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).

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.

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

I am Black, gay, and a social worker. I work in a recovery center where I help individuals attain and maintain their sobriety.  I have had experience on both sides of the “social service” table, and my personal and professional experience has given me access to the elusive community of crystal meth users.

A friend of mine who experienced addiction once asked me to accompany him to a Crystal Meth Anonymous (CMA) meeting. Upon our arrival, the room buzzing with conversation, I noticed that my friend and I were two of only three people of color in the space of about 25 people. When the meeting opened up the floor to share, the only other person of color present shared about a tough time he was going through and broke into tears. He was raw in the moment, and as much as I wanted to walk over and console him, I froze. No one approached him. 

I didn’t know what to do at that moment. So I waited until after the meeting and then I pulled him aside. He shared that this wasn’t the first time he had a breakdown or breakthrough in a CMA meeting, and that he didn’t expect comfort because no one had ever comforted him before. He went on to say that even in a room filled with people who share the same pain, he still felt alone. 

Racism: the elephant in the room

This is not unusual: within the larger gay community, I often hear stories of cultural difference–that in these spaces of “inclusion,” there is an elephant in the room that many refuse to acknowledge or address. Many of the white men in this room were on dating and hookup sites advertising their attraction to men of color; they plastered their desire for “BBC” (big black cocks) all over these apps, accompanied by the capital letter T as a silent signal to meth users. Why is it so difficult for these same individuals to console someone in an emotional state of need? Is it because they don’t see our value outside of the bedrooms? Wealthy white men’s fetishizing and desire of Black men‘s bodies while using is not uncommon, and they dangle crystal meth like a carrot hoping for a treat from their trick.

I remember being in these rooms and feeling afraid, embarrassed and mostly alone. These dark emotions fueled my desire to use so that I could lower my inhibitions and allow myself to engage in these humiliating experiences.  All for Tina. These sex rooms were eerily similar to that CMA meeting room, but here, the white men couldn’t keep their hands off me, nor anyone who looked like me.  When I finally crossed paths with those who shared my same hue and were also users, I discovered that we shared that same experience. That’s when I decided to look for help, which wasn’t easy.

Addiction as a disease of isolation for Black gay men

It can be difficult as a Black gay man who has suffered from addiction, whether current or in the past, to find community support. Black crystal meth users have a harder time because it is widely seen as a “white man’s drug.” The Black gay men with whom I have worked often express their fears of sharing about their struggle with addiction even with their friends. With the fear and shame of their addiction, most of these men succumb to one of the most dangerous symptoms of crystal meth addiction: isolation. 

Connection is a pillar in the Black community. Connection informs how we give and receive love,  how we communicate, and also how we feel valued. Connection bonds the value and friendships that we create with our chosen families. Chosen families are an essential part of the LGBTQIA+ community; they enable us to find the support and love that our biological families might not provide. Crystal meth addiction can be detrimental to these connections, forcing the men who use it to suffer in silence. They may not share about their addiction because of how they will be viewed, or for fear of becoming the subject of the latest gossip.

Unfortunately, that fear became my reality. I had reached out for help from someone I thought was part of my circle of support, only to end up being grist for the rumor mill. These experiences severed my trust in people, scaring me from looking for help. I was afraid of sharing more with old friends, for fear that they would repeat the same behavior. I also struggled with making new connections, afraid that they would somehow find out about my addiction and want nothing to do with me.

On being both client and service provider

It took some time, but I was able to connect myself with services; I credit my professional experience with helping me locate resources. My background in linking consumers to community supports like Medicaid and substance abuse programs became my reality. I was on the other side of the table, having been in the position of both client and provider. 

I am confident that many out there can maneuver beyond their addiction and locate the necessary support to begin their own journeys to sobriety. However, there are so many others who are unable or are too discouraged by the daunting process. 

Applying for Medicaid and enrolling in substance abuse treatment programs can be tasks within themselves. Fortunately, organizations like the D.C.-based Us Helping Us and Whitman-Walker Clinic offer streamlined services for MSM with crystal meth addiction, help with applying for health benefits, and much more.  In New York, there is the Ike & Tina meeting, which centers the experiences of Black queer and trans folx seeking recovery. 

