Working with trans clients (Reading)

The reasons for transgender clients to visit a psychologist can be because:

• they need a diagnosis for starting a desired treatment,
• need support in exploring their trans identity,
• need support with the process of transition,
• they come with clinical issues,
• they are in need for consultation or support regarding regular life issues that have nothing to do with their transgender status.

Trans client are the most vulnerable in the LGBTQI+ population (more info in Module 2), and they can have more comorbidities (depression, anxiety, suicide ideation and BPD).

According to trans persons’ experience, psychologists either lack knowledge and thus can’t understand some aspects of the client’s identity or they use the client as a source of information and tend to ignore the original goal the client came to therapy for.

With the high rate of individual uniqueness within the trans community, it is important for the therapist not to stick to labels, but rather let the client explain and use their own definitions. Sexual orientation and gender identity are two different issues, and need to be adressed separately. Sexual orientation may not be a concern for the trans client, but there are cases when it can be in focus, for example if sexual orientation is affected by the fact of transition, so the client has to work with a “new” heterosexual or LGB identity. While sexual orientation might not be a concern of the trans client, sexuality itself is often an inherent topic to one’s gender identity. The feelings of attractiveness and sexual desires can – amongst many other factors – inform the gender identity of the client, and also a client can be on the search for sexual experiences that might affirm their sense of self.

For example, there can be a self-identified trans woman who feels that they can only experience their gender to the fullest with a person who is relatively high in masculine presentation. Thus while sexual orientation is a separate issue from gender identity, sexuality should be adressed by the psychologist in the therapeutic process, and the therapist should demonstrate their openness to and comfort with the topic.

For trans clients, their body is a means of self expression and self representation.  Gender expression and gender characteristics are twofold concepts: they are both the expression of someone’s inner world, and also an interaction point between others and the self, or a “surface” based on which others form their impressions about the person. Being able to express oneself and being perceived in line with one’s identity are both important. Thus there can be elements of the client’s gender expression that are mainly for ensuring that others perceive them correctly, and there can be elements that are more about their inner desires. It is difficult to find the right balance between the emphasis on others’ perceptions and one’s own bodily experiences, and there can be cases when perfectionism or the compulsion to conform can become a topic of discussion with the trans client.

Trans persons can experience a “pressure” that if they undergo more severe treatments to transition, the result has to be worth it, it has to conform to society’s gender norms. The preponderance of these feelings can make the process heavier on the individual.

In every possible situation that a trans client might come into therapy with, it is essential that the psychologist validates and accepts the experiences of the individual, and affirms them in their ways of self expression and identity.

Important note: regarding treatment and diagnosis every country has different legal and healthcare protocols, so provide valid information for the participants. For example in Hungary neither clinical psychologists nor psychotherapists can give official diagnoses, only psychiatrists, even though evaluation is done by the psychologist.

Gender dysphoria

Being transgender is not an illness; however, it is important to recognise that experiencing gender-identity confusion often causes psychological distress. In most countries, gender dysphoria is the official DSM-V diagnosis that is needed for the individual to seek medical support for their transition. However, clinicians should be aware that in some cases, such severe distress can be experienced that it should be considered as a disorder and would need further help.