Out On The Couch
COVID-19 & (Re)claiming Gender
As a non-binary, genderqueer, and trans femme therapist myself, I have encountered my own fair share of microaggressions related to gender identity. During the pandemic, I have witnessed many people for the first time in their lives take a break from performing gender in a way society deems acceptable. As a result, many folx are exploring their gender identity and expression more than ever before. Many clients have questions and self-doubt about who they are with respect to their gender identity and/or gender expression. However, this is an aspect of mental health that is under-researched and is often overlooked in the graduate training of therapists, both masters and doctoral.
Because many clinicians lack in-depth training with regards to working with gender expansive people, many clients encounter harm in session. For example, being misgendered is just one of many microaggressions that occur in therapy sessions with gender expansive clients. For the purposes of this article, I will be focusing primarily on nine common microaggressions experienced by non-binary people in the therapy setting.
Before we delve into this important topic, let’s take a moment to define some key terms. Cisgender is in reference to a person who’s sex assigned at birth matches their gender. Endosex refers to people whose sex characteristics meet medical and social norms for typically ‘male’ or ‘female’ bodies, which is the antonym to intersex. Heterosexuality refers to sexual and/or romantic attraction to or between people of the opposite sexes assigned at birth.
Transgender is an an umbrella term covering a range of identities that transgress socially defined gender norms. Additionally, transgender can refer to a person who lives as a member of a gender other than the one expected based on their biological sex assigned at birth. Non-binary is also an umbrella term covering any and all gender identities that do not fall exclusively in man/male or woman/female categories. And, non-binary refers to a person whose gender identity and or expression exists between or outside the rigid gender binary system.
But first… Microaggressions – What’s that?
The term microaggression was originally coined by Dr. Chester Middlebrook Pierce, who was an African American psychiatrist and Harvard University professor who died in September of 2016 (Sue & Spanierman, 2020). Early research focused on racial microaggressions, but has since been expanded to create a series of classification for most existing systems of oppression. Microaggressions are brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative slights and insults toward people with marginalized identities (Sue & Spanierman, 2020; Sue et al., 2007).
Nadal (2013) wrote the book That’s So Gay! Microaggressions and the Lesbian, Gay, Bisexual, and Transgender Community. This book is one of the first of its kind to make academic literature both accessible to a wide audience. Also, Nadal (2013) offered strategies to make the world a better place for queer and gender expansive people. Furthermore, Nadal (2013) provided distinctions between microaggressions based on sexual orientation as compared to gender identity.
Of the microaggressions highlighted for transgender and gender non-conforming (TGNC) people, the book identified ten distinct classifications (Nadal, 2013).
Why should I care about this topic?
Non-binary folx continue to encounter harm and rejection both for cisgender and transgender communities. TGNC folx experience higher rates of gender-based victimization than cis- individuals, and the highest rates of suicidality of any group (Testa et al., 2015). Additionally, TGNC folx report significantly more negative clinical encounters in therapy (Levitt & Ippolitto, 2014). Lastly, gender identity microaggressions have been associated with therapeutic dissatisfaction, reduced ability to establish a therapeutic alliance, and early dropout from therapy (Spatrisano, 2019).
So what gender based microaggressions are happening to non-binary folx in therapy?
I came to learn through my own consultations with prospective therapy clients that I wasn’t alone in my experiences of encountering gender based microaggressions. Although I don’t believe that all of the following microaggressions were intentionally meant to harm non-binary clients, it’s important to center the impact of our questions and statements as clinicians. The following common microaggressions occur to non-binary folx in therapeutic encounters:
In the following sections I will briefly explain why each of these examples is microaggressive. Alternative tips will also be provide for how to ask more affirming questions to non-binary folx.
This is the most common form of microaggression that happens both within and outside therapeutic spaces. Misgendering is when language is used that does not correctly reflect the gender with which the person identifies. This can include using a person’s “dead name” or name given at birth when the client has specifically requested that the clinician not do so. Additionally, misgendering emerges with the misuse of pronouns, whether the client is present or not. Non-binary folx experience misgendering countless times throughout the day. This can occur on the phone, in an email, while “politely” holding the door for someone, and so many other interactions. McLemore’s (2014) study indicated that non-binary folx, and people who had taken fewer steps in the transition process, were most likely to be misgendered.