But there is a tremendous need for culturally sensitive program models offered on a national level, along with greater accessibility of culturally cognizant therapists. Affirmative therapy provides safer spaces in which to unpack one’s life experiences, which is essential for anyone in or seeking recovery. My love for my profession plays an instrumental role in my search for the best way to support those with addiction. However, beyond this passion for the work that I do, my reach as an individual is limited. 

It is time to tailor, on a larger scale, recovery services to our clients’ cultural experiences and needs. Community and mental health providers must seek training specifically designed to address the intersections of addiction and culture. Continuing education is vital for any and all of us providing services to clients whose multiplicity of identities and experiences we recognize and respect. In addition to pursuing ongoing training to create a workforce rich in cultural humility, providers should engage in advocacy efforts to ensure the creation and funding for recovery programs that will meet our clients where they are and propel them forward. There is much work ahead for affirmative providers! 

In my third and final article in this series, I will explore the resources available to help practicing clinicians address the intersections of culture and addiction. 

“Not everything that is faced can be changed; but nothing can be changed until it is faced.” –  James Baldwin

Reference

Lee, C., Oliffe, J. L., Kelly, M. T., & Ferlatte, O. (2017). Depression and suicidality in gay men: Implications for health care providers. American Journal of Men’s Health, 11(4), 910–919. https://doi.org/10.1177/1557988316685492

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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. 

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

Coloring Books in Therapy

Coloring books aren’t just for children anymore: adult coloring books have gained great popularity in the last few years. They have been found to reduce symptoms of anxiety and depression; increase perseverance; and provide short-term stress relief (Eaton & Tieber, 2017; Flett et al., 2017; Rajendran et al., 2020; Simmons, 2016). Adult coloring books have also been used to promote relaxation, help people unplug from technology, and even increase socialization in groups (Blackburn & Chamley, 2016). Many adult coloring books have themes similar to those designed for children: whimsical scenes in forests and the ocean, cute animals, or meditative images like mandalas.

As therapists, we need to be mindful about what we keep in our offices and how we utilize the tools we have on hand. Fortunately, the reaction in my office to the five affirmative coloring books I was given the opportunity to review and use has been overwhelmingly positive. These books, which include Butch Lesbians from the 20s, 30s, and 40s; Butch Lesbians from the 50s, 60s, and 70s; Transgender Heroes; Queer Heroes; and Resistance: The LGBT Fight Against Fascism in WWII, were created to provide education about the history of the LGBTQIA+ community in a fun and creative way.

Since I brought the coloring books into my office, clients commented on how safe they felt coming in. Several have mentioned the sense of inclusivity that seeing one of these books on the coffee table or on my bookshelf imparted. Some clients travel a good distance to see me, and will often bring a partner along to get a meal together after therapy. I have walked out of my office after a session to find a client’s partner with one of these books–either coloring it or reading the historic facts about the individuals featured.

Clients with children have commented on their appreciation of these coloring books, too, as their children sometimes use the books while the clients are in session. Some clients have asked where they can find similar books, whose educational aspect they welcome, as they want to expose their children to history that includes more than solely cisgender and heterosexual people.

One transgender client teared up when they saw the Transgender Heroes coloring book, expressing appreciation that it included a wide cross-section of transgender community members rather than focusing in on only certain gender identities and expressions. The book’s representation of trans male and non-binary characters, in addition to that of trans women, makes for a genuinely inclusive experience that one may not always find in other forms of media.

I recommend these coloring books for any clinician who wants to make their office a safer and more inclusive space, as well as for educating the general public about LGBTQIA+ history and individuals. The books are not recommended for individuals with sensory processing disorders who do not like the feeling of paper on their skin. I would love to see coloring books published that are geared specifically toward gay men, femme lesbians, or pan- and bisexual individuals, as well as ones that focus on alternative relationships and sexual practices such as polyamory, relationship anarchy, and kink.

LGBT Resistance: COVID-19 and WWII Parallels

I took these coloring books home from my waiting room and perused them at more length in order to finish writing this article after COVID began. I particularly enjoyed flipping through Resistance: The LGBT Fight Against Fascism in WWII. As someone with an interest in history and some newfound free time, I spent quite a while reading the stories of numerous activists highlighted in this book. Their stories are not ones that we commonly see in our history books or discuss in our history classes. Although each biography is short–about a page and a half for each person–it brings to light every figure’s individual relationships within the context of history.

