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Out On The Couch

Non-binary Microaggressions in Psychotherapy

Posted: 9-24-21 | Nicholas Moran

The number 9 is set behind the word microaggressions to the right of a dart board bulls eye in yellow, white, and purple; the nonbinary colors. The darts represent the non-binary microaggressions people regularly experience in therapy. .

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. 

Defining terminology

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).

Nadal’s (2013) classifications included:  Using Transphobic Terminology Endorsing Gender Normative Culture and Behavior Assumption of Universal Transgender Experience Exoticization Discomfort with or Dissapproval of Transgender Experience Assumption of Sexaul Pathology, Deviance, or Abnormality Denial of the Reality of Transphobia Physical Threats or Harassment Denial of Bodily Privacy Systemic Microaggressions

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:

Misgendering If you’re not a man, woman, or trans, then what are you? That (insert gender identity or neo-pronouns) sounds made up. Did you have the surgery? How are you non-binary if you aren’t androgynous? It sounds like your (insert gender identity) is a product of your past trauma. Are you sure? I know being non-binary is trendy now. Making the assumption that all non-binary people want to talk about in therapy is gender. Using words such as normal and regular as synonyms for cisgender, endosex and heterosexuality.

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.

1. Misgendering

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: 

  1. fae/faer/faers
  2. xe/xem/xyr
  3. ey/em/eir
  4. ze/zim/zir
  5. ne/nem/nir. 

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. 

Other considerations

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: 

  1. A Clinician’s Guide to Gender-Affirming Care: Working with Transgender and Gender Nonconforming Clients
  2. The Queer and Transgender Resilience Workbook: Skills for Navigating Sexual Orientation and Gender Expression
  3. 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. 

 

Learn more about working with transgender and nonbinary clients

References

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

Clinician Resources for Internalized Transphobia

Posted: 5-11-21 | Mikey Anderson

Books and Clinician Resources for Internalized Transphobia

(Re)imagining gender through stories 

In my first article in this two-part series, I explored and reviewed works created by queer and trans clinicians who approached internalized transphobia from a clinical perspective, and offered actionable steps to dismantle it in the therapeutic space with clients. In this second and final installment, I explore memoirs from TGNB authors–including clinicians, artists, writers, and activists–who offer deep learning about the ways in which the intersections of identity, race, class, sexuality, and gender impact how TGNB people navigate the world. 

The beauty of these books lay in their illustration of both the pains and joys of growing into  TGNB identities. Their authors reimagine trans stories to be more fluid and person-centered. They reject notions of the classical trans narratives, mostly created by cis folx in positions of power who showcase trans folx’ trauma timeline. These tell a story until a trans person fully transitions to fit back into the binary structure, so that man becomes woman or woman becomes man and is then “self actualized.” 

These memoirs provide alternative narratives of trans stories, celebrating trans folx’ experience and speaking to the truth of internalized transphobia. Furthermore, these resources shed light on how TGNB folx are treated as a monolith in clinical training and academic articles. They bring greater awareness to the many ways of being and expressing one’s TGNB identity by sharing with us how there is no one way to do or express gender. 

The authors of the books I reviewed dispel constant media reports that are often overwhelmingly negative and contain invalidating messages about the trans community that serve to feed into and spread internalized transphobia (Rood et al., 2017). The mainstream media’s focus on only one type of story about TGNB people is an example of what Tobia (2019) calls “the limits of cisgender imagination.”

Non-binary journeys

Beyond the Gender Binary by Alok Vaid-Menon–a gender non-conforming writer who uses they/them pronouns–provides a prime example of how the personal is political when it comes to TGNB folx living in our Western context. The book brings to light the everyday experiences of non-binary folx, from going to the grocery store to spending time with friends. Vaid-Menon explores the pain of having to censor their beauty- and fashion-related identities, due to the fear that transgressing gender may elicit a violent reaction from individuals outside of LGBTQIA+ community. Non-binary folx have to be on alert to everyday microaggressions we can attribute to a system that rewards conformity rather than creativity (Vaid-Menon, 2020). 

