Out On The Couch
In recent years, both the ethics and efficacy of affirmative mental healthcare have been debated on a national stage. In 2022 alone, Florida state legislators have proposed a “Don’t Say Gay” bill, Alabama passed a law outlawing gender-affirming medical or mental healthcare for teens, and more than a dozen states like Ohio have followed in their wake. Conservative lawmakers feel that things have “gone too far” by allowing transgender and gender nonbinary (TGNB) people access to care that validates their identity, especially youth, and are using their power and influence to limit that access.
While these dog whistles may be daunting, it is important for mental health providers to have all the evidence when making decisions about clinical care. To be clear: the literature of the field strongly reflects that providing gender-affirming care is associated with positive outcomes for TGNB clients. In this article, we will address arguments against providing affirmative care and summarize recent evidentiary support and best practices.
Criticisms of gender-affirming care
A common criticism of gender-affirming care is that children and adolescents are not mature enough to self-identify their gender. Any psychotherapist with an understanding of human development can easily debunk this claim. According to the work of Lawrence Kohlberg, a foundational theorist in the field of psychology, children develop a sense of gender identity as early as preschool (Sravanti & Sagar K, 2019). Many gender-expansive youth opt to socially transition long before entering puberty, though the standard approach in our field is that of “watchful waiting,” in which the child’s medical team closely observe their exploration of gender until puberty (Ehrensaft et al., 2018). In contrast, a gender-affirmative approach stresses the importance of self-identification by allowing the child to socially transition at any age, access puberty blocking medication if desired, and pursue medical transition after the onset of puberty (Ehrensaft, 2017). Both of these approaches have been heavily researched in recent years, yet the public consensus remains that we don’t (or can’t) know enough to establish gender-affirming care as a best practice.
One reason is that concerns about regret and detransition abound — though there is a paucity of research to support this. One study of adults who identify as transgender in the United Kingdom found that out of 175 individuals, only 12 reported detransitioning in the 16 months after receiving cross-gender hormone treatment (Hall et al., 2021). Out of that already small sample, only two patients reported feeling regret (Hall et al., 2021, p. 7). However, many clinicians actually recommend against further research on detransition or “desistance” rates, stating that it contributes to public mistrust and skepticism without serving youth. Academics have raised concerns about the methodology of desistance studies, as well as the working definition of “gender identity” that is used by other researchers, as lacking consensus may muddy the waters (Brooks, 2018).
Research in support of gender-affirming care
So how do we reach this consensus? Emerging research strongly indicates that affirmative care improves the mental health of transgender and gender nonbinary clients. A 2021 study of 104 TGNB youth at Seattle Children’s Hospital found that receiving gender-affirming interventions such as puberty blockers or gender-affirming hormones was associated with 60 percent lower odds of moderate to severe depression and 73 percent lower odds of self-harm or suicidal thoughts during their first year of involvement in gender care (Tordoff et al., 2022). A recently published secondary analysis of the 2015 United States Transgender Survey found that out of over 3,500 respondents reporting gender-affirming surgeries in the prior two years, undergoing surgery was associated with lower past-month psychological distress and was not associated with greater lifetime risk of suicidality (Almazan & Keuroghlian, 2021). The authors of this analysis answer earlier concerns about the methodology of “desistance” studies by controlling for baseline mental health status in their work (Almazan & Keuroghlian, 2021).
Similarly, a 2018 study published in JAMA Pediatrics found that out of 68 trans masculine patients undergoing chest reconstruction (top surgery), only one reported experiencing regret “sometimes” (Olson-Kennedy et al.). This study found no statistically significant differences between participants who underwent top surgery before age 18 and those who had surgery as adults (Olson-Kennedy et al.). The inverse effect can be observed when taking the impact of the COVID-19 pandemic into consideration — an international survey of 964 TGNB people conducted between April and August 2020 found that 55 percent of respondents experienced reduced access to gender-affirming resources, and this was correlated with higher prevalence of depression, anxiety, and suicidal ideation (Jarrett et al., 2020).
The literature of the field reflects clear conclusions: increasing access to gender-affirming care improves mental health outcomes, and limiting access negatively impacts them. Our profession’s division over best practices for the mental healthcare of TGNB clients has laid the groundwork for public uncertainty, as well as legislative harm. It is crucial that we continue to pursue research into mental health outcomes for TGNB clients and publish these findings in ways that are accessible outside of academia — not hidden behind a paywall or requiring institutional access. For cisgender psychotherapists, we need leverage our privilege and be generous with our labor, sharing this information with friends, family, colleagues, and writing to our elected representatives. It is an issue worth the extra time and effort, and can have life-altering consequences.
Learn more about working with transgender and nonbinary clients
Almazan, A. N., and Keroughlian, A. S. (2021, April 28). Association between gender-affirming surgeries and mental health outcomes. JAMA Surgery 156 (7), 611-618.
Brooks, J. (2018, May 23). The controversial research on ‘desistance’ in transgender youth.
Ehrensaft, D. (2017). Gender nonconforming youth: current perspectives. Adolescent Health, Medicine, and Therapeutics (8)1, 57-67.