For example, the tale of Charlotte Wolff, a Jewish psychotherapist, sexologist, and palm reader living in Nazi Germany, was far more humanizing in this format. From her short biography, I learned about her falling in love with an artist named Lisa, who later broke up with her. In 1931, she was warned by the Nazi government to stop her work on women’s reproductive health services, and in 1932 her lover of nine years left her because by then, it was dangerous to be associated with Jews in Germany.

This intermixing of the personal and political dialogue during WWII is intriguing and particularly relevant as we experience the current global pandemic. Our politics, our health, and our personal lives are all entwined; wars and pandemics do not stop breakups, heartache, trauma processing, grieving, or food insecurity, nor do they stop the celebrations of graduations, pregnancies, new love, weddings, or home ownership–although they can make these things more difficult to celebrate. We may forget that these things were still happening when we learn about WWII or any other major historical event. But now we are living through a worldwide crisis ourselves, and are learning new ways in which to grieve or celebrate our personal amidst the political.

As a bisexual therapist navigating the personal and political intersections of my own identities, I have had to balance discussions about politics, health and safety, and personal relationships with all of my clients. These are intertwined, as they had been for the people written about in these coloring books. We may forget about the personal lives of activists from history, and we rarely learn of the very real relationships, emotions, and experiences they had. Laura Antoniou puts it well in the foreword to Resistance: The LGBT Fight Against Fascism in WWII: these are the stories “of people who, nevertheless, persisted.” We are persisting in today’s world as we strive to calm our anxieties, survive, and continue to love during this pandemic. Looking back on our LGBTQIA+ brothers and sisters, we may be able to draw strength from the struggles of the past as we look to the future.

Note: These coloring books were supplied to The Affirmative Couch for review purposes by the publisher at no charge. The Affirmative Couch does not supply affiliate links and does not profit from any resulting sale of these books.

Want to learn more about how to support your clients throughout the challenges posed by the COVID-19 pandemic? Check out the related courses from our catalog:

• From a Distance: Navigating Polyamory During a Pandemic (1 CE) Presented by Esther Benoit, PhD, LPC (VA)
• HIV/AIDS Retraumatization During the COVID-19 Pandemic (3 CEs) Presented by Samuel Donath, MS
• The Psychological Impact of Suppressing Kink Identity (2 CEs) Presented by Elyssa Rice, MA, LMFT 

Learn More from Stephanie M. Sullivan

You can get all of these courses and more with Annual Membership or the Lifetime Membership. 

If you run a group practice or clinic, learn more about making collective and systemic changes toward a more welcoming culture with our affirmative organizational consulting and training.

References

Avery, T. M. & Cameron, G. (Eds.). (2019). Transgender heroes coloring book. Stacked Deck Press.

Blackburn, H., & Chamley, C. E. (2016). Color me calm: Adult coloring and the university library. Criss Library Faculty Proceedings & Presentations, 6(1), 1-11.

Cassell, A. (2018). Resistance: The LGBT fight against fascism in WWII (D. Kanzler, Ed.). Stacked Deck Press.

Cassell, A. & Macy, J. (Eds.). (2018). Butch lesbians of the 50s, 60s, and 70s coloring book. Stacked Deck Press.

Cassell, A. & Macy, J. (Eds.). (2017). Butch lesbians of the 20s, 30s, and 40s coloring book. Stacked Deck Press.

Eaton, J., & Tieber, C. (2017). The effects of coloring on anxiety, mood, and perseverance. Art Therapy: Journal of the American Art Therapy Association, 34(1), 42-46.

Flett, J. A. M., Lie, C., Riordan, B. C., Thompson, L. M., Conner, T. S., & Hayne, H. (2017). Sharpen your pencils: Preliminary evidence that adult coloring reduces depressive symptoms and anxiety. Creativity Research Journal, 29(4), 409-416. doi:https://doi.org/10.1080/10400419.2017.1376505

Macy, J. & Avery, T. M. (Eds.). (2016). The queer heroes coloring book. Stacked Deck Press.

Rajendran, N., Mitra, T. P., Shahrestani, S., & Coggins, A. (2020). CME information: Randomized controlled trial of adult therapeutic coloring for the management of significant anxiety in the emergency department. Society for Academic Emergency Medicine, 27(2), 91-99. doi:10.1111/acem.13838

Simmons, C. (2016). Effects of coloring on immediate short-term stress relief. Sally McDonnell Barksdale Honors College: Honors Theses. https://egrove.olemiss.edu/hon_thesis/230