may be more important to some transgender persons than it is to others. Passing should never be more important to the counsellor than it is to the transgender client.
It is counsellorsí responsibility to reduce the shame associated with self-stigmatization and internalized transphobia that transgender clients may experience and to help them replace that shame with pride. Knowing that the antidote to shame is self-esteem and pride, counsellors must help these clients identify positive resources and strengths. It is our responsibility as counsellors to cultivate a safe therapeutic environment for transgender clients ó a safe zone where they feel supported, affirmed, respected and appreciated for their courage and resolve.
It is helpful for counsellors to know that transgender clients are likely to want to take steps to change their names and gender markers on legal documents such as driverís licenses, birth certificates, passports, academic/school records, medical records, Social Security cards, bank accounts, credit cards and other financial records such as trusts and wills. The ease or difficulty in making such changes depends on the jurisdiction and particular offices involved (and, if the transgender person is a minor, the support of parents or legal guardians). Ideally, counsellors will know or learn enough about making changes to legal documents to be able to direct their clients to people and resources that will be helpful.
Families of transgender persons
Although family members vary in their degree and pace of acceptance, most struggle adjusting to the change in their identity as a family. When individuals come out as transgender in mid or late adulthood, cisgender spouses or children may be affected. Couples or family counselling may assist cisgender spouses and children in making accommodating adjustments to the changing gender identity of a spouse or parent.
Some couples work through the issues associated with such a change and maintain their love and commitments to stay together, whereas for others, such adjustments are too difficult. Some couples part amicably and the individuals remain friends, whereas others feel betrayed, and if minor children are in the home, custody battles sometimes transpire. Counsellors can help spouses and children (whether younger or older) by providing information about being transgender, enlisting their empathy and caring for their transgender loved one, and empathizing with their feelings, which may include grief, shame, anger and worries about their family.
When a child, teenager or young adult comes out as transgender, parents and siblings also make accommodating adjustments in their identity as a family. Counsellors can assist parents by supporting them in their grief and worry about the well-being of their transgender child. Counsellors can also serve as a resource for information about gender identity and the coming out process, and they can assist parents and their transgender children in determining when and how to inform grandparents, extended family members, friends, school personnel and church personnel. Advising parents about books and articles to read and websites to educate themselves about their transgender child or teen can also prove beneficial.
Parents and other family members often struggle, at least temporarily, with the names and pronouns by which their transgender loved ones want to be referred. Counsellors can encourage family members to be intentional about using these names and pronouns, while also recognizing that mistakes happen and that it will take practice to get everything right consistently. Whether working with parents in counselling or in support groups, counsellors can address parental concerns about medical and cosmetic interventions and procedures for changing legal documents. It is important for counsellors to support and affirm appropriate action when parents of transgender youth express concerns about bullying or harsh treatment by peers or school personnel, their childís depression or suicidal ideation, and negative reactions by extended family or others
Transgender persons face problems and challenges that are unique to them and their situation. It is therefore important for professionals working with transgender people to be aware and knowledgeable about the different experiences and challenges faced by transgender people so that they come up with effective ways of helping them. Counselling of transgender people also requires a multi disciplinary approach involving personnel from different fields so as to tackle all challenges faced by them.
1. Counselling Transgender Persons and their Families
2. Counselling Transgender Individuals: Issues and Considerations
3. Transgender Counselling| The Beaumont Society