Competent Care for Transgender and Gender Non-Conforming People is Trauma-Informed

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By: Cristina Magalhaes, Ph.D., Madeline Brodt, M.S., and Jessica Punzo, Psy.D.

Cristina Magalhaes, Ph.D.
Cristina Magalhaes, Ph.D.

Transgender and gender non-conforming people (TGNC) face numerous challenges due to stigma associated with gender non-conformity, transgenderism, and transsexualism. In a landmark national survey with over 6,000 participants, researchers found that TGNC people experience alarming rates of discrimination, mistreatment, harassment, and physical and sexual abuse perpetrated by family members and other individuals in their communities – including educational, health care, and law enforcement professionals (Grant et al., 2011). Despite increased legal protections at the federal and, in some cases, at the state and local levels, deadly hate-motivated violence also disproportionately affects TGNC people, especially low-income transgender women of color, who experience multiple levels of social oppression and marginalization due to the compounding effects of racism, classism, sexism, and transphobia (National Coalition of Anti-Violence Programs (NCAVP), 2015).

Madeline Brodt, M.S.
Madeline Brodt, M.S.

Transphobia refers to intense feelings of disgust, repulse, fear, or dislike of all TGNC people–regardless of who they are as individuals–simply because their gender identity or gender expression does not match the gender they were assigned at birth, or because their sex anatomy is atypical or ambiguous. Common transphobic misconceptions about TGNC people include the beliefs that they are mentally unstable, anatomically aberrant, sexually deviant, morally defective, and dangerous to society. These beliefs are often used to justify mistreatment and victimization of TGNC people, who are deemed unworthy of respect and dignity as human beings. Kidd and Witten (2007) argue that abuse and violence toward TGNC people is a global phenomenon cutting across many cultures and nations. Unlawful arrests, violent assaults, gang rapes, murders, and other forms of abuse and violence motivated by hate have been reported in every continent – often in the name of family values and religion.

Jessica Punzo, Psy.D.
Jessica Punzo, Psy.D.

Clinical work with TGNC people, regardless of presenting problem, should therefore be trauma-informed. High rates of anxiety, depression, suicidality, substance use, and other symptoms associated with post-traumatic stress among TGNC people are well documented in the literature, and are known to be associated with experiences of victimization (American Psychological Association, 2015). Clinicians should also remain aware that discrimination, abuse, and violence toward TGNC people impact not only individuals who are directly targeted, but the entire TGNC community, including TGNC family members and friends who remain vigilant and concerned for their loved one’s well-being and safety.

Resilience

Resilience is defined as successful adaptation to adversity and can be seen as a trait one possesses (or develops), a process that results in positive changes for an individual, or the outcome of effective coping. TGNC people can be resilient despite challenges. Considering high rates of victimization in the TGNC community, continuing to exist in the world as a TGNC person can itself be an indicator of resilience (Singh & McKleroy, 2011).

Several factors can build resiliency in TGNC individuals, including affiliation with the larger lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community (Bariola, Lyons, Leonard, Pitts, Badcock, & Couch, 2015; Singh & McKleroy, 2011). Though lesbian, gay and bisexual (LGB) social support has been identified as helpful in developing resilience in TGNC people, this effect can be magnified if positive peer support comes primarily from fellow TGNC individuals (Pflum, Testa, Balsam, Goldblum, & Bongar, 2015). Community engagement, such as organizing against discrimination or sharing stories of success, can also assist in fostering resilience in TGNC people (Asakura & Craig, 2014). Another well-documented resilience factor is family support. Family members have an important role in helping buffer the effects of social oppression and other stressors in the lives of TGNC people (Ryan, Russell, Huebner, Diaz, & Sanchez, 2010). Working with family members to increase understanding of TGNC identity and gender non-conformity, and to improve relationships between TGNC people and their loved ones, can be instrumental in helping TGNC clients improve coping and increase wellbeing.

