The first step toward clinical work with any client involves understanding the individual, their reasons for seeking treatment, and the goals they hope to accomplish through therapy. It is important to remember that every client is unique regardless of the aspects that may be used to describe them, including physical appearance, ethnic background, and system of beliefs. Generalizations and assumptions can cause chaos in clinical work. An awareness of the concerns or issues related to how individuals describe themselves is always helpful.
To work with a transgender client, it is imperative to possess a basic understanding of what the term means. Someone identifies as transgender when their assigned or biological gender does not describe their gender identity. Gender identity is the subjective internal sense or experience of one’s own gender. Terms such as “Trans man” and “Trans woman” are terms that may be used by individuals who identify and live as an affirmed gender that is different from their birth assigned sex. Gender Queer, Agender, Bi-gender or Non-binary are terms that may be used by those whose gender identify is more fluid and/or who blur the binary assignment as male or female. It is always best to ask which term an individual prefers to use.
Our understanding of clinical work with transgender individuals has been recently redefined. One major change included in the Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition (DSM-5) published in 2013, was the revision of the diagnosis Gender Identity Disorder to Gender Dysphoria. This revision has important implications. The dropping of the word ‘Disorder’ highlights that the clinician is treating the client’s issues with experiences associated with identifying as transgender, not labeling the identification as a disorder or condition that should be treated or changed.
For a person to be diagnosed with Gender Dysphoria, there must be a marked difference between the individual’s expressed or experienced gender and the gender others would assign to him or her, and it must continue for at least six months. The DSM-5 diagnosis adds a post-transition specifier for people living full-time as the desired gender, with or without legal sanction of the gender change. This was done to ensure treatment access for individuals who continue to undergo hormone therapy, related surgery, or psychotherapy to support their gender transition. (American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition, 2013). It is important to highlight however, that we should avoid assumptions when working with any client. A transgender individual may come to treatment with a concern unrelated to gender identity. Overemphasis on gender identity could then be detrimental to treatment.
The acceptance and validation that a clinician offers to a client in treatment can be invaluable. This is especially true for transgender clients, many of whom come to treatment because they lack self-acceptance and/or support from family, friends and their surrounding communities. One way to encourage validation is to respectfully address certain preliminary concerns. Clients should be called by the name they have assigned to themselves, not their legal name if a name change has not yet occurred. It is important to be mindful of the pronouns used when referring to a transgender client. If you don’t know what pronouns to use, ask politely and follow the client’s preference. Never use “he/she” or “it.” You may want to consider incorporating a brief question about gender and language preferences into the intake process for all clients, not just those who you may think or look transgender.
When working with children and adolescents we are faced with discerning whether such identification should be considered temporary, part of the developmental journey to determine an identity, or a stable facet of an individual’s identity. The APA reasons that these considerations can be clarified by focusing on whether the child or adolescent presents with a “pervasive, consistent, persistent, and consistent sense of being the other gender.” (C. Meier, and MA. J. Harris, American Psychological Association Fact Sheet: Gender Diversity and Transgender Identity in Children, undated). Although research in this area is limited, the few studies available report that a vast majority of pre-pubescent children who experience gender dysphoria (between about 78-96%) no longer report gender dysphoria in adulthood. This is especially true for boys. A majority of gender dysphoric pre-pubescent boys however, identify as gay in adulthood. More recent studies have indicated that 73-88% of girls no longer report gender dysphoria in adulthood. These statistics are in great contrast with research regarding gender dysphoric adolescents. Adolescents identifying as gender dysphoric are more likely to persistently report dysphoria into adulthood. This suggests that in contrast to pre-puberty gender dysphoria, post-puberty adolescents are more likely to identify as transgender.
An aspect of treatment unique to work with children and adolescents is to clarify that at this stage in life gender identity is not necessarily permanent. Parents should be encouraged to validate their children by supporting their gender identifications. At the same time it is important to ensure children and teens who may be confused or questioning their identity know that exploration is acceptable and supported For older adolescents and for children and adolescents who have a firm and pervasive identification as transgender, clinicians will need to coordinate with healthcare providers involved in repressing puberty, and/or other medical treatments related to reassignment. In some cases, clinicians may need to provide families with appropriate referrals.
Clinicians working with gender dysphoric children and teens should be aware that it is quite common for such young people to present with comorbid anxiety, depression, and/or oppositional defiant disorder. A disproportionate number of teens reporting gender dysphoria also meet the criteria for autism spectrum disorder. Transgender youth may experience gender based verbal and physical harassment and abuse and bullying. Adolescents identifying as transgender are at higher risk than their peers for attempting suicide. Some studies have found that risk to be at least two times greater. When surveyed, up to 25% of transgender teens have reported making at least one suicide attempt. For youth who are highly rejected by their family, peers and community, the risk is eight times greater. Such highly rejected youth are three times more likely than other adolescents to use illegal drugs, three times more likely to at high risk for HIV and sexually transmitted disease, and nearly six times as likely to report high levels of depression.
Thus, engendering family support is a pivotal part of treatment for adolescents. By offering education and understanding to clients and their families, clinicians can encourage empowerment and dispel common concerns and myths. A major part of treatment often entails helping transgender teens to develop skills to manage their family, school, and of course social environments. It is imperative to connect the client with resources that provide safe forums for self-expression. Clinicians offer transgender (and all) clients the most efficacious and supportive treatment when they become informed and educated regarding their clients’ related concerns and challenges.
Four Winds Hospital has transgender affirming policies to ensure respectful and knowledgeable mental health treatment for transgender patients. William Riccadelli, MD, staff psychiatrist and member of the World Professional Association of Transgender Healthcare Providers (WPATH) is available to consult with hospital treatment teams, patients, parents and families about transgender health. WPATH, www.wpath.org, publishes Standards of Care and Ethical Guidelines, which articulate a professional consensus about the psychiatric, psychological, medical, and surgical management of gender identity disorders, and help professionals understand the parameters within which they may offer assistance to those with these conditions. Other resources for families and youth include: Trans Youth Family Allies, www.imatyfa.org; Advocates for Youth, www.advocatesforyouth.org; Parents and Friends of LGBT People, www.pflag.org (Westchester County phone numbers: 914-245-8236, Phone 2: 914-948-8435),Westchester Spanish-speaking 914-967-9429, and Rockland County: 845-268-2373); WJCS Center Lane LGBTQ youth program, www.centerlange.ny.org.
Dr. Jennifer Powell-Lunder is a Senior Clinical Program Liaison at Four Winds Hospital. Her past roles at Four Winds have included Director of an inpatient adolescent unit and Director of the Adolescent and Child Partial Programs. She is an adjunct professor of psychology at Pace University.