Sissy: A Coming-of-Gender Story by Jacob Tobia, a non-binary writer and actor who also uses they/them pronouns, approaches gender trauma from an intersectional and social justice lens. Tobia brings awareness to the reader of the harsh punishment faced by TGNB youth until they conform to society’s standards of male and female, and of how TGNB youth are policed by parents, family members, teachers, and other children to ensure their alignment with the gender binary. Tobia’s humorous approach to the book creates a sense of ease in learning about both the challenges they confronted and their success in their non-binary journey from childhood to early adulthood at Duke College. They also illustrate their internalized transphobia, which manifested as self-hatred. The book explores how there are many ways to be queer, and through their commitment to social justice causes, Tobia is passionate about ensuring other TGNB folx have the chance to live their most authentic lives.

Tobia and Vaid-Menon as non-binary/genderfluid folx have been what gender therapist and writer Dara Hoffman-Fox (2017) may define as “hands-off mentors” to me: TGNB folx to whom I look up and consider role models in learning and understanding my own experiences as a non-binary artist, clinician, and person. They provide insight into, and describe similar pain in reckoning with, the sadness of being forced into binary systems. We and our clients face situations that range from invalidating to dangerous–from choosing between gendered restrooms to lacking adequate identification markers on our driver’s licenses. Our capitalist health insurance systems force both clinicians and clients into checking off binary boxes, furthering the notion that being TGNB is some kind of preference. This is illustrated by the GOP’s outrageous and repeated transphobic attacks on youth, entailing attempts to pass bills in numerous states across the country that would interfere with the rights of young people and their families to make their own medical decisions in conjunction with their providers.

Intersectional perspectives in TGNB stories

It is crucial for clinicians to consider how intersectional experiences of gender, race, and class shape violence against the TGNB folx with whom we work (Babine et al., 2019). These memoirs remind us to recognize the specific threats faced by QTBIPOC (queer and trans Black, Indigenous, and People of Color), specifically Black trans women, who are disproportionately targeted by white supremacist and transphobic violence.

Fairest by trans writer Merideth Tulsan (she/they pronouns) speaks directly to an intersectional experience of being trans, Filipino, immigrant, and albino, and to the privilege of being white-passing. Tulsan’s trans memoir illustrates the limits of the imagination of Western society’s perceptions of gender, and of the constant trauma inflicted upon TGNB folx in America inflamed by internalized transphobia in our society. They speak to their pre-colonial two-spirited indigenous ancestors Bakla, who in their culture are male-bodied people who live as women and who are pillars of their society. This aspect of the text speaks powerfully to the historical roots of TGNB folx, who have long existed, and to the negative impact colonization–which to this day continues to attempt to erase TGNB folx from the fabric of society–has had on our communities.

In Fierce Femmes and Notorious Liars: A Dangerous Trans Girl’s Confabulous Memoir, trans womxn social worker Kai Cheng Thom takes the idea of a trans narrative and completely reshapes it into a fictionalized coming of age memoir filled with mermaids, magic, zombies, and collective trans love. Through the lens of a fairytale, Thom portrays a radical trans Asian girl protagonist who runs away from an abusive city of gloom and joins a vigilante girl gang called the Lipstick Lacerators, who become her chosen family. The story speaks to the many TGNB youths who have to leave their abusive homes out of safety concerns and to be able to live their authentic genders. The memoir brings to light the tragic reality of the violence trans womxn of color face in our society as a result of internalized transphobia, transmisogyny, police brutality, white supremacy, racism, abuse, and sexual exploitation. 

Both Tulsan and Cheng, through their intersectional perspectives, offer clinicians the opportunity to learn more about their clients who hold multiple identities; they remind us that there is no “one size fits all” approach to working with TGNB community members. These books can serve as important tools for clinicians to deepen their understanding of intersectionality. Their authors, with their formidable presence on social media, may themselves become hands-off mentors to readers seeking connection and inspiration.

Take-Aways for queer clinicians

Internalized transphobia is inextricably linked to oppression, white supremacy,  and power. With this information from the workbooks, stories, and memoirs reviewed in this article series, we are presented with the opportunity to cultivate a greater awareness of internalized transphobia. We are given more tools and language that can help us stand up against transphobia, ending our (perhaps unwitting) complicity in a system of oppression that harms TGNB folx. A through-line in all of these memoirs is how transphobic and racist policies are being greenlighted by bias and discrimination authorized at the local, state, and federal levels. Our previous administration’s flow of constant disinformation about TGNB folx fanned the flames of transphobia. I ask my fellow clinicians to hold our new Biden and Harris administration accountable for rolling back the hate-filled policies affecting our TGNB community, and to demand inclusion and equity in all aspects of society. 