Hall, R., Mitchell, L., and Sachdeva, J. (2021, October 1). Access to care and frequency of detransition among a cohort discharged by a UK national adult gender identity clinic: retrospective case-note review. British Journal of Psychiatry 7(6), 1-8.
Jarrett, B. A., Peitzmeier, S. M., Restar, A., Adamson, T., Howell, S., Baral, S., and Beckham, S. W. (2020, November 4). Gender-affirming care, mental health, and economic stability in the time of COVID-19: a global cross-sectional study of transgender and non-binary people. medRxiv: the preprint server for health sciences (2), 1-32.
Olson-Kennedy, J., Warus, J., Okonta, V., Belzer, M., and Clark, L. F. (2018, May). Chest reconstruction and chest dysphoria in transmasculine minors and young adults: Comparisons of nonsurgical and postsurgical cohorts. JAMA Pediatrics 172(5), 431-436.
Sravanti, L., and Sagar K, J. V. (2019). Gender Identity: Emergence in Preschoolers. Journal of Psychosexual Health I(3-4), 286-287.
Tordoff, D. M., Wanta, J. W., Collin, A., Stepney, C., Inwards-Breland, D. J., and Ahrens, K. (2022, February 25). Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care. JAMA Pediatrics (5)2, 1-13.
COVID-19 & (Re)claiming Gender
As a non-binary, genderqueer, and trans femme therapist myself, I have encountered my own fair share of microaggressions related to gender identity. During the pandemic, I have witnessed many people for the first time in their lives take a break from performing gender in a way society deems acceptable. As a result, many folx are exploring their gender identity and expression more than ever before. Many clients have questions and self-doubt about who they are with respect to their gender identity and/or gender expression. However, this is an aspect of mental health that is under-researched and is often overlooked in the graduate training of therapists, both masters and doctoral.
Because many clinicians lack in-depth training with regards to working with gender expansive people, many clients encounter harm in session. For example, being misgendered is just one of many microaggressions that occur in therapy sessions with gender expansive clients. For the purposes of this article, I will be focusing primarily on nine common microaggressions experienced by non-binary people in the therapy setting.
Before we delve into this important topic, let’s take a moment to define some key terms. Cisgender is in reference to a person who’s sex assigned at birth matches their gender. Endosex refers to people whose sex characteristics meet medical and social norms for typically ‘male’ or ‘female’ bodies, which is the antonym to intersex. Heterosexuality refers to sexual and/or romantic attraction to or between people of the opposite sexes assigned at birth.
Transgender is an an umbrella term covering a range of identities that transgress socially defined gender norms. Additionally, transgender can refer to a person who lives as a member of a gender other than the one expected based on their biological sex assigned at birth. Non-binary is also an umbrella term covering any and all gender identities that do not fall exclusively in man/male or woman/female categories. And, non-binary refers to a person whose gender identity and or expression exists between or outside the rigid gender binary system.
But first… Microaggressions – What’s that?
The term microaggression was originally coined by Dr. Chester Middlebrook Pierce, who was an African American psychiatrist and Harvard University professor who died in September of 2016 (Sue & Spanierman, 2020). Early research focused on racial microaggressions, but has since been expanded to create a series of classification for most existing systems of oppression. Microaggressions are brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative slights and insults toward people with marginalized identities (Sue & Spanierman, 2020; Sue et al., 2007).
Nadal (2013) wrote the book That’s So Gay! Microaggressions and the Lesbian, Gay, Bisexual, and Transgender Community. This book is one of the first of its kind to make academic literature both accessible to a wide audience. Also, Nadal (2013) offered strategies to make the world a better place for queer and gender expansive people. Furthermore, Nadal (2013) provided distinctions between microaggressions based on sexual orientation as compared to gender identity.
Of the microaggressions highlighted for transgender and gender non-conforming (TGNC) people, the book identified ten distinct classifications (Nadal, 2013).
Why should I care about this topic?
Non-binary folx continue to encounter harm and rejection both for cisgender and transgender communities. TGNC folx experience higher rates of gender-based victimization than cis- individuals, and the highest rates of suicidality of any group (Testa et al., 2015). Additionally, TGNC folx report significantly more negative clinical encounters in therapy (Levitt & Ippolitto, 2014). Lastly, gender identity microaggressions have been associated with therapeutic dissatisfaction, reduced ability to establish a therapeutic alliance, and early dropout from therapy (Spatrisano, 2019).
So what gender based microaggressions are happening to non-binary folx in therapy?
I came to learn through my own consultations with prospective therapy clients that I wasn’t alone in my experiences of encountering gender based microaggressions. Although I don’t believe that all of the following microaggressions were intentionally meant to harm non-binary clients, it’s important to center the impact of our questions and statements as clinicians. The following common microaggressions occur to non-binary folx in therapeutic encounters:
In the following sections I will briefly explain why each of these examples is microaggressive. Alternative tips will also be provide for how to ask more affirming questions to non-binary folx.