What can a therapist do when misgendering happens? Firstly, I encourage folx to not make any assumptions about honorifics (Mr., Mrs., Mx.) and routinely check in with clients about pronouns. Secondly, it’s helpful to practice not using gender language and this may require an accountability buddy, which is something I continue to engage in myself. Thirdly, avoid using passive language such as: “X identifies as” and “X prefers” as this robs the person autonomy over their own identity. Lastly, make a brief apology, correct yourself, and set an intention to gender a person correctly two or three times in a follow-up sentence.
2. If you’re not a man, woman, or trans, then what are you?
This microaggression both invalidates and insults a non-binary persons lived experience. Gender is a construct, made up to control and classify people. Many non-binary folx reject the construct of the gender binary entirely. Asking a person, “what are you,” is cruel considering the fact that we are all simply humans. A more affirming question here could be, “how would you classify your gender identity and/or gender expression?” and “who are you, in terms of your gender?” Additionally, you may ask the client, “Would you be willing to share with me your experience exploring your gender and where you find yourself today?” With each of these suggestions, you allow the client the opportunity to self-identify and open up a dialogue about the client’s lived experience. As clinicians, it’s important that we do not restrict our client’s ability to explore. Above all, I encourage all therapists and wellness providers to center curiosity.
3. That (insert gender identity or neo-pronouns) sounds made up.
Woah! This one hurts to type. I like to remind folx that gender inherently is a fabricated classification system. Though for many non-binary, transgender, and gender expansive people, out lives are only just beginning to feel like our own. New terms for gender identity continue to emerge daily. A client once said in a group session, “I bet there are as many gender identities as people in the world, because we all experience life differently.” I couldn’t agree more with this comment. It would be more helpful to say something like, “I have never heard of the gender identity or pronouns you just mentioned, would you be willing to talk to me about how you define this gender identity or pronouns?” Or you may elect to offer to do research on your own time outside of session to spare your client from having to educate you, the clinician.
Though new terms like gendervague and genderfuck continue to emerge, the definitions of each of these terms will vary depending on who you ask. Neo-pronoun, or new pronouns, also continue to emerge as an outlet for non-binary folx to replace their name with a non-gendered word. Some common examples of neo-pronouns include:
If you’re anything like me, you’re probably going to need some practice using these in a sentence. Find a friend to practice with or try out this helpful website.
4. Did you have the surgery?
Eek! It’s important to note that there are numerous gender affirming medical procedures that gender expansive people can pursue. There is no ONE surgery that all non-binary folx undergo. For many non-binary folx, there is no interest in pursuing gender affirming medical procedures. While others may elect to engage in one or many gender affirming medical procedures.
As a clinician, I urge you to first ask yourself whether you ask your endosex, cisgender and heterosexual clients about their medical history. If you do not, then ask yourself why you feel entitled to ask your non-binary client this question? Two affirming questions could include: (1) what forms of transition are part of your path; and (2) have you considered gender affirming medical procedures to affirm your gender identity and/or gender expression?
Types of Transitions
With respect to transitions, they are not necessary to be a non-binary person. They are also not necessary for binary transgender people either! However, there are three distinct types of transition that could be a part of a client’s gender journey: (1) social transition, (2) legal transition, and (3) medical transition.
Firstly, social transition is in reference to the ways in which a person identifies and presents their gender in public. Some aspects of social transition include, choice of clothing and/or makeup, changing one’s name, selecting pronouns, tucking, packing, binding, and coming out.
Secondly, legal transition is in reference to the ways in which a person actualized their gender through updating legal documents. These documents can include a person’s name, social security number, birth certificate, passport and driver’s license.
Lastly, medical transition is in reference to the various procedures available to folx to actualize their gender. Some common procedures may include surgery, hormone replacement therapy (HRT), vocal training, laser hair procedures, and fertility preservation.
