by Libbey Ketterer MSW, LSW
At The Anxiety Center, we are committed to providing all our patients with evidence-based treatment approaches to ensure everyone under our care has access to the most productive, effective means of achieving their mental health goals regardless of diversity factors. For the transgender and gender non-conforming (TGNC) population, current research indicates that providing gender-affirming therapy is associated with improved outcomes. At The Anxiety Center, we believe that we have a responsibility to all of our patients to utilize treatment methods that maximize those treatment outcomes and minimize risks.
In the 2015 U.S. Transgender Survey (USTS), the largest survey of transgender people in the U.S. to date, 81.7% of respondents reported seriously contemplating suicide in their lifetimes, while 40.4% reported attempting suicide at some point in their lifetimes (James et. al, 2016). When compared to the rates of suicidality in the general U.S. population, the rates of suicidality in the transgender population are disproportionately high. There are many factors that contribute to this, including societal stigma, bias, and discrimination. Frequent examples based on national surveys include employment discrimination, housing discrimination, acts of violence (including physical and sexual violence), the use of the incorrect pronouns and/or dead name, assumptions about a person’s gender identity, and asking inappropriate questions about a person’s gender and body. Additionally, a lack of gender-affirming care may worsen the patient’s dysphoria, invalidate their sense of self, and promote continued discriminatory practices. We now have evidence that interventions aimed at changing a person’s gender identity to better align with their sex assigned at birth are also associated with increased mental suffering and an increase in suicidality.
Although psychological research among the TGNC population is in its infancy, we are beginning to assemble a more robust understanding of the critical ingredients in their care. A recent study by Tordoff and colleagues for transgender and nonbinary youths demonstrated positive results for youth who gained access to gender-affirming care. In this study, participants exhibited 60% lower odds of moderate to severe depressive symptoms and 73% lower odds of self-harm or suicidal thoughts during their first year of multidisciplinary gender-affirming care (Tordoff et. al, 2022). These types of results in clinical trials only continue to confirm our belief in the importance of validation and acceptance as a transdiagnostic tool in supporting all types of youth suffering from emotional dysregulation. This is why the team at The Anxiety Center is committed to providing gender-affirming psychological care to transgender and gender non-conforming clients. This is also in-step with the ethical expectations of The American Psychological Association who encourages all mental health providers to examine their personal knowledge, understanding, and acceptance of gender and sexuality, gender stereotypes, and TGNC identities. This may include a provider examining their own gender identity, as well as their gendered experiences related to privilege, power, or marginalization (American Psychological Association, 2015). It is also helpful to train all staff on how to respectfully interact with TGNC people as well as ensure all paperwork, forms, and materials are inclusive (Spade, 2011).
A person’s gender identity is not inherently pathological. However, some TGNC people experience distress around the discordance between their gender identity and their body and/or sex assigned at birth, as well as the societal stigma and discrimination mentioned earlier (Coleman et al., 2012). The American Psychological Association encourages mental health providers to help TGNC people understand the influence of minority stress and discrimination in their lives, including their internalized attitudes about themselves and their TGNC identity (American Psychological Association, 2015). Trauma, shame, depression, self-harm, violence, sexuality, medical treatment, and societal stigma are some other common themes discussed in gender-affirming therapy (American Psychiatric Association). The World Professional Association for Transgender Health lists more possible focuses of therapy as facilitating a coming-out process; “exploring gender identity, role, and expression; addressing the negative impact of gender dysphoria and stigma on mental health; alleviating internalized transphobia; enhancing social and peer support; improving body image; or promoting resilience” (World Professional Association for Transgender Health, 2012). Further, TGNC clients may be seeking therapy services for other reasons. These reasons can include needing assessment and referral for gender-affirming medical services or needing psychological support for family members (World Professional Association for Transgender Health, 2012).
At the same time, we recognize the importance of remembering that a person’s mental health concerns may or may not be related to their gender identity.
Currently, evidence-based practices have not been developed specifically for TGNC people. The American Psychological Association encourages mental health providers to utilize current evidence-based practices related to the client’s mental health concerns (American Psychological Association, 2015). For depressive disorders, this could include the use of Dialectical Behavior Therapy and Behavioral Activation. For anxiety disorders, this could include the use of Cognitive Behavioral Therapy and Exposure Therapy. If a TGNC client is experiencing distress relating to the discordance between their gender identity and body and/or sex assigned at birth, acceptance-based prinicples may be utilized. This could include Dialectical Behavior Therapy and Acceptance and Commitment Therapy.
We understand that there is an intersection between this topic and the cultural and religious beliefs of many families. In our discourse with your family please know that we are committed to providing a safe space to work through these issues in a non-judgmental manner. In fact, we welcome conversation as long as we can all show an ultimate commitment to improving the outcome.
Works Cited
American Psychiatric Association. Gender-Affirming Therapy. American Psychiatric Association.https://www.psychiatry.org/psychiatrists/cultural-competency/transgender-and-gender-nonconforming-patients/gender-affirming-therapy
American Psychological Association. (2015). Guidelines for Psychological Practice with Transgender and Gender Nonconforming People. American Psychologist, 70 (9), 832-864. doi: 10.1037/a0039906
Child Mind Institute. Quick Guide to Gender Dysphoria. Child Mind Institute. https://childmind.org/guide/gender-dysphoria-quick-guide/
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J.,... Zucker, K. (2012). Standards of care for the health of transsexual, transgender, and gender nonconforming people, 7th version. International Journal of Transgenderism, 13, 165–232. http:// dx.doi.org/10.1080/15532739.2011.700873
James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality.
Spade, D. (2011). Some very basic tips for making higher education more accessible to trans students and rethinking how we talk about gendered bodies. Radical Teacher, 92, 57– 62
Tordoff, D. M., Wanta, J. W., Collin, A., Stepney, C., Inwards-Breland, D. J., & Ahrens, K. (2022). Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care. JAMA Network Open, 5(2). DOI:10.1001/jamanetworkopen.2022.0978.
World Professional Association for Transgender Health. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People [7th Version]. https://www.wpath.org/publications/soc
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