To combat transphobia in mental health care, we must demand that other clinicians recognize transphobia, even if others are unaware of their engagement in it (Levy, 2020). This means no more dead TGNB folx as a result of inequitable access to basic human rights created by a transphobic society. Clinicians must be cognizant of how transphobia, whether internalized or not, prevents progress in therapeutic relationships with our TGNB clients. When we confront transphobia head-on, we create a shift in perspective and progress toward a more inclusive mental health care system for our TGNB clients (Morrison, 2019). 

As a non-binary clinician, I am aware that there are many aspects of TGNB community to which I cannot relate–but I must act as a radical ally for trans folx by owning my mistakes, examining my privileges, advocating for the community, and always grounding my mental health care practice in empathy. All of the workbooks and memoirs I reviewed offer clinicians more expansive and creative ways in which to offer affirmative care to our TGNB clients. In our efforts to stay updated with best practices in working with LGBTQIA+ community members, it is imperative for clinicians to continue learning and creating safe and affirmative spaces for our queer and trans clients. With our knowledge, we can move forward in continuing to dismantle heterosexist and cissexist practices in mental health care. 

Additional resources: 

Podcasts:

Translash

Gender Reveal 

The Gender Rebels 

Transform: Beyond the Transition

Books: 

Homie by Danez Smith

Nonbinary: Memoirs of Gender and Identity by Micah Rajunov and A. Scott Duane

I HOPE WE CHOOSE LOVE: A Trans Girl’s Notes From the End of the World by Kai Cheng Thom 

YA Books:

All Boys Aren’t Blue by George M. Johnson

Felix Ever After by Kacen Callender

I Wish You All The Best by Mason Deaver

PET by Akwaeke Emez

The Black Flamingo by Dean Atta

Trans Teen Survival Guide by Owl and Fox Fisher

Trans + Love, Sex, Romance, and Being You by Kathryn Gonzales, MBA, and Karen Rayne, PhD

Gender Queer by Maia Kobabe

References 

Babine, A., Torho, S. S., Fizpatrick, O., Kolodkin, S. R., & Daly, L. (March 2019). Dismantling Stigma in the Transgender and Gender Non-Conforming Community. The New York Transgender Advocacy Group.

Hoffman-Fox, D. (2017). You and your gender identity: A guide to discovery. Skyhorse Publishing.   

Levy, V. (2020). Exploring my Identity(ies): Interactive. Self Published.

Morrison, L. (2019). Facing Fragility: The Burden of Cisgender Fragility. 

http://www.theinclusionsolution.me/facing-fragility-the-burden-of-cisgender-fragility/

Talusan, M. (2020). Fairest: A memoir. Viking.

Tobia, J. (2019). Sissy: A coming-of-gender story. G.P. Putnam’s Son.

Vaid-Menon, A. (2020). Beyond the gender binary: Penguin Workshop.

Check out Mikey Anderson’s Course

Image of embroidery. Radical Crafting with Queer Clinicians: Self-care, Healing and Activism Presenter: Mikey Anderson, MA, LPC This is a Non-CE Course.

 

 

Check out other courses about Transgender Affirmative Therapy

 

Learn More

Dinner plate with transgender flag and rainbow heart on it. Eating Disorders and Diet Culture: Inclusive Care for Trans Communities Presenter: Sand Chang, PhD 2.5 CE CourseTwo hands (one with transgender flag colors and one with genderqueer flag colors) making a heart. Helping Transgender and Gender Nonbinary Young Adults Develop Self-Compassion Presenter: M. Tucker, PsyD 1.5 CE Course Black and white blocks saying "stress" and trans flag colored blocks saying "resilience" Gender Minority Stress and Resilience in Transgender and Gender Nonbinary Clients Presenter: M. Tucker, PsyD 1.5 CE Course

Therapists Facing Internalized Transphobia

Posted: 1-20-21 | Mikey Anderson

Collage of Artwork created by Mikey Anderson as they completed the exercises in the workbooks reviewed in the article

Moving Towards Trans and Nonbinary-Affirmative Therapy Practice

As psychotherapists, we know that transphobia’s pervasive social impact affects our clients and our own internal worlds. This results in transgender and gender nonbinary (TGNB) folx internalizing society’s gender-normative attitudes and lays the groundwork for them to develop negative attitudes about themselves and their communities, which can ultimately lead to poor mental health outcomes (Babine et al., 2019). 