Please respect your client’s right to privacy as non-binary folx are often encountering invasive questions related to their body from all directions. Historically and through stereotypical media portrayals of gender expansive people, transgender and non-binary bodies have been labeled perverse, odd, and unusual for far too long. If you don’t ask your endosex, cisgender and heterosexual clients about their body parts, then why do you feel entitled to do so with non-binary clients?
Furthermore, I urge you to validate and normalize the response of “I don’t know” from a client in your care. I have found that this can be challenging for client’s to say as there are so many societal pressures to have answers. As a result, modeling and normalizing that not having an answer is acceptable can be incredibly validating to non-binary clients.
Also, it is important to mirror the language of your client when discussing aspects of the client’s physical body. I suggest asking, “how will we refer to the insert body part?”
5. How are you non-binary if you aren’t androgynous?
Just like there is no one way to look like a cisgender woman or man, there is no right way to look non-binary. This question is incredibly harmful as many non-binary folx experience imposter syndrome. Additionally, most non-binary folx experience discomfort or dysphoria due to being perceived as a cisgender person. Being androgynous is only one way in which the vastness of non-binary gender expression is embodied. Many non-binary folx experience and express their gender more fluidly.
Instead of reinforcing a false narrative of how to be a non-binary person, consider empowering your client. You may ask, “how do you embody and affirm your gender?” Or you may ask, “what makes you feel most like your fully embodied self?” Sometimes these questions will open a door of exploration and other times clients will find themselves unable to answer. If your client has no answer, I would invite you to ask them if they’d be willing to explore this with you. Furthermore, I will sometimes offer to lead a client through a creative arts or visualization exercise. This offers the opportunity for the client to move away from traditional language and engage their playful imagination.
6. It sounds like your (insert gender identity) is a product of your past trauma.
Ouch! Whether or not there could be truth to this statement, no one can go back and rewrite their history. Instead of focusing on how the past may or may not have caused a person to become gender expansive, why not focus on the now? So many non-binary folx feel disempowered and therapy is an intentional space to reclaim that power. Getting caught up in the what ifs of the past prevents clients from becoming more assured of themself in the present.
It can be powerful to validate a client’s past lived traumatic experience. I also encourage you as a clinician to assist your non-binary client with cultivating self-esteem. You might say something like, “Your past experiences have shaped the person you are today, and I am so grateful for the opportunity to know the person you’re becoming (or you have become).” Embolden your client to lead the conversation and connect to their past, if and only if that’s their own desire. Otherwise, continue to center the here-and-now of their gender journey.
7. Are you sure? I know being non-binary is trendy now.
This comment is loaded for a variety of reasons. Firstly, many folx are currently exploring their gender and identifying as non-binary for many may be the first step on that journey. Secondly, some experience gender as an aspect of self in constant movement and evolution. Thirdly, whether or not being non-binary is trendy or not, we need to reclaim our gender expansive history.
Gender diverse people have existed throughout history such as the First Nations, two spirit and Hijras, who are officially recognized as a third gender in India. Additionally, you may want to learn more about the transgender history in the U.S. and globally as well as the history of trans health care in the United States. And if you haven’t already started, it’s never too late to explore your own gender identity and gender expression in greater depth.
8. Making the assumption that all non-binary people want to talk about in therapy is gender.
There are certainly a vast number of people seeking therapy at this time to explore their gender. Then there is a large number of non-binary folx who are more confident in who they are and are seeking therapy for alternative reasons. Many non-binary folx express in consultations that their previous therapist would only ask questions about the client’s gender identity. This stifles our clients ability to be fully human and process the vastness that is the human experience.
Instead of assuming that non-binary and gender expansive clients want to discuss gender, perhaps you will ask what they would like to focus one. I, like many therapists, offer an intake questionnaire, which serves to allow the client to self-determine goals for therapy. Some clients are seeking an affirming provider with or without lived experience, but with the purpose of processing depression, anxiety, trauma, substance use, life transitions, and so much more. I can’t stress enough how important it is to allow your client to have control over their therapy goals. It also helps to add to your intake forms a place to add pronouns, salient identities, and chosen names.