Furthermore, cisgender people (people whose gender identity or expression aligns with social expectations regarding gender) can also help foster resilience in TGNC people. One way is to help create safe and welcoming environments for TGNC people in various settings (e.g., educational, health care, law enforcement, workplace), thus decreasing the amount of systemic oppression TGNC people experience in society at large. Cisgender people can also help identify, support, and contribute to TGNC affirming media and online communities, which have a wide reach – beyond constraints of geographic location – helping TGNC people anywhere in the world to feel stronger, fight back against minority oppression, and recover from experiences of victimization (Craig, McInroy, McCready, & Alaggia, 2015).

Clinical Implications

While the TGNC community is resilient and perseveres despite challenges, many individuals still struggle with serious emotional, behavioral, and substance use problems and seek services from mental health professionals to improve coping and increase functioning. According to the American Psychological Association (APA) Guidelines for Psychological Practice with Transgender and Gender Nonconforming People (American Psychological Association, 2015), psychologists should strive to understand how mental health concerns may or may not be related to a TGNC person’s gender identity and the psychological effects of minority stress. Given the alarming rates of violence against this community, it is not surprising that TGNC individuals would suffer from the vast sequelae of posttraumatic stress. Rates of both depression and anxiety are higher in TGNC communities than in the general population (Hepp, Kraemer, Schnyder, Miller, & Delsignore, 2005; Bockting, Miner, Swinburne Romine, Hamilton, & Coleman, 2013). Additionally, estimates of lifetime rates of suicidal thoughts among transgender people range from 48% to 79% and estimates of suicide attempts range from from 21% to 41% (Hopwood & dickey, 2014). These rates are much higher than national averages, which range from 1.9% to 8.7% for adults who attempt suicide (Nock et al., 2008). Substance use problems are also common; research findings indicate that TGNC individuals turn to drugs and alcohol to cope more frequently than cisgender individuals (Lombardi, 2008; Grant et al., 2011; Testa et al., 2012).

Another reason TGNC people seek mental health care is to obtain support for gender transition, which may include a request for a recommendation letter to start hormone replacement therapy or undergo gender reassignment surgery. Although the need for mental health professionals to be in this type of gate-keeping role seems to be decreasing in recent years, some TGNC clients still seek care specifically for obtaining a letter for surgery, and clinicians should follow the World Professional Association for Transgender Health (WPATH) guidelines when asked to provide this type of service (see list of resources below).

While the cultural implications of working with TGNC clients are complex and unique,, many practicing psychologists who serve TGNC clients have had no formal training in TGNC-specific issues, with very few graduate programs addressing the needs of this population within academic curriculum. In 2009, the APA Task Force on Gender Identity and Gender Variance survey found that less than 30% of psychologist and graduate student participants had some familiarity with issues that impact TGNC people (American Psychological Association, 2009).  A critical need remains for cultural sensitivity, especially around historical psychopathology of transgender identities, such as the introduction of a gender diagnosis in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IIII) in 1980. Gender Identity Disorder (GID) was re-conceptualized and renamed as Gender Dysphoria (GD) in the DSM-5 with the intent to be less pathologizing of transgender identities (American Psychiatric Association, 2013).  However, professionals must be aware that TGNC people still need to be diagnosed with a mental disorder (i.e., GD) to access gender-related care, which inherently affects how TGNC people are treated in health care settings and how they feel about themselves. Furthermore, numerous studies have noted that transphobia is a significant barrier to competent care within the mental health system. TGNC people often report feeling disrespected by and receiving poor care from health care providers, including mental health professionals, which causes many to avoid accessing services altogether (Shipherd, Green, & Abramovitz, 2010; Lucksted, 2004; Colton Meier, Fitzgerald, Pardo, & Backcok, 2011; Kidd, Veltman, Gately, Chan, & Cohen, 2011).

Clinical and counseling psychologists are trained to assess for emotional and behavioral problems, and to help individuals restore wellness when feeling distressed and depleted of resources for coping. They can be of great help to TGNC people, many of whom struggle with complex trauma stemming from personal and/or community histories of marginalization and victimization. Competent transgender care is, first and foremost, affirmative of TGNC identities, but also grounded in a clear understanding of the lived experiences of TGNC people and the need for trauma-informed services that center around fostering resilience and improving coping.