I reviewed these resources for clinicians to help them address internalized transphobia; this term is used, for the purposes of this article, to mean phobia toward and discrimination against trans binary and non-binary individuals. In doing so, I encourage all of us to use our positions of power to educate community members including educators, employers, health care providers, and other support service staff who work with TGNB folx. It is incumbent upon us to help ensure that our clients are offered LGBTQIA+ affirmative care in every aspect of their lives (Babine et al., 2019). The resources listed in this article are a call to action to all providers offering care to the TGNB community; my hope is that we can consider these readings to create a more inclusive and gender-just world in which TGNB folx can live fully. 

This review comes from my perspective as a white, able-bodied, licensed clinical therapist and nonbinary art therapist. I encountered some difficulties in reading through these books because they hit close to home for me and in relation to the everyday trauma my TGNB clients face. I recommend that other TGNB therapists and clients working through these books take breaks and engage in self-care practices when needed. Fortunately, Hoffman-Fox has included a Self-Care Checklist on page xxxi in their workbook, reviewed in this article.

Interactively Challenging Internalized Transphobia Through Workbooks 

Transphobia is deeply rooted in a cis-hetero, capitalist, western settler-colonial political system, and it will take a much more organized response to address than filling out a workbook.  But we can start by addressing internalized transphobia in ourselves, thus moving towards challenging it on a larger scale. 

Exploring my Identity(ies): Interactive by Van Ethan Levy, LMFT

Written by a queer, non-binary, trans, AFAB (assigned female at birth), NBPOC (Not Black Person of Color) who uses the pronouns Van/they, Exploring my Identity(ies): Interactive asks clinicians to address their privileges, power, biases, and the stereotypes they have absorbed, and how these are intrinsically linked to internalized transphobia. Van engages the reader immediately by asking the reader “Who am I?” as a starting point to encourage vulnerability. This helps readers reduce shame and examine all the ways in which they have internalized negative messages about the TGNB community. 

The workbook offers clinicians actionable steps to confront and address their internalized transphobia by breaking down language in an interactive format. This allows them to deepen their understanding of the ways in which internalized transphobia impacts us and our clients on both individual and systemic levels (Soto & Garman, 2018). The book names how internalized transphobia takes hold of us via unconscious bias by absorbing messages from our cis-focused society that shames, criticizes, and dehumanizes TGNB people. These messages, some overt and some subtle, serve to exclude trans people from full participation in life and are especially harmful to TGNB people trying to live freely in our world (Lighthouse Inc., 2020). 

Levy (2020) closes the book by offering clinicians ways to be better allies. They challenge how our inflated academic egos are informed by the experiences of mostly white cis-hetero folx, rather than through the lens of the many marginalized TGNB folx fighting for their lives. The author recognizes that this is a lifelong practice for clinicians, and recommends approaching social issues with an intersectional lens. 

Brainstorm from Mikey Anderson explored the question 'who am I?' from the workbook Exploring my Identity(ies): Interactive. Exploring one's own internalized transphobia is essential to transgender affirmative psychotherapy.

You and Your Gender Identity: A Guide to Discovery by Dara Hoffman-Fox, LPC

Written by a white, queer, nonbinary mental health counselor who uses the pronouns Dara/they/them, You and Your Gender Identity: A Guide to Discovery offers affirmation to readers in a person-centered way, wherever they are in their own gender journeys. Hoffman-Fox breaks down the journey into three accessible stages: 1) Preparation, 2) Reflection, and 3) Exploration. In stage one, Hoffman-Fox (2017) speaks directly to removing the stigma of putting labels or diagnoses on ourselves, which one may find a healing experience due to the historical precedent of the DSM labeling TGNB folx with a “mental illness.”

Using this workbook, I felt as if I was creating my gender memoir, inspired by what Hoffman-Fox would consider “hands-off mentors”; this type of mentor is someone with whom you won’t be interacting on an individual or personal basis (Hoffman-Fox, 2017). I was excited to learn about this concept, as my own experience with hands-off mentors has led me to discover TGNB folx to whom I look up and relate. These mentors have assisted me in understanding my own nonbinary identity as well as my TGNB clients’ experiences. 