This is the most common form of microaggression that happens both within and outside therapeutic spaces. Misgendering is when language is used that does not correctly reflect the gender with which the person identifies. This can include using a person’s “dead name” or name given at birth when the client has specifically requested that the clinician not do so. Additionally, misgendering emerges with the misuse of pronouns, whether the client is present or not. Non-binary folx experience misgendering countless times throughout the day. This can occur on the phone, in an email, while “politely” holding the door for someone, and so many other interactions. McLemore’s (2014) study indicated that non-binary folx, and people who had taken fewer steps in the transition process, were most likely to be misgendered.
What can a therapist do when misgendering happens? Firstly, I encourage folx to not make any assumptions about honorifics (Mr., Mrs., Mx.) and routinely check in with clients about pronouns. Secondly, it’s helpful to practice not using gender language and this may require an accountability buddy, which is something I continue to engage in myself. Thirdly, avoid using passive language such as: “X identifies as” and “X prefers” as this robs the person autonomy over their own identity. Lastly, make a brief apology, correct yourself, and set an intention to gender a person correctly two or three times in a follow-up sentence.
2. If you’re not a man, woman, or trans, then what are you?
This microaggression both invalidates and insults a non-binary persons lived experience. Gender is a construct, made up to control and classify people. Many non-binary folx reject the construct of the gender binary entirely. Asking a person, “what are you,” is cruel considering the fact that we are all simply humans. A more affirming question here could be, “how would you classify your gender identity and/or gender expression?” and “who are you, in terms of your gender?” Additionally, you may ask the client, “Would you be willing to share with me your experience exploring your gender and where you find yourself today?” With each of these suggestions, you allow the client the opportunity to self-identify and open up a dialogue about the client’s lived experience. As clinicians, it’s important that we do not restrict our client’s ability to explore. Above all, I encourage all therapists and wellness providers to center curiosity.
3. That (insert gender identity or neo-pronouns) sounds made up.
Woah! This one hurts to type. I like to remind folx that gender inherently is a fabricated classification system. Though for many non-binary, transgender, and gender expansive people, out lives are only just beginning to feel like our own. New terms for gender identity continue to emerge daily. A client once said in a group session, “I bet there are as many gender identities as people in the world, because we all experience life differently.” I couldn’t agree more with this comment. It would be more helpful to say something like, “I have never heard of the gender identity or pronouns you just mentioned, would you be willing to talk to me about how you define this gender identity or pronouns?” Or you may elect to offer to do research on your own time outside of session to spare your client from having to educate you, the clinician.
Though new terms like gendervague and genderfuck continue to emerge, the definitions of each of these terms will vary depending on who you ask. Neo-pronoun, or new pronouns, also continue to emerge as an outlet for non-binary folx to replace their name with a non-gendered word. Some common examples of neo-pronouns include:
If you’re anything like me, you’re probably going to need some practice using these in a sentence. Find a friend to practice with or try out this helpful website.
4. Did you have the surgery?
Eek! It’s important to note that there are numerous gender affirming medical procedures that gender expansive people can pursue. There is no ONE surgery that all non-binary folx undergo. For many non-binary folx, there is no interest in pursuing gender affirming medical procedures. While others may elect to engage in one or many gender affirming medical procedures.
As a clinician, I urge you to first ask yourself whether you ask your endosex, cisgender and heterosexual clients about their medical history. If you do not, then ask yourself why you feel entitled to ask your non-binary client this question? Two affirming questions could include: (1) what forms of transition are part of your path; and (2) have you considered gender affirming medical procedures to affirm your gender identity and/or gender expression?
Types of Transitions
With respect to transitions, they are not necessary to be a non-binary person. They are also not necessary for binary transgender people either! However, there are three distinct types of transition that could be a part of a client’s gender journey: (1) social transition, (2) legal transition, and (3) medical transition.
Firstly, social transition is in reference to the ways in which a person identifies and presents their gender in public. Some aspects of social transition include, choice of clothing and/or makeup, changing one’s name, selecting pronouns, tucking, packing, binding, and coming out.
Secondly, legal transition is in reference to the ways in which a person actualized their gender through updating legal documents. These documents can include a person’s name, social security number, birth certificate, passport and driver’s license.
Lastly, medical transition is in reference to the various procedures available to folx to actualize their gender. Some common procedures may include surgery, hormone replacement therapy (HRT), vocal training, laser hair procedures, and fertility preservation.
Please respect your client’s right to privacy as non-binary folx are often encountering invasive questions related to their body from all directions. Historically and through stereotypical media portrayals of gender expansive people, transgender and non-binary bodies have been labeled perverse, odd, and unusual for far too long. If you don’t ask your endosex, cisgender and heterosexual clients about their body parts, then why do you feel entitled to do so with non-binary clients?
Furthermore, I urge you to validate and normalize the response of “I don’t know” from a client in your care. I have found that this can be challenging for client’s to say as there are so many societal pressures to have answers. As a result, modeling and normalizing that not having an answer is acceptable can be incredibly validating to non-binary clients.
Also, it is important to mirror the language of your client when discussing aspects of the client’s physical body. I suggest asking, “how will we refer to the insert body part?”