Resources

  • Brill, S. A., & Kenney, L. (2016). The transgender teen: A handbook for parents and professionals supporting transgender and non-binary teens. San Francisco, CA: Cleis Press.
  • Brill, S. A., & Pepper, R. (2008). The transgender child: A handbook for families and professionals. San Francisco, CA: Cleis Press.
  • Erickson-Schroth, L. (2014). Trans bodies, trans selves: A resource for the transgender community. New York, NY: Oxford University Press.
  • Gender Odyssey (http://www.genderodyssey.org/)
  • Lev, A. (2008). Transgender emergence: therapeutic guidelines for working with gender-variant people and their families. Binghampton, NY: The Howorth Clinical Practice Press.
  • National Center for Transgender Equality (http://www.transequality.org/)
  • Singh, A. & Dickey, l. (2015). Affirmative counseling and psychological practice with transgender and gender nonconforming clients: Perspectives on sexual orientation and gender diversity. Washington, DC: American Psychological Association.

References

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.

American Psychological Association. (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70(9), 832-864. doi: 10.1037/a0039906

American Psychological Association. (2009). Report of the task force on gender identity and gender variance. Washington, DC: Author. Retrieved from http://www.apa.org/pi/lgbt/resources/policy/gender‐identity‐report.pdf

Asakura, K., & Craig, S. L. (2014). ‘It Gets Better’ … but how? Exploring resilience development in the accounts of LGBTQ adults. Journal of Human Behavior In The Social Environment, 24(3), 253-266. doi:10.1080/10911359.2013.808971

Bariola, E., Lyons, A., Leonard, W., Pitts, M., Badcock, P., & Couch, M. (2015). Demographic and psychosocial factors associated with psychological distress and resilience among transgender individuals. American Journal of Public Health, 105(10), 2108-2116. doi:10.2105/AJPH.2015.302763

Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Hamilton, A., & Coleman, E. (2013). Stigma, Mental Health, and Resilience in an Online Sample of the US Transgender Population. American Journal of Public Health, 103(5), 943–951. http://doi.org/10.2105/AJPH.2013.301241

Craig, S. L., McInroy, L., McCready, L. T., & Alaggia, R. (2015). Media: A catalyst for resilience in lesbian, gay, bisexual, transgender, and queer youth. Journal of LGBT Youth, 12(3), 254-275. doi:10.1080/19361653.2015.1040193

Colton Meier, S. L., Fitzgerald, K. M., Pardo, S. T., & Backcok, J. (2011). The effects of hormonal gender affirmation treatment on mental health in female-to-male transsexuals. Journal of Gay and Lesbian Mental Health, 15(3), 281-299. doi: 10.1080/19359705.2011.581195

Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Keisling, M. (2011). Injustice at every turn: A report of the national transgender discrimination survey, executive summary. National Center for Transgender Equality and National Gay and Lesbian Task Force. Retrieved from http://www.thetaskforce.org/static_html/downloads/reports/reports/ntds_summary.pdf

Hepp, U., Kraemer, B., Schnyder, U., Miller, N., & Delsignore, A. (2005). Psychiatric comorbidity in gender identity disorder. Journal of Psychosomatic Research, 58(3), 259–261. http://doi.org/10.1016/j.jpsychores.2004.08.010

Hopwood, R. & dickey, L. M. (2014). Mental health services and support. In L. Erickson-Schroth (Ed.), Trans bodies, trans selves: A resource for the transgender community (pp. 291-332). New York, NY: Oxford University Press.

Kidd, J. D., & Witten, T. M. (2007). Transgender and Trans sexual Identities: The Next Strange Fruit-Hate Crimes, Violence and Genocide Against the Global Trans-Communities. Journal of Hate Studies, 6(1), 31–63.

Kidd, S. A., Veltman, A., Gately, C., Chan, K. J., & Cohen, J. N. (2011). Lesbian, gay, and transgender persons with severe mental illness: Negotiating wellness in the context of multiple sources of stigma. American Journal of Psychiatric Rehabilitation, 14(1), 13-39. doi: 10.1080/15487768.2011.546277

Lombardi, E. L. (2008). Substance use treatment experiences of transgender/transsexual men and women. Journal of LGBT Health Research, 3(2), 37-47.