Stage two speaks directly to how internalized transphobia manifests in our internal world beginning in childhood, when the adults around us began to censor and police our genders.  The section breaks down such experiences by ages including childhood (ages 3 to 11) and adolescence (ages 12-17), with a reflection piece describing how some TGNB people experienced their gender at each age. Hoffman-Fox touches on the impact puberty has on young TGNB folx, and how this feeds into gender dysphoria and affects both their development and mental health.  For cis-hetero clinicians who may not have questioned their gender and who, unlike many TGNB young folx, experienced puberty simply as a rite of passage, this section of the workbook may be very eye-opening. 

In stage three, Hoffman-Fox encourages readers to reflect on how they feel about their gender in the present; the reader may take on an explorer role to deepen their understanding of their gender and gain agency in defining their gender identity through various questions. Hoffman-Fox notes the many barriers one may face in their gender exploration in terms of financial stability, relationships, resources, and health care, noting that no exploration process is right or better than another. It’s about tapping into the reader’s unique strengths and abilities (Hoffman-Fox, 2017). In this section, Hoffman-Fox offers the reader actionable ways to combat internalized transphobia by journaling and recognizing when one engages in internalized transphobia, reframing it to positive self-talk about one’s gender. At times I struggle with the idea that, by the end of this chapter, readers will unearth, gather, and digest enough information about themselves to gain a deeper understanding of how to define their gender identity (Hoffman-Fox, 2017). The author’s recognition of how one’s experience with their gender as a life-long multifaceted and complex exploration resonates more deeply with me. 

The Queer & Trans Resilience Workbook: Skills for Navigating Sexual Orientation & Gender Expression by Anneliese Singh, Ph.D., LPC

The third workbook I reviewed is The Queer & Trans Resilience Workbook: Skills for Navigating Sexual Orientation & Gender Expression by Anneliese Singh, Ph.D., LPC, a South Asian multiracial Sikh queer and genderqueer femme clinician who uses she/they pronouns. Singh’s workbook speaks to the crucial skills TGNB folx need to build resiliency skills to thrive in a trans- and queerphobic world that demands conformity (Singh, 2018). Singh’s workbook centers intersectionality with TGNB folx and speaks to myriad LGBTQIA+ identities such as same-gender-loving, asexual, omnisexual, monosexual, polysexual, and pansexual, many of which may get overlooked by clinicians as well as by the general population. Further, Singh discusses the importance of developing a sense of body positivity, which the other workbooks do not address. Singh describes actively valuing one’s body and with whom one decides to share their body (Singh, 2018). 

Singh’s workbook describes ten resilience skills for LGBTQIA+ folx to develop. A few of these skills include You Are More Than Your Gender and Sexual Orientation, Knowing Your Self Worth, Affirming and Enjoying Your Body, and Building Relationships and Creating Community. Each section offers a resilience exercise to encourage the reader to practice these skills, and many of the practices borrow from cognitive behavioral therapy with an added queer lens. One example is how to use positive self-talk to affirm one’s gender, and as a way to reframe negative thoughts about it. 

Too often we focus on the ideas of self-care with TGNB clients to heal and manage pain inflicted on them via micro- and macroaggressions from our heterosexist and transnegative society. But we may fail to offer actionable ways to build up resiliency, like assertiveness skills, to empower our clients to survive and thrive. When discussing self-care with our TGNB clients, we must talk about cultivating resilience and how to develop skills to build up their confidence, communication, and self-esteem to navigate life in the face of discrimination and adversity (Singh, 2018). This workbook speaks to gender liberation to celebrate, respect, affirm, love, and recognize the value TGNB folx across the lifespan bring to our society, along with the power of enacting mutual aid efforts, as a way to develop resilience and create stronger communities. 

Final Thoughts about Workbooks Addressing Internalized Transphobia in Clinicians

I found these workbooks to be engaging and useful, and I appreciate that they were created by clinicians who are themselves a part of our TGNB community. They share their own pain from having to navigate a cis-heteronormative society and the joy of experiencing gender liberation. Too often, books about LGBTQIA+ clients are authored by cis and/or heterosexual folx who are white/white-passing, of middle to higher socioeconomic status, neurotypical, and able-bodied. They come up with their own biased conclusions about our TGNB community members. 