5. How are you non-binary if you aren’t androgynous?
Just like there is no one way to look like a cisgender woman or man, there is no right way to look non-binary. This question is incredibly harmful as many non-binary folx experience imposter syndrome. Additionally, most non-binary folx experience discomfort or dysphoria due to being perceived as a cisgender person. Being androgynous is only one way in which the vastness of non-binary gender expression is embodied. Many non-binary folx experience and express their gender more fluidly.
Instead of reinforcing a false narrative of how to be a non-binary person, consider empowering your client. You may ask, “how do you embody and affirm your gender?” Or you may ask, “what makes you feel most like your fully embodied self?” Sometimes these questions will open a door of exploration and other times clients will find themselves unable to answer. If your client has no answer, I would invite you to ask them if they’d be willing to explore this with you. Furthermore, I will sometimes offer to lead a client through a creative arts or visualization exercise. This offers the opportunity for the client to move away from traditional language and engage their playful imagination.
6. It sounds like your (insert gender identity) is a product of your past trauma.
Ouch! Whether or not there could be truth to this statement, no one can go back and rewrite their history. Instead of focusing on how the past may or may not have caused a person to become gender expansive, why not focus on the now? So many non-binary folx feel disempowered and therapy is an intentional space to reclaim that power. Getting caught up in the what ifs of the past prevents clients from becoming more assured of themself in the present.
It can be powerful to validate a client’s past lived traumatic experience. I also encourage you as a clinician to assist your non-binary client with cultivating self-esteem. You might say something like, “Your past experiences have shaped the person you are today, and I am so grateful for the opportunity to know the person you’re becoming (or you have become).” Embolden your client to lead the conversation and connect to their past, if and only if that’s their own desire. Otherwise, continue to center the here-and-now of their gender journey.
7. Are you sure? I know being non-binary is trendy now.
This comment is loaded for a variety of reasons. Firstly, many folx are currently exploring their gender and identifying as non-binary for many may be the first step on that journey. Secondly, some experience gender as an aspect of self in constant movement and evolution. Thirdly, whether or not being non-binary is trendy or not, we need to reclaim our gender expansive history.
Gender diverse people have existed throughout history such as the First Nations, two spirit and Hijras, who are officially recognized as a third gender in India. Additionally, you may want to learn more about the transgender history in the U.S. and globally as well as the history of trans health care in the United States. And if you haven’t already started, it’s never too late to explore your own gender identity and gender expression in greater depth.
8. Making the assumption that all non-binary people want to talk about in therapy is gender.
There are certainly a vast number of people seeking therapy at this time to explore their gender. Then there is a large number of non-binary folx who are more confident in who they are and are seeking therapy for alternative reasons. Many non-binary folx express in consultations that their previous therapist would only ask questions about the client’s gender identity. This stifles our clients ability to be fully human and process the vastness that is the human experience.
Instead of assuming that non-binary and gender expansive clients want to discuss gender, perhaps you will ask what they would like to focus one. I, like many therapists, offer an intake questionnaire, which serves to allow the client to self-determine goals for therapy. Some clients are seeking an affirming provider with or without lived experience, but with the purpose of processing depression, anxiety, trauma, substance use, life transitions, and so much more. I can’t stress enough how important it is to allow your client to have control over their therapy goals. It also helps to add to your intake forms a place to add pronouns, salient identities, and chosen names.
9. Using words such as normal and regular as synonyms for cisgender, endosex and heterosexuality.
This is a prime example of systemic microaggressions. We have all been socialized in a world that assumes heterosexuality and cisgenderism as the baseline. There is nothing odd, unusual, or irregular about being gender expansive. For most, actualizing their non-binary gender identity and/or expression is a liberating experience. In short, this example upholds systems of oppression that harm everyone.
I recommend that all therapists engage in implicit bias exercises to identify the ways we internalize gender, gender roles, and gender expectations. The following three books are incredible resources:
- A Clinician’s Guide to Gender-Affirming Care: Working with Transgender and Gender Nonconforming Clients
- The Queer and Transgender Resilience Workbook: Skills for Navigating Sexual Orientation and Gender Expression
- You and Your Gender Identity: A Guide to Discovery.
As clinicians, we can only go with clients where we have dared to venture ourselves.
I microaggressed my client – What do I do?
As humans, we all have the ability to harm. Apologies are opportunities to take accountability; however, refrain from lengthy apologies. When apologizing, center the harm and avoid providing an excuse for your intentions. I have and continue to make mistakes as a therapist. I welcome these experiences as opportunities to deepen the therapeutic relationship. Therefore, these instances are opportunities to collaborate and empower our clients to identify their needs.
I am also a fierce advocate for therapists engaging in their own therapy and supervision. These can certainly be expensive endeavors, but so important for our own growth both personally and professionally. For example, seek out or create peer supervision groups. Obtain adequate training from folx of lived experience with regards to providing affirming care to TGNC clients. Lastly, please Please PLEASE avoid advertising yourself as a gender affirming provider until you’ve gained specialized training.
Learn more about working with transgender and nonbinary clients
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
(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.”
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.
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
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
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.
