Ask Matt: What Should Therapists Know About Trans Issues?

A reader writes: “I have two related questions about psychotherapists and trans clients when the trans client is not specifically seeking transition-related medical approval stamps, but simply seeking psychotherapy for any number of things that may include trans and transition-related stresses.

“For psychotherapists who are not very familiar with gender variation and trans issues, and who may have clients who are trans and who seek therapy: What would you put on your top three to five things such therapists should know or be aware of?

“For trans people: What would you put on your top three to five things a person should be aware of when pursuing therapy with a therapist who is not very familiar with trans issues?

“The other factor is that I’m sometimes pulled into playing the role of educator and I’m really torn about it because 1) I know nothing about therapeutic worlds and am not trained to be a trainer, 2) I am a client, not a teacher, and 3) I don’t know where else they should be looking. How do therapists train themselves or learn about these things?”

These are interesting questions, and very timely, because the Gender Identity Center of Colorado is having its annual Colorado Gold Rush Conference on March 22-25, and the conference has a two-day clinical track for therapists and other professionals who are working or want to work with trans people (this includes students in an MSW or other counseling program). This is one way that therapists can learn about trans issues.

Since I’m answering your last question first, I will say this – it’s unfortunate that most university MSW and doctorate programs don’t have specific training or classes on trans issues. This should actually be an entire semester-long class in and of itself. What most higher-education programs (and most therapists) don’t understand is that therapists will run into clients with gender issues regardless of what area of counseling they are entering – family counseling, marital counseling, drug and alcohol treatment, child therapy, and pretty much any other area.

Whether or not these therapists choose to treat clients with gender issues or refer them on to someone else, they will see them in their practice. And even if they do refer them to someone else for work with gender issues, they should at least know what to do and how to handle the initial contacts and referrals.

The positive thing is that an increasing number of instructors are taking matters into their own hands and bringing trans people into their classes to speak. Every year, I speak to several master- and doctorate-level social work and psychology classes in the Denver metro area alone. While I am only able to scratch the surface of what these future therapists need to know, they at least get some exposure to trans issues and are able to start thinking about what they might want to explore further.

Most therapists have to take on in-depth training themselves. The Gender Identity Center of Colorado has an internship program where future therapists can learn under the supervision of a doctorate-level therapist. Other gender centers might have similar programs.

But new and seasoned therapists are usually on their own, and they need to seek out conferences, read books, and find mentors within their community who can help them. They can also join the World Professional Association for Transgender Health (WPATH) and get information, contacts, and resources. Readers might also have other suggestions with regard to organizations, conferences, and other programs.

What I think any therapist should understand is that the client should not have to teach the therapist. I know many trans people who have trained their therapist, because the therapist had no prior knowledge of trans issues, and the client had nowhere else to go. Sometimes this works very well, and a strong therapeutic relationship is formed. Other times, it can be very problematic, because the client is already dealing with a lot of very stressful stuff, and having to train a therapist along with everything else can be overwhelming and exhausting.

If university boards, licensing boards, and professional organizations would listen to me, I would say that a Trans Issues or Transgender 101 class should be a required course for all therapeutic professionals. But I am rarely (actually, never) consulted when universities are setting up their curriculum and state licensing and oversight boards are setting up their requirements. So, given that, we have to make do with the enlightened professors across the country who are bringing in trans speakers and trainers for their own classes.

Now, to your other questions:

“What would you put on your top three to five things such therapists should know or be aware of?”

1. Have a working definition of the terms “transgender,” “transsexual,” and other associated terms, while realizing that these definitions vary from community to community, and from individual to individual within certain communities. When your client comes out to you as transgender, transsexual, genderqueer, or uses any other self-definition, say, “I know what that means to me. Tell me what that means to you.” If, as a therapist, you aren’t able to say this because you don’t know what those words mean to you, find out.

2. If you are working with, or want to work with, trans clients on trans issues specifically, be aware of WPATH, the Standards of Care (SOC), and the various opinions within the community regarding the SOC, the DSM-IV, and the upcoming DSM-V, along with other issues that are central to transitioning clients. Along these lines, do not use the DSM as your sole diagnostic tool. Use it, if you must, as one of many. With regard to the Standards of Care, remember that they are guidelines.

3. If you are working with transitioning or transitioned clients on other issues, remember that not all problems or difficulties in a trans person’s life are related to his or her transness. Like anyone else, trans people have relationship problems, work-related problems, life stressors, depression, and other mental-health and emotional struggles. Many of these have nothing to do with being trans. Transition doesn’t solve all of a person’s problems. It solves one problem. The rest remain. However …

4. Don’t dismiss gender issues as a possible factor in a problem situation, no matter how long ago someone might have transitioned. Transition can impact a person for a lifetime, so while you should not assume that all of a person’s problems are the result of being trans, you should also not assume that any particular problem is not trans related. Explore all possibilities.

“What would you put on your top three to five things a person should be aware of when pursuing therapy with a therapist who is not very familiar with trans issues?”

1. If you believe that your issue is not trans-related, then you don’t even have to come out to this person, which eliminates the issue of that therapist being unfamiliar with trans issues. However, because it is often difficult for us to see the scope and all the causes of certain problems that impact us personally, it’s possible that your transness could have something to do with your issue. By not coming out to your therapist, you are shutting down any possibility of exploring the impact that your transness might have on the presenting problem. If you decide to come out to your therapist, gauge his or her response and make your decision about whether or not to stay.

2. As a client, your comfort level takes precedence over your therapist’s comfort level. In addition, it is not your job to make your therapist comfortable. If your therapist is uncomfortable working with you, find someone else.

3. As a client, it is not your job to teach your therapist about trans issues. However, many clients are put into this role because of the lack of knowledge and training that most therapists have on trans stuff. If you want to do it, that’s fine, and there are times when you might feel as if you have no other choice, because your available options are limited, and that’s understandable. But if your therapist is not even willing to pick up a couple of books, go to a conference, or visit a few websites, I would be wary. If this is the case, he or she does not seem to be invested in your care or your best interests.

4. There are very good therapists who do not know anything about trans issues and very bad therapists who know a lot about trans issues. The relationship between the client and the therapist is the most important thing. If you feel really good about a particular therapist, see if you can work it out. If you feel uncomfortable with a particular therapist, no matter how experienced that person is with trans issues, find someone else.

That’s the tip of the iceberg, but those are some things that I consider important, and I hope that we will hear from readers with many more thoughts. With that, I’ll turn it over and find out what other people have to say.