At the same time, I do reflect critically on who creates these books. I recognize how the language used in these workbooks about affirming queer experiences comes from queer folx in positions of power. They may, at times, use too much vocabulary from academic circles, a stark contrast to the reality of  trans, nonbinary, and gender non-conforming folx who are fighting to survive (Levy, 2020). I wonder who gets to engage in these books, and who even knows they exist. Too often, TGNB folx–especially TGNB folx of color–are in constant survival mode, facing housing and food insecurity, compared to cis and hetero folx. Black trans womxn are being murdered at alarming rates each year. Are clinicians expecting TGNB folx to use workbooks in therapy, homeless shelters, or community mental health settings amid a deadly pandemic, one disportionately impacting BIPOC?

I note how my own position of privilege has exposed has me to the wonders of queer theory; I can see the benefits of these works in clinical practice with clients exploring their gender and internalized transphobia, which too often holds our TGNB clients back from embracing all the ways of being in our world. Each workbook speaks to the role that shame and guilt play in shaping one’s experience with internalized transphobia. Hoffman-Fox takes it one step further to break down shame and guilt and explore how each negatively impacts TGNB folx’ existence. Furthermore, shame and guilt together form a powerful force that perpetuates gender trauma in our society and leads our TGNB clients to isolation, censorship, and submission into a binary. Clinicians must work through shame and guilt with their clients across the gender spectrum because of the relentless grip this combined force can have on one’s gender identity. 

At the core of these workbooks is their commitment to combat transphobia and their demand for others to recognize transphobia–even if unaware of their engagement in it–which will get us closer to ending it (Levy, 2020). This means no more dead TGNB folx as a result of inequitable access to basic human rights created by a transphobic society. The workbooks can serve as a set of armor for our TGNB clients to learn how to experience positive self-growth (Singh, 2018) that helps them thrive and affirms their identity. 

To fully grasp and address internalized transphobia, mental health professionals need continuing education that includes listening to the stories created by TGNB community members outside of the academic sphere of clinical practice. This will help providers continue to develop more TGNB-affirmative therapy practices. In my next article, I will review memoirs from TGNB artists who speak to their lived experience of navigating a cis-normative society and recount the ways in which they have developed resilience strategies to address both socially imposed and internalized transphobia. Additionally, I will offer takeaways, resources, and further recommendations to address internalized transphobia.

References 

A Therapist’s Guide to Navigating & Overcoming Internalized Transphobia. Lighthouse. (2018). https://blog.lighthouse.lgbt/overcoming-internalized-transphobia/

American Psychological Association. (2015). Guidelines for Psychological Practice with Transgender and Gender Nonconforming People. American Psychologist, 70 (9), 832-864. DOI: 10.1037/a0039906

Babine, A., Torho, S. S., Fizpatrick, O., Kolodkin, S. R., & Daly, L. (March 2019). Dismantling Stigma in the Transgender and Gender Non-Conforming Community. The New York Transgender Advocacy Group.

Hoffman-Fox, D. (2017). You and your gender identity: A guide to discovery. Skyhorse Publishing.                                                     

Levy, V. (2020). Exploring my Identity(ies): Interactive. Self Published.

Singh, A. (2018). The Queer and Transgender Resilience Workbook Skills for Navigating Sexual  Orientation and Gender Expression. New Harbinger Publications.

Garman, S. & Soto, M. (Hosts.) (2018-present) Transform: Beyond the transition. [Audio Podcast]. Stitcher. https://www.stitcher.com/show/transform-beyond-the-transition

Check out our Continuing Education Courses on Transgender Affirmative Therapy

Two hands create a heart shape. The left hand is painted in blue, pink and white: the stripes of the transgender pride flag. The right hand is painted in purble, white, and green: the colors of the gender nonbinary flag. The title of the course Helping Transgender and Nonbinary Young Adults practice self-compassion presented by addyson tucker, psyD 2.5 CE course is printed below the image.  Text "Gender Minority Stress and Resilience in Transgender and Gender Nonbinary Clients presented by addyson tucker, PsyD 1.5 CE Course" under an image of blocks in black and white spelling out stress and in the trans flag colors spelling resilence  "Working Alliance with Transgender and Gender Nonbinary clients Presented by Cadyn Cathers, PsyD 2 CE Course" under two rainbow arrows converging to denote the working alliance