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
Check out other courses about Transgender Affirmative Therapy
With the global COVID-19 pandemic continuing into its second year, the conversation around access to healthcare has never been more relevant. For many people, going to a doctor for an annual physical was not feasible before the pandemic, whether due to lack of insurance coverage, financial cost, taking time off from work, transportation issues, or anxiety around healthcare-related trauma. On top of this, the added stress of COVID-19 exposure risk has led many to postpone necessary care. LGBTQIA+ people often face an additional barrier: whether the provider they see will be affirming, supportive–or even safe.
Primary Care as a “Medical Home”
Primary care is founded on a “medical home” model, meaning that patients will return periodically to the same practice, developing a relationship with their provider or medical team to ensure high-quality, comprehensive healthcare (Rosenthal, 2008). This can include physicians, nurses, social workers, and non-medical staff in the office. In an article for the Journal of American Board of Family Medicine, physician Thomas Rosenthal writes that “When people get sick, they use stories to describe their experience,” and goes on to say that “patient-oriented care is bound up in a physician’s ability to accurately perceive the essence of a patient’s story” (2008, p. 428).
This is a fundamental principle of the medical home model, and it speaks to the importance of primary care providers demonstrating expertise in LGBTQIA+-affirmative care. By gaining an understanding of how LGBTQIA+ people live and experience the world, providers build an essential framework for interpreting their stories and addressing their concerns. In this way, LGBTQIA+-affirmative primary care becomes a partnership, with patients and providers allying together to promote good health.
Social Determinants of Health in Primary Care
Furthermore, there has been a push in recent years for primary care practices to focus on the impact of social determinants of health–the factors that impact a patient’s well-being outside of their physical traits. Emerging from the Center for Disease Control and Prevention’s Healthy People 2020 campaign, social determinants of health include elements like poverty, depression, alcohol or drug use, social isolation, and exposure to violence in one’s home or neighborhood (CDC, 2020). To incorporate this into the flow of the office visit, patients may answer a paper or digital questionnaire about their experiences, or may be interviewed by a medical professional. In their medical homes, patients would ideally feel comfortable answering questions about such sensitive topics, as they have a relationship with their team.
However, without expertise in LGBTQIA+-affirming care, this is not always the case. Additionally, there is evidence to suggest that LGBTQIA+ people are more likely to be impacted by one or more of these elements due to the social stigma of being out in their communities (Knight et al., 2014). In a 2014 study of LGBTQIA+ youth in primary care, researchers examined the impact of “a set of social conditions that influence [the] health-related outcomes [of LGBTQIA+ people], including heteronormative and cisnormative assumptons, stigma, and social exclusion” (Knight et al., p. 662). In addition, queer and trans people comprise a large percentage of the gig economy and part-time workforce. As such, they are less likely to have employer-sponsored health insurance coverage, and are less likely to be able to afford out-of-pocket insurance costs (National LGBTQ Workers Center, 2018). This means that members of the LGBTQIA+ population may not make it to the doctor’s office at all when they are sick. As our understanding of health changes, primary care must be responsive to it.
With so many barriers to accessing healthcare, skipping appointments or going long times in between them is a reality for many LGBTQIA+ patients. Particularly during a global pandemic, this has become commonplace, and even necessary, for many people. But foregoing essential healthcare can have significant and long-lasting impacts on patients’ physical and mental health. A 2019 study in BMC Medicine concluded that missed appointments comprise a significant risk factor for increased comorbidities and overall mortality (McQueenie et al.). This means that patients who skip necessary appointments are likely to only get sicker. LGBTQIA+ people are at unique risk for various health problems as well, including higher rates of depression and substance abuse, as opposed to the general population (Ng & McNamara, 2016).
The need for affirmative care surfaces in the long-term treatment of HIV, for which LGBTQIA+ people–particularly gay men and transgender women of color–face a disproportionate risk (Feldman et al., 2014). HIV is a chronic illness that is often managed by a patient’s primary care provider. With daily medication and regular follow-up, patients can live healthy lives. However, this depends greatly on a patient’s retention in care, i.e. their ability to stay connected to their provider and maintain adherence to their medication regimen. When we factor in the influences previously mentioned, this becomes an increasingly challenging task.
Trans-Affirming Medical and Mental Healthcare
As the patients’ medical homes, primary care providers serve as liaisons to other specialties (Rosenthal, 2008). We know about the negative impact of postponing necessary health maintenance, but to make matters worse, LGBTQIA+ people without primary care providers are cut off from necessary specialist care. For transgender and gender non-conforming people, medical transition may be inaccessible without documentation of treatment by a primary care provider. While some clinics have adopted an informed-consent model for cross-gender hormone therapy, the majority of gender-affirming surgeons require that patients have a working relationship with not only a primary care provider, but a mental healthcare provider as well.
