Out On The Couch
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.
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
Ask Us Anything: How should I handle the pronouns of and name for adolescent trans clients when their parents refuse to use the correct ones? Obviously I want to support my client by using their pronouns and name, but I also feel like it is a fine line between that and making parents angry so they stop bringing their child to see me.
This is a conundrum that many affirmative therapists may face in the course of their work with young trans and gender non-binary clients, and your question is a critically important one! Training in working not only with transgender and gender non-binary communities but with their families can be invaluable. This is a short response to a complex answer, so we recommend further consultation and training!
Although difficult for all affirmative therapists, this situation can be particularly triggering for transgender and gender non-binary therapists. It can be triggering for those TGNB therapists who have experienced unsupportive parents. Make sure to take care of yourself, as this is a difficult situation for affirmative therapists to navigate. Consultation with colleagues, your own therapy, and whatever self-care works for you can help you be emotionally available as a therapist for this difficult situation.
In a situation like this, it can be best to have a meeting or several with only the parents in which you refer to the client simply as “your child” to help build rapport. During this time, you are establishing your ‘authority’ by building a solid relationship with them. Having some level of perceived authority or expertise established is what will help with challenging them on names/pronouns after you have good rapport with them.
Note that, of course, this is something you can do for only a short period of time as you are building rapport with the parents. This method can get awkward quickly as sentence structure can get clunky. It takes a lot of mental energy to avoid using any pronouns altogether, so there is also an energetic cost to the therapist.
Avoiding names/pronouns isn’t an affirmative stance, but rather a neutral one. Avoiding using names or pronouns avoids misgendering and deadnaming, but it also avoids embracing the child’s authenticity. This should not be done in front of the child, as it communicates to them that you don’t support their identity and will destroy rapport with the child. The point here is to avoid a power struggle with the parents, build rapport, and establish yourself as a helpful figure who can help them navigate this new information about their child. As you establish rapport, you can start to challenge their transphobic thinking to help them move towards a more supportive, affirmative stance towards their child.
It is important to help parents connect with their love for the child. Every parent wants ‘what is best,’ but they don’t always know what that is! Every parent wants their child to grow up happy and healthy, but there is so much information about how transgender and gender non-binary people struggle and suffer that parents get terrified! Building a connection with the parents about love for their child driving their fears will be helpful to building rapport.
Once you communicated clearly that you, the therapist, know how much the parents want to help their child grow up into a successful, fulfilled adult, then you can start educating about the best ways that parents can help. This is where that perceived authority is important. You do know what is best for the transgender or gender non-binary child; the research is clear. Supporting the child through using their name and pronoun is a huge protective factor! The world is a tough place and it is the parents’ job to prepare them for it. We do this by building resilience through offering a support system. It is essential to educate the parents about the importance of their being a support system for their child–if they want their kid to succeed in the world, they really have to show up 110%. Sharing research about the importance of parental support in mental health can be helpful, as no parent wants to be responsible for their kid’s misery.
You’ll want to drive that point home to them; your most effective route will be “I know you want what’s best for your child.” If you find that it’s particularly difficult to foster empathy in this situation, that’s completely understandable–but it is essential, because you’re right: if you attack the parents, they will shut down and terminate.
Referring the parent to affirmative resources can be helpful. Connecting parents to good information can help them learn on their own time rather than having their child educate them. Parenting is hard! Connecting with other parents going through the same process as they are can be transformative (no pun intended here). Here are some resources that can be helpful for you and possible referrals for the parents:
Books for Parents
Books for Therapists
Do you have a question? You can ask us anything.
Learn more about affirmative therapy with transgender and gender nonbinary clients
at The Affirmative Couch