Research with the trans and non-binary (TNB) community across fields and disciplines has increased substantially over the last few decades (Moradi et al., 2016; Valentine & Shipherd, 2018). However, the extant body of work with this community remains in its infancy, with many gaps in empirical knowledge that includes best practices for clinicians working with the unique trauma experienced by TNB individuals and their communities (Burnes et al., 2016; Richmond et al., 2012; Shipherd et al., 2011). Only a decade ago, a special issue of Traumatology illuminated the ways trauma scholarship and LGBTQ+ scholarship have been created in silos, thus hindering the development of trauma-focused interventions for a unique population that experiences disparate rates of trauma, violence, and abuse (Brown & Pantalone, 2011). Even less research exists focusing on the T in LGBTQ+ communities and their experiences of trauma (Brown & Pantalone, 2011). This is alarming, as TNB individuals are more likely to experience potentially traumatic events (PTEs) such as physical assault (Shipherd et al., 2011) and victimization by overt and covert acts of prejudice and transphobia, such as misgendering and employment discrimination (Kattari et al., 2016; McLemore, 2018; Mizock & Lewis, 2008; Richmond et al., 2012). These experiences each have negative mental health impacts, contributing to heightened rates of mental health disorders when comparing TNB and cisgender individuals (Lefevor et al., 2019). Therefore, it is imperative that psychologists examine the unique experiences and consequences of trauma in TNB communities in order to employ culturally responsive, trauma-informed approaches in clinical practice.
Brief Overview of Trauma in TNB Communities
The experience of trauma in TNB communities is unique due to several factors. The “onset” or “trigger” of post-traumatic events’ impacts on mental and physical health is located within social structures embedded in the cisnormative culture. Identity-based trauma is often chronic and insidious, experienced within micro, mezzo, and macro-level contexts ranging from transnegative policies to internalized self-hatred and rejection (Matsuno, 2019; Richmond et al., 2012). The Minority Stress Model, theorized first to understand health disparities in LGB communities (Meyer, 2003) and then extended to specify unique stressors of the TNB community (Hendricks & Testa, 2012; Meyer, 2015; Testa et al., 2015) is a helpful tool for clinicians to conceptualize the potential impact of various types of TNB-specific stressors on health and wellbeing. For instance, TNB-specific distal, or external, stressors include workplace discrimination, bodily violence, and non-affirmation of identity (Testa et al., 2015). TNB-specific proximal, or internal, stressors include internalized negative beliefs, fear of future experiences of rejection, and feeling stigmatized due to being misgendered (McLemore, 2018; Meyer, 2015).
Additionally, scholars have elucidated that these distal and proximal stressors exist in various domains, including at the collective or community (e.g., barriers to affirming healthcare), interpersonal (e.g., rejection by family members), and intrapersonal (e.g. pervasive guilt and shame; Burnes et al., 2016; Richmond et al., 2012) levels. Even in the absence of in-the-moment threats to internal and external safety, the cumulative impact of experiencing distal and proximal stressors decreases TNB individuals’ accessibility to resilience and coping factors such as accessing social capital, health and socioeconomic resources, social support, and a positive sense of self and safety in the world (Richmond et al., 2012; Shipherd et al., 2019; Shipherd et al., 2011). As Reisner and colleagues contend, “chronic and persistent threats to one’s identity…threaten[s] a person’s core human needs for trust, understanding, control, and belonging…” (Reisner et al., 2016, p. 2).
It is important to note that the TNB community is heterogeneous in nature, comprised of individuals who identify within the gender binary (i.e., man, woman), outside of the binary (i.e., non-binary, genderqueer), or experience no gender identity at all (e.g. agender; Matsuno, 2019). While research specifying the unique experiences and needs of non-binary individuals is still emerging, extant literature supports that non-binary persons experience unique forms of minority stress. These include misunderstanding and rejection by binary-identified trans communities, skepticism and dismissive attitudes by providers regarding their identity as non-binary, near-constant misgendering through the use of incorrect pronouns, and heightened levels of discrimination due to nonconforming expressions of gender when compared to binary-identified trans persons (Johnson et al., 2020; Lefevor et al., 2019; Matsuno, 2019). Additionally, Intersectionality Theory, created by Black feminist scholars to elucidate the impact of intersecting systems of oppression, such as racism and sexism, on minoritized individuals (Crenshaw, 1990) is vital in order to fully understand the range of TNB experiences (Reisner et al., 2016; Wesp et al., 2019). Utilizing an intersectional framework, paired with the minority stress model helps make sense of the heightened levels of discrimination, violence prejudice, and subsequent heightened levels of mental health disparities experienced by TNB people of color (TNBPOC; Brown & Jones, 2014; James et al., 2016; Seelman et al., 2017; Singh & McKleroy, 2011).