Depression and anxiety are 1.5 times higher in lesbian, bisexual, and gay adults than in the general population (Ng & McNamara, 2016). In a 2017 study of over 400 transgender adults in primary care, foregoing or postponing medical care due to fear of discrimination was associated with poor mental health, including increased incidence of depression and suicide attempts (Seelman et al). This suggests that the impression of discriminatory or stigmatizing healthcare practices is out there, and is acting as a barrier to care for many transgender patients before they even get in the door. When trans people are denied medical transition care, whether due to lack of access to healthcare services or to medical gatekeeping, the impact on their mental health can be devastating. In a population already at disproportionate risk of poor mental health and increased substance abuse, this is not a risk we can afford to take.
By developing a continuous relationship with their patients, primary care providers can foster trust with them to address health inequities. Many patients feel uncomfortable discussing their sexual and reproductive health with providers, and providers who are not trained in LGBTQIA+-affirming care may fumble or avoid these conversations altogether. Assumptions around patients’ sexual behaviors can lead to missed opportunities for STI screening and reproductive health counseling. For example, providers may believe that women who identify as lesbian or bisexual do not need the HPV vaccine or routine Pap smears, and may forego inquiring further about sexual behavior or partners. A 2018 qualitative study included interviews with 39 assigned-female-at-birth patients about their experiences with reproductive healthcare, revealing discrepancies in treatment but indicating similar needs between cisgender, heterosexual patients and LGBTQIA+ patients (Wingo et al.). This suggests that reproductive healthcare providers must be both well-versed in LGBTQIA+-affirming practices and also practice from what Ng & McNamara (2016) refer to as an anatomical inventory, or “screen what you have” model.
The authors suggest that providers “screening for breast, cervical, and prostate cancer…should consider an individual patient’s surgical history and hormonal status” (2016, p. 535). This means that, for example, transgender men or gender non-conforming people who have had a mastectomy may not need breast cancer screening. By “screening what you have,” physicians can individualize care to the needs of a specific patient, and further avoid making gendered assumptions or using exclusionary language like “women’s health screenings.”
The Imperative of Becoming an Affirmative Healthcare Provider
Bearing this in mind, there are a number of practices that primary care offices can adopt to create LGBTQIA+-affirming environments and retain their patients in care. For employees at every level, this can include practical or administrative changes, like changing documentation and medical records to reflect a patient’s sexual orientation or gender identity, or designating gender-neutral restrooms in an office setting (Ng & McNamara, 2016). For medical providers, adopting screening for mental health and substance use disorders is critical when working with LGBTQIA+ patients, as well as shifting cis- and heteronormative assumptions around patients’ responses (Ng & McNamara, 2016; Knight et al., 2014). Increasing education of all staff around LGBTQIA+-affirming care, social determinants of health, and their intersections can improve patients’ experiences in primary care and prevent negative health outcomes.
One final note to consider is that in many studies, recommendations are made for improving primary care practices for providers who are “interested” in LGBTQIA+ populations. This view is outdated and simply no longer reflects the reality of the patients coming into our offices. According to the Williams Institute at UCLA Law School, an estimated 4.5 percent of all Americans identify as LGBTQ+ (2019). These data are several years old, and do not include the responses of adults in Generation Z, who are predicted to identify as LGBTQ+ at higher rates. The message here is clear: whether or not providers have a special “interest” in working with LGBTQIA+ patients, those patients are here in our practices. To serve these community members and promote better health overall, our care must reflect an understanding of their unique needs and experiences, and affirm their LGBTQIA+ identities.
Affirmative Organizational Development Consulting
The Affirmative Couch offers affirmative organizational development consulting for mental and medical healthcare clinics who want to create a safe, welcoming environment for all patients who walk through their doors.
Our consulting team joins your clinic and gathers information to identify all the ways in which you can improve your services for LGBTQIA+ community members. We utilize the community narration approach to begin exploring the mission and values of your organization, and the gaps in service delivery to these communities. Our tailored needs assessment will review our findings from these interactions, offer next steps, and provide the foundation for your ongoing training with The Affirmative Couch.
Through this empowered approach, you will have all the information and support you need to make systemic change in your paperwork, administrative procedures, staff training, and organizational culture. We are here to answer every question in a non-judgmental, non-shaming way to help you become a more affirmative provider.
If you want to learn more, schedule a call with us to discuss your needs!
Learn more from our continuing education courses
Centers for Disease Control and Prevention (2020, August 19). About Social Determinants of Health (SDOH). https://www.cdc.gov/socialdeterminants/about.html
Feldman, J., Romine, R. S., & Bockting, W. O. (2014). HIV risk behaviors in the U.S. transgender population: prevalence and predictors in a large internet sample. Journal of homosexuality, 61(11), 1558–1588. http://www.tandfonline.com/doi/abs/10.1080/00918369.2014.944048
Knight, R. E., Shoveller, J. A., Carson, A. M., & Contreras-Whitney, J. G. (2014). Examining clinicians’ experiences providing sexual health services for LGBTQ youth: considering social and structural determinants of health in clinical practice. Health Education Research, 29(4), 662-670.
Movement Advancement Project & The National LGBTQ Workers Center. (2018). LGBT People in the workplace: Demographics, Experiences and pathways to equity. [Infographic]. lgbtmap.org. https://www.lgbtmap.org/file/LGBT-Workers-3-Pager-FINAL.pdf
Ng & McNamara (2016). Best practices in LGBT care: a guide for primary care physicians. Cleveland Clinic journal of medicine, 83(7), 531.
