Out On The Couch

Misgendering a Client in Therapy

Posted: 3-4-21 | The Affirmative Couch

Collage of a woman holding her head, a woman with her face on her desk, and a man looking frustrated to depict therapists feeling frustrated with themselves when they misgender a client. In the corner, there are two talk bubbles with the words "ask us Anything" to represent our Ask Us Anything campaign.

Ask Us Anything: How to navigate moments of rupture and repair in the therapeutic relationship when a therapist missteps re: a client’s gender identity or expression? Important to acknowledge and apologize to the client and strive to do better – other things to keep in mind if/when this happens?

Wonderful question! You are definitely on the right track regarding acknowledging the misstep and apologizing to the client. Here are a few other things to keep in mind:

An Invitation to Work on Your Own Internalized Transphobia

If you have not worked through your own internalized transphobia, you will inflict this injury on your clients regularly. More training, consultation, your own therapy, workbooks, and whatever else is necessary to work through your own biases is necessary in order to be an affirmative therapist. Whenever you commit this microaggression, take it as a sign that you need to explore your own reactions further. This is true for all therapists, even those that have been working in the field for a while. Internalized transphobia can be sneaky and catch us all off guard! If you are unable or unwilling to do that inner work, it may be better for you to refer your client to someone else. 

Short & Sweet Apology for Misgendering

When you apologize (as you should), make sure it is short and sweet. This isn’t the time to make your client take care of your guilt and/or shame around your misstep. You may already know that often people’s apologies can be really about taking care of themselves rather than taking care of the injury they have incurred. Don’t get defensive or excuse it as “really hard for you.” Just own that you made a mistake and move on. 

Client Dynamics to Explore

Pay close attention to the client over the course of the rest of the session. Did they just say “It’s fine,” but then withdraw from the discussion? Did they try to reassure you? Did they minimize their pain in that moment? Familiarity with the client’s dynamics will be helpful as they will likely play out in this circumstance as well. For example, a client who tends to be overly compliant may struggle to share how painful a misstep in a space that they felt was ‘supposed’ to be safe really is. If you notice these things, make sure to point them out compassionately. 

Using the Misgendering to Talk about the Client’s Experience

Although this may feel like a small misstep to you, it is one that your client likely faces on a regular basis. Microaggressions can add up into something much bigger. Exploring clients’ experiences with microaggressions, like this one, can be helpful. Few people who make a misstep like this take the time to make space for the rage, pain, hurt, and other feelings that can arise without getting defensive. A simple statement like, “Using the wrong pronouns happens all the time. What do you do to manage your feelings with these situations?” can open up a conversation about self-care, assertiveness, and boundaries.  

Exploring the Negative Transference

Many clinicians are afraid of negative transference, and that missteps will bring this out. Regardless of how the negative transference emerges (through a misstep or something else), it is important to work through it. The best clinical work isn’t in the positive transference, but in the negative. Learning how to work with these intense emotions can be therapeutic and healing. This is not to say that you should purposely injure your client to engage with negative transference, but when it shows up, you can use it to the client’s benefit. This is a complicated issue that involves understanding the client’s personality structure and is therefore outside the scope of this article; you can check out Seinfeld (2002), Maroda (2012), and McWilliams (2020). That being said, if you really struggle with people having negative feelings towards you, it’s time to seek consultation and supervision.   

Projective Identification & Countertransference with Misgendering

Another dynamic to consider is a little more controversial. It doesn’t apply in most circumstances, so be mindful of whether this applies to your situation or not. If it does, exploring it can be quite meaningful. Projective identification is a defense mechanism that clients (well, anyone) can use to “get rid of” parts of themselves they want to disown. It is a two-person process in which one person splits off a part of themselves and projects it and another person identifies with the disowned part. If you have ever experienced a client discussing something aggravating with constricted affect and found yourself feeling angry, projective identification may be at play. The client has disowned their anger and projected it into you! Relational psychoanalytic theory explores how to use these projections to help the client integrate all their parts more effectively (Finley, 2015). 

If you are someone who doesn’t usually struggle with pronouns with your clients, but you are struggling with a particular client, there may be other issues at play. This is more likely to be true if you didn’t struggle before and now are misgendering a client. To be clear, if you struggle with pronouns often, you won’t have the clarity to see if this dynamic is afoot. So make sure that you have done your inner work and explored your internalized transphobia before considering this possibility. 

Clients who use projective identification as a defense can also utilize it in the area of gender. Sometimes clients who are struggling with integration can reject a part of themselves (like a gender or gender expression) and project it into the therapist; the therapist may then respond accordingly. For example, if someone who uses male pronouns rejects a feminine part of themselves and projects it into you, you may unconsciously pick up on that and gender them with female pronouns. If this dynamic is present, there are likely other areas in which the client engages in projective identification; this would be a normal occurrence in the countertransference.

Exploring this dynamic is super complicated, as addressing it directly may cause more injury due to the client’s need to disown this part of themselves. But not addressing it means that this dynamic never gets worked through. It becomes further complicated if the therapist has internalized transphobia or hasn’t done the inner work to thoroughly understand gender identities. 

If you suspect this dynamic is at play, we highly recommend consultation or supervision with someone familiar with relational dynamics and transgender and enby identities to help sort out what may be happening in the therapeutic relationship. This is not something for a beginning affirmative therapist to manage.

Learn More about working with Transgender and Gender Nonbinary Clients

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Ask Us Anything!

We hope that this has been helpful! We cannot emphasize enough that if this is an ongoing event for you with multiple clients, that you need to do more inner work around your internalized transphobia to be a transgender affirmative therapist.  

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