Working with identity-based traumatic exposure has been likened to working with complex post-traumatic stress due to the increased likelihood of exposure to chronic, multi-faceted stressors as described above (Richmond et al., 2012). Emerging findings have reported symptom profiles similar to PTSD and complex PTSD (Courtois, 2004) in TNB identified clients presenting for treatment. These include hypervigilance, difficulty with emotion regulation manifesting as mood disorders, learned helplessness, negative core beliefs about the self, internalization of the “abuser’s” (in this case, cisnormative society) belief system manifesting as internalized transprejudice, intrusive thoughts, and difficulty navigating interpersonal relationships manifesting through high rates of interpersonal violence (Richmond et al., 2012; Shipherd et al., 2019). Additional impacts of TNB identity-based trauma include substance use, risky sexual behaviors, non-suicidal self-injury (NSSI), social isolation, suicidal ideation, high levels of guilt, shame, and other negative emotions, sleep disturbances, and disordered eating patterns (Brown & Pantalone, 2011; Burnes et al., 2016; Mizock & Lewis, 2008; Richmond et al., 2012; Shipherd et al., 2019). It is important to note that TNB identified clients might come to therapy presenting with post-traumatic symptom profiles due to experiencing TNB-specific minority stressor(s) from their intersecting identities, and/or due to experiencing traumatic events unrelated to their minoritized identities (Shipherd et al., 2019). Relevant guidelines in the helping professions warn against practitioners assuming that TNB-identified clients’ presenting concerns are related to their TNB identity (e.g. Burnes et al., 2010). Thus, it is imperative that clinicians obtain a holistic clinical assessment instead of narrowly focusing solely on the client’s gender identity.
While the minority stress model and intersectional framework illuminates various pathways for post-traumatic symptomology, it also shines a light on potential avenues for coping, resilience, and healing trauma in TNB individuals (Meyer, 2015; Singh & McKleroy, 2011). For instance, observed resilience processes essential to healing trauma include connecting with TNB community and TNBPOC communities, garnering familial support, being and having positive role models, creating a self-defined identity inclusive of gender and racial identities, gaining access to affirming medical care, developing a strong sense of self-worth, and engaging in advocacy for self and others (Matsuno & Israel, 2018; Puckett et al., 2019; Singh et al., 2011; Singh & McKleroy, 2011; Stone et al., 2020). As Matsuno and colleagues (2018) reported, these resilience processes operate at the group, community, and individual level, thus helping TNB individuals respond to assaults on their personhood from the micro, mezzo, and macro levels (Matsuno & Israel, 2018). Thus, interventions employed by trauma therapists working with traumatized TNB individuals should be employed across levels and contextual domains as well. Basic tenets of treating complex trauma reactions should be applied, following the phase-based approach described by leading traumatologists (e.g. Courtois & Ford, 2012; Herman, 2015)
Examples of micro-level interventions include helping the client stabilize through establishing safety and trust within the therapeutic alliance, teaching emotion regulation skills from Dialectical Behavior Therapy and Cognitive Behavioral Therapy, and decreasing maladaptive coping mechanisms such as substance abuse (Burnes et al., 2016; Richmond et al., 2012; Shipherd et al., 2019). Trauma-informed, strength-based perspectives contextualize the symptomology of complex post-traumatic disorders as being the mind’s and body’s way of self-protection and can be conceptualized with the client as being forms of survival instead of something “wrong” with the client, and can be employed with TNB clients experiencing post-traumatic symptoms (Schwartz, 2020). One way in which clinicians can establish rapport, safety, and trust from the outset of therapy is through microskills such as asking the client for their identified pronouns, modeling use of pronouns, and ensuring all aspects of the therapy environment (e.g., paperwork, pictures and posters) are trans-affirming (Chang & Singh, 2018; Matsuno, 2019; Singh, 2017). Additional micro-level interventions include helping the client identify and challenge internalized negative beliefs regarding their identity, assertiveness training, build positive self-talk, and help the client develop a positive body image and navigate body dysphoria (Singh, 2018). Finally, somatic experiencing modalities can be used to help gender minority-based trauma experienced within the body to help with nervous system responses (Briggs et al., 2018)
Examples of mezzo or group level interventions include connecting clients to peer support groups or group therapy, intervening with family systems to reduce rejection and stigmatization within the unit, ensuring that policies and procedures at the therapist’s clinical site are TNB-affirming, and connecting the client with community level resources such as TNB-affirming medical care, housing, and/or legal services (Chang & Singh, 2018; Matsuno & Israel, 2018; Shipherd et al., 2019; Singh, 2018). Intervening at the family-level may be especially important, as recent research has shown the impact of familial support supersedes the impact of other forms of social support and belonging (Puckett et al., 2019). Additionally, the clinician can and should step into roles such as consultant and educator within training programs, hospital settings, schools, and businesses. This should only occur in tandem with ongoing personal reflection and growth on the part of the clinician. Finally, fully incorporating TNB-identified individuals within organizations and ensuring leadership positions are held by TNB-identified persons is essential towards ensuring environments are TNB-affirming (Shipherd et al., 2019).