Rosenthal, T. C. (2008). The medical home: growing evidence to support a new approach to primary care. The Journal of the American Board of Family Medicine, 21(5), 427-440.
Seelman, K. L., Colón-Diaz, M. J., LeCroix, R. H., Xavier-Brier, M., & Kattari, L. (2017). Transgender noninclusive healthcare and delaying care because of fear: connections to general health and mental health among transgender adults. Transgender health, 2(1), 17-28.
The Williams Institute, UCLA School of Law. (January 2019). LGBT Demographic Data Interactive. https://williamsinstitute.law.ucla.edu/visualization/lgbt-stats/?topic=LGBT#density
Wingo, E., Ingraham, N., & Roberts, S. (2018). Reproductive Health Care Priorities and Barriers to Effective Care for LGBTQ People Assigned Female at Birth: A Qualitative Study. Women’s health issues : official publication of the Jacobs Institute of Women’s Health, 28(4), 350–357. https://linkinghub.elsevier.com/retrieve/pii/S1049386717305996
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
13 Signs You Need to Decolonize Your Practice with Trans Clients: Paying Attention to Your Colonization-Connected Behaviors
This two-part series is intended to first reflect on the ways in which transgender and gender nonbinary (TGNB)-affirming clinicians perpetuate harm connected to colonization, then to present actionable ways of moving toward decolonization and gender liberation. I am a queer, white, able-bodied, and “cis-ish” person (i.e., I do not feel discomfort in my body or with she/her pronouns, though I struggle with the construct of “womanhood”). I am an uninvited guest occupying the land of the Narragansett & Wampanoag people in what is now called Rhode Island in North America (note: I strongly recommend learning more about Indigenous culture, e.g. the All My Relations podcast).
While social justice movements tend to focus on addressing the oppression of marginalized communities, decolonization involves a discrete and critical understanding of settler colonization and the movement toward reparation of land and resources (Tuck & Yang, 2012). I cannot discuss decolonization without acknowledging that I benefit from stolen land and resources as well as oppressive systems that are violent toward Indigenous and Black communities, including that of mental health care. MarleyAyo LLC (2020) defines decolonization as the “intentional repairing and reclaiming of ancestry, traditions, and values lost or violently disrupted by colonization and the transatlantic slave trade.”
“…colonization was a direct attack to our physical AND spiritual beings…they cut off a line to that ancestral knowledge and almost guaranteed that history would be lost.” – Decolonizing Gender (jackson & Shanks, 2020)
The history of settler colonization has deep roots connected to white supremacy and racism, anti-blackness, transphobia, fatphobia, and essentially any system, community, or person that vilifies, criminalizes, punishes, rejects, and erases those who at first glance seem “different” (Morgensen, 2012). For additional context, you can learn more about the 4 I’s of oppression in this Healing While Black podcast episode. Also, consider learning about the characteristics of white supremacy culture, which can show up in any group or organization as a reflection of the attitudes and behaviors of all people (regardless of race)–for example, believing there is only one right way to do something.
The construct of gender liberation expanded on the work of Ignacio Martín-Baró, a social psychologist who lost his life because of his revolutionary work; see Helping Queer Clients Become Their Own Liberators (Spector, 2020) for more details. Gender liberation involves shifting our focus from basic gender affirmation with the TGNB community toward liberation by addressing power dynamics, advocating for systemic and social change, and freeing ourselves and our clients from the systems of gender oppression (Singh, 2016; note: Anneliese Singh is a phenomenal speaker, writer, and researcher in this area–see also her TedX talk). This includes an awareness that the concept of “transness” itself is a historically white construct, meaning that gender fluidity and diversity existed and were accepted for centuries prior to settler colonization (e.g. A Map of Gender-Diverse Cultures; see also The Platypus Poem by J Mase III).
I have chosen not to explore these constructs more deeply because a) individuals who have experienced that history and live it every day do not need an explanation, b) it’s not my place to tell their stories, and c) there are many other appropriate sources that do so (e.g. Adrienne Maree Brown, Rachel Cargle, & Alok V Menon). It is my responsibility to listen, learn, and do better to honor the voices, bodies, and land that have been telling the story for years and continue to do so.
“Cisheteropatriarchy holds its roots in colonialism, and dismantling and unlearning these Western agendas forced upon us is a necessary action in the liberation of all oppressed peoples. If we are to obliterate white supremacy, a key component of that necessary project is recognizing and dismantling transphobia as an ongoing destructive phenomenon directly rooted in colonialism.” (Paramo, 2018)
Some clinicians may be completely new to these concepts and what this work looks like. Other clinicians may already be doing this work more intentionally. Still other clinicians may have no choice but to do this work because of their own personal experiences of marginalization, oppression, and intergenerational trauma.
13 common forms of colonization-connected behaviors in your clinical work with TGNB people
To be clear, it would be toxic allyship to consider completing a ‘checklist’ as the way to do this work, given the need for decolonization to be a long-term commitment. Decolonization work is ongoing with the intention of returning land, resources, and opportunities to the populations from which they were taken, as well as supporting Indigenous and Black communities as they continue to navigate intergenerational and present-day trauma.