Lucksted, A. (2004). Lesbian, gay, bisexual, and transgender people receiving services in the public mental health system: Raising issues. Journal of Gay & Lesbian Psychotherapy, 8(3-4), 25-42. doi: 10.1300/J236v08n03_03

National Coalition of Anti-Violence Programs (2015). Report on Lesbian, Gay, Bisexual, Transgender, Queer, and HIV-Affected Hate Violence – AVP: The Anti-Violence Project. (n.d.). Retrieved from http://www.avp.org/resources/avp-resources/520

Nock, M. K., Borges, G., Bromet, E. J., Cha, C. B., Kessler, R. C., & Lee, S. (2008). Suicide and suicidal behavior. Epidemiology Review, 30(1), 133-154. doi: 10.1093/epirev/mxn002

Pflum, S. R., Testa, R. J., Balsam, K. F., Goldblum, P. B., & Bongar, B. (2015). Social support, trans community connectedness, and mental health symptoms among transgender and gender nonconforming adults. Psychology of Sexual Orientation and Gender Diversity, 2(3), 281–286. http://doi.org/10.1037/sgd0000122

Ryan, C., Russell, S. T., Huebner, D., Diaz, R., & Sanchez, J. (2010). Family Acceptance in Adolescence and the Health of LGBT Young Adults. Journal of Child & Adolescent Psychiatric Nursing, 23(4), 205-213. doi:10.1111/j.1744-6171.2010.00246.x

Shipherd, J. C. Green, K., & Abramovitz, S. (2010). Transgender clients: Identifying and minimizing barriers to mental health treatment. Journal of Gay and Lesbian Mental Health, 14(2), 94-108. doi: 10.1080/19359701003622875

Singh, A. A., & McKleroy, V. S. (2011). ‘Just getting out of bed is a revolutionary act’: The resilience of transgender people of color who have survived traumatic life events. Traumatology, 17(2), 34-44. doi:10.1177/1534765610369261

Testa, R. J., Sciacca, L. M., Wang, F., Hendricks, M. L., Goldblum, P., Bradford, J., & Bongar, B. (2012). Effects of violence on transgender people. Professional Psychology: Research & Practice, 43(5), 452–459. Retrieved from http://doi.org/10.1037/a0029604

 

Cristina Magalhaes, PhD is a licensed clinical psychologist in private practice.  She is also an associate professor in the Clinical Psy.D. Program and in the Rockway Certificate in LGBT Studies at the California School of Professional Psychology at Alliant International University, Los Angeles. She is a graduate of Nova Southeastern University (Fort Lauderdale, Florida) and Faculdade Maria Thereza (Rio de Janeiro, Brazil). Her clinical work, teaching, and research activities focus on LGBTQ and women psychology, cross-cultural psychology, and treatment of posttraumatic-stress and anxiety. She is an active member of APA Divisions 12, 35, 44, 52 and 56.

Madeline Brodt, MS, is a doctoral candidate in Counseling Psychology at the University of Massachusetts Boston. She conducts research on a variety of topics including sexuality, consent, conflicts of interest, suicidality, ​gender issues, ​and trauma. Her primary interests include sexual assault and social justice issues. She is currently conducting clinical work at the ​VA in ​Bedford, Massachusetts through a doctoral level practicum.​ Her primary clinical interests are traumatic experiences and marginalized identities.

Jessica Punzo, Psy.D, is a licensed clinical psychologist and Director of the Anti-Violence Project at the Center on Halsted, the Midwest’s most comprehensive community center dedicated to securing the well-being of LGBTQ people within Chicagoland, IL. The Anti-Violence Project provides support to LGBTQ survivors of violence through counseling and advocacy. Dr. Punzo is also an adjunct faculty member at The Chicago School of Professional Psychology. Her clinical and research interests include aspects of sexuality/sexual functioning that are affected by sexual trauma, the impact of trauma on spirituality, specific needs of bisexual individuals, and the efficacy of evidenced-based trauma therapies within the LGBTQ community.