9. Using words such as normal and regular as synonyms for cisgender, endosex and heterosexuality.
This is a prime example of systemic microaggressions. We have all been socialized in a world that assumes heterosexuality and cisgenderism as the baseline. There is nothing odd, unusual, or irregular about being gender expansive. For most, actualizing their non-binary gender identity and/or expression is a liberating experience. In short, this example upholds systems of oppression that harm everyone.
I recommend that all therapists engage in implicit bias exercises to identify the ways we internalize gender, gender roles, and gender expectations. The following three books are incredible resources:
- A Clinician’s Guide to Gender-Affirming Care: Working with Transgender and Gender Nonconforming Clients
- The Queer and Transgender Resilience Workbook: Skills for Navigating Sexual Orientation and Gender Expression
- You and Your Gender Identity: A Guide to Discovery.
As clinicians, we can only go with clients where we have dared to venture ourselves.
I microaggressed my client – What do I do?
As humans, we all have the ability to harm. Apologies are opportunities to take accountability; however, refrain from lengthy apologies. When apologizing, center the harm and avoid providing an excuse for your intentions. I have and continue to make mistakes as a therapist. I welcome these experiences as opportunities to deepen the therapeutic relationship. Therefore, these instances are opportunities to collaborate and empower our clients to identify their needs.
I am also a fierce advocate for therapists engaging in their own therapy and supervision. These can certainly be expensive endeavors, but so important for our own growth both personally and professionally. For example, seek out or create peer supervision groups. Obtain adequate training from folx of lived experience with regards to providing affirming care to TGNC clients. Lastly, please Please PLEASE avoid advertising yourself as a gender affirming provider until you’ve gained specialized training.
Bergner, D. (2021, July 23). The Struggles of Rejecting the Gender Binary. The New York Times. https://www.nytimes.com/2019/06/04/magazine/gender-nonbinary.html?auth=login-google
Chang, S. C., Singh, A. A., & dickey, l. m. (2018). A Clinician’s Guide to Gender-Affirming Care: Working with Transgender and Gender Nonconforming Clients (1st ed.). Context Press.
Hoffman-Fox, D. (2017). You and your gender identity: A guide to discovery. Skyhorse Publishing.
Indug. (2018, October 29). India’s Relationship with the Third Gender. UAB Institute for Human Rights Blog. https://sites.uab.edu/humanrights/2018/10/29/indias-relationship-with-the-third-gender/
Levitt, H. M., & Ippolito, M. R. (2014). Being transgender: The experience of transgender identity development. Journal of Homosexuality, 61(12), 1727–1758. https://doi.org/10.1080/00918369.2014.951262
McLemore, K. A. (2014). Experiences with Misgendering: Identity Misclassification of Transgender Spectrum Individuals. Self and Identity, 14(1), 51–74. https://doi.org/10.1080/15298868.2014.950691
Nadal, K. (2013). That’s So Gay!: Microaggressions and the Lesbian, Gay, Bisexual, and Transgender Community (Perspectives on Sexual Orientation and Diversity) (1st ed.). American Psychological Association.
Singh, A. A. (2018). The Queer and Transgender Resilience Workbook (Skills for Navigating Sexual Orientation and Gender Expression) (1st ed.). New Harbinger Publications.
Spatrisano, J. (2019, August). Microaggressions Towards Gender Diverse Therapy Clients and the Mediating Effects of Repair Attempts on the Therapeutic Process (No. 13903396). ProQuest LLC. https://www.proquest.com/openview/628748913234c0faf3ae03f578067f7c/1?pq-origsite=gscholar&cbl=18750&diss=y
Stryker, S. (2017). Transgender History, second edition: The Roots of Today’s Revolution (Seal Studies) (2nd ed.). Seal Press.
Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M. B., Nadal, K. L., & Esquilin, M. (2007). Racial microaggressions in everyday life: Implications for clinical practice. American Psychologist, 62(4), 271–286. https://doi.org/10.1037/0003-066x.62.4.271
Sue, D. W., & Spanierman, L. B. (2020). Microaggressions in Everyday Life (2nd ed.). Wiley.