Perhaps most importantly for the healing and liberation of TNB communities are interventions at the macro or community level. Community and Liberation psychologists have criticized individual, internal-level foci of coping with identity-based trauma and have called for radical models of healing and transformation located within communities and social structures (French et al., 2020; Prilleltensky, 2013; Singh, 2016). Racial trauma, while different from trauma due to gender minority stress, operates in similar ways regarding the locus of traumatizing experiences being embedded in culture and systems (Richmond et al., 2012). Therefore, utilizing French and colleagues (2020) definition of radical healing for POCI could be helpful in working with TNB-identified clients, especially TNBPOC clients. Aspects of radical healing in this framework at the macro-level includes practitioners and clients working together to actively advocate for change and disrupt oppressive policies, systems, and structures (French et al., 2020). Additionally, connecting with one’s community and embracing collectivism norms and values can help TNB clients normalize their experiences, increase social capital, and feel supported in their advocacy efforts (French et al., 2020; Prilleltensky, 2012). Without changing the source of traumatizing events and experiences within society, clients and therapists will be locked in a battle focused on increasing quality of life inside a maladaptive, toxic environment, which will prevent achieving holistic and lasting healing.
Conclusion and Future Directions
While more research is needed to fill the gaps in knowledge regarding best practices for treating trauma in TNB communities, especially TNB communities of color, there is a baseline literature foundation with which clinicians should be familiar. One of the most important contributors to being a culturally responsive, TNB-affirming clinician is ongoing self-reflection into the ways that cisnormativity exists within the personhood, actions, and beliefs of the clinician. Utilizing the gold standard of cultural-competence (awareness, knowledge, and skills; Sue et al., 2019) as a guiding framework for clinician self-work is vital towards being a TNB-affirming, culturally-responsive practitioner. Students and practitioners should also advocate for the inclusion of specific training regarding TNB-affirming practices in training programs. The healing professions have a history of pathologizing and harming TNB communities, and clinicians should be aware that TNB identified clients might enter the therapeutic alliance wary of potentially experiencing harm (Mizock & Lewis, 2008). Finally, in addition to increasing the body of knowledge regarding trauma-informed treatment of TNB individuals, practitioners should step into roles of advocate, disrupter, and accomplice in order to change social and cultural systems of oppression negatively impacting TNB identified individuals while maintaining cultural humility and awareness of the impact of their identities and privileges within TNB spaces.
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Bekah (she/her) is a current PhD candidate in Counseling Psychology at the University of Georgia. She previously completed her master’s in counseling also at the University of Georgia. Her research interests include resilience, the impact of intersectional oppression on mental health, best counseling practices for working with the LGBT community, and examining the lived experience of partners to trans persons of color. Bekah is the co-founder of the University of Georgia’s College of Education Trans-Affirming Practices Taskgroup, she provides individual counseling services for a wide range of presenting concerns as a psychologist in training and is involved in advocacy for the LGBT community as a Student Representative for APA’s Division 44. Bekah is Project Coordinator for Project AFFIRM, an NIH-sponsored study examining the identity development and resilience of the trans and non-binary community.