Testa, R. J., Habarth, J., Peta, J., Balsam, K., & Bockting, W. (2015). Development of the Gender Minority Stress and Resilience Measure. Psychology of Sexual Orientation and Gender Diversity, 2(1), 65–77. https://doi.apa.org/doiLanding?doi=10.1037%2Fsgd0000081
Two-Spirit. (n.d.). Indian Health Service: The Federal Health Program for American Indians and Alaska Natives. Retrieved August 28, 2021, from https://www.ihs.gov/lgbt/health/twospirit/
Yee, N. & Gonzalez, M. (2021). History of Transgender Inequality in Health Care – THINQ at UCLA. Medium. https://medium.com/thinq-at-ucla/history-of-transgender-inequality-in-health-care-77e5370fd939
Ask Us Anything: How should I handle the pronouns of and name for adolescent trans clients when their parents refuse to use the correct ones? Obviously I want to support my client by using their pronouns and name, but I also feel like it is a fine line between that and making parents angry so they stop bringing their child to see me.
This is a conundrum that many affirmative therapists may face in the course of their work with young trans and gender non-binary clients, and your question is a critically important one! Training in working not only with transgender and gender non-binary communities but with their families can be invaluable. This is a short response to a complex answer, so we recommend further consultation and training!
Although difficult for all affirmative therapists, this situation can be particularly triggering for transgender and gender non-binary therapists. It can be triggering for those TGNB therapists who have experienced unsupportive parents. Make sure to take care of yourself, as this is a difficult situation for affirmative therapists to navigate. Consultation with colleagues, your own therapy, and whatever self-care works for you can help you be emotionally available as a therapist for this difficult situation.
In a situation like this, it can be best to have a meeting or several with only the parents in which you refer to the client simply as “your child” to help build rapport. During this time, you are establishing your ‘authority’ by building a solid relationship with them. Having some level of perceived authority or expertise established is what will help with challenging them on names/pronouns after you have good rapport with them.
Note that, of course, this is something you can do for only a short period of time as you are building rapport with the parents. This method can get awkward quickly as sentence structure can get clunky. It takes a lot of mental energy to avoid using any pronouns altogether, so there is also an energetic cost to the therapist.
Avoiding names/pronouns isn’t an affirmative stance, but rather a neutral one. Avoiding using names or pronouns avoids misgendering and deadnaming, but it also avoids embracing the child’s authenticity. This should not be done in front of the child, as it communicates to them that you don’t support their identity and will destroy rapport with the child. The point here is to avoid a power struggle with the parents, build rapport, and establish yourself as a helpful figure who can help them navigate this new information about their child. As you establish rapport, you can start to challenge their transphobic thinking to help them move towards a more supportive, affirmative stance towards their child.
It is important to help parents connect with their love for the child. Every parent wants ‘what is best,’ but they don’t always know what that is! Every parent wants their child to grow up happy and healthy, but there is so much information about how transgender and gender non-binary people struggle and suffer that parents get terrified! Building a connection with the parents about love for their child driving their fears will be helpful to building rapport.
Once you communicated clearly that you, the therapist, know how much the parents want to help their child grow up into a successful, fulfilled adult, then you can start educating about the best ways that parents can help. This is where that perceived authority is important. You do know what is best for the transgender or gender non-binary child; the research is clear. Supporting the child through using their name and pronoun is a huge protective factor! The world is a tough place and it is the parents’ job to prepare them for it. We do this by building resilience through offering a support system. It is essential to educate the parents about the importance of their being a support system for their child–if they want their kid to succeed in the world, they really have to show up 110%. Sharing research about the importance of parental support in mental health can be helpful, as no parent wants to be responsible for their kid’s misery.
You’ll want to drive that point home to them; your most effective route will be “I know you want what’s best for your child.” If you find that it’s particularly difficult to foster empathy in this situation, that’s completely understandable–but it is essential, because you’re right: if you attack the parents, they will shut down and terminate.
Referring the parent to affirmative resources can be helpful. Connecting parents to good information can help them learn on their own time rather than having their child educate them. Parenting is hard! Connecting with other parents going through the same process as they are can be transformative (no pun intended here). Here are some resources that can be helpful for you and possible referrals for the parents:
Books for Parents
Books for Therapists
Do you have a question? You can ask us anything.
Learn more about affirmative therapy with transgender and gender nonbinary clients
at The Affirmative Couch