Regardless, it may be helpful to reflect on possible warning signs of colonization-connected behaviors in your clinical work with TGNB people, including the following:
1. Limited historical knowledge
(e.g. relying on mostly white and/or cisgender people and systems to teach you what you need to know about settler colonization, antiracism and gender; understanding a lot about trans identities but less about working with BIPOC clients; having little understanding of how colonization, white supremacy, and fatphobia intersect with gender)
2. Exploitation of BIPOC and/or TGNB people
(e.g. expecting BIPOC and/or TGNB experts to train/consult with you for free; asking TGNB and/or BIPOC clients to explain things to us; using before-and-after photos of TGNB bodies without considering the potential felt objectification and dehumanization)
3. Relying on diagnosis and “the written word”
(e.g. doubting someone’s knowledge of their gender because of their developmental stage or another diagnosis like autism; noticing yourself getting bogged down by what is written in the DSM, WPATH manual, or trans guidelines; focusing on whether or not someone meets the criteria for gender dysphoria to accept their TGNB identity)
4. Performative/toxic allyship
(e.g, telling yourself that you are anti-racist while rarely engaging in action steps that help you to learn, grow, and change in movement toward anti-racism; privileged ‘allies” jumping to judge others who make a mistake when talking about race/gender without inviting them into a conversation; expressing how important this work is but not being willing to pay for consultation/supervision/training to improve competence).
Deborah Plummer’s work talks more about how to take anti-racist allyship to the next level.
“Achieving a healthy white-identity resolution and feeling racially secure enough not to exhibit racial superiority does more for eradicating racism than just being an enlightened ally.” ~Plummer, 2020
5. Shame and shutting down
(e.g. feeling frustrated about how hard it is to to “keep up” with the movements and language; defensiveness and/or shame reaction when you make a mistake; dismissing or challenging a perspective shared by a BIPOC and/or TGNB colleague or client about their experience; feeling offended/hurt by a client’s decision to see a “lived experience” clinician)
6. Treatment barriers
(e.g. limited treatment access; high cost of full fee; not taking insurance or having an inaccessible sliding scale range; and/or requiring multiple sessions for a surgery assessment without transparency and collaboration)
7. Saviorism and lack of humility
(e.g. believing that if you don’t do this work, no one will; not seeking training/consultation/supervision when you have a growth edge, i.e. room for improvement; frequent signaling to your TGNB and BIPOC clients, colleagues, and friends the extent of your allyship)
8. Poor boundaries
(e.g. taking on additional clients for extra money; not saying no to people because we feel guilty; not prioritizing our own self-care and work-life balance)
“…it should not be forgotten that one of the privileges of whiteness is having a gender that is defacto more legitimate and more coherent because of the binary framework in which it necessarily exists.” -binaohan, 2014
9. Colonized gender norms
(e.g. making an assumption about a client’s desired gender destination; encouraging forms of social/physical expression that someone hasn’t asked for; using any language/identifiers for gender/body part/surgery etc. that the client hasn’t already expressed or without checking that the language feels okay for them)
10. Colonized race-related norms
(e.g. failing to acknowledge the impact of colonization; assuming that all clients desire and feel safe coming out in all spaces; being unaware of resources that are specific to BIPOC TGNB people; using research and clinical interventions that have not been normed on BIPOC people)
11. Colonized body and ability norms
(e.g. reinforcing the racist history of fatphobia and diet culture by encouraging a client’s attempts at weight loss via dieting; focusing on client weight as a potential barrier to surgery rather than framing from the perspective of medical fatphobia and helping to advocate for client needs; making an assumption about a client’s health status based on their weight and/or eating habits; using ableist language, making assumptions about someone’s capacity to do something, or limiting communication and processing methods). Please see Fearing the Black Body (Strings, 2019).
12. Time and outcome expectations
(e.g. using language that suggests a “full transition” or “complete surgery”; assuming that trans men want to be masculine; finding yourself thinking that clients are moving too slowly and pushing someone to come out to their family and friends)
13. Insisting on comfort
(e.g. having a shame reaction and apologizing excessively when you make a mistake or client provides feedback; mentioning how hard it is to keep up with the language; not bringing up racism or anti-Blackness unless the client mentions they are struggling with the sociopolitical climate; addressing your privilege in the room the first time and then not bringing it up again)
Decolonizing Mental Health is Hard: Take a Moment of Reflection
Notice what comes up in your body and how it feels as you reflect on the above examples. Did you notice any feelings of shame? Embarrassment? Discomfort? Denial? Guilt? Relief? Irritation? Uncertainty?
After checking in with your body, consider how these examples are connected to your clinical training and approach to treatment, your knowledge of history or lack thereof, and your worldview.
I believe that a clinician’s ability to wholeheartedly and effectively serve the TGNB population requires ongoing critical awareness, examination, and acknowledgment of the following:
- A likely skewed lens of the world: past, present, and future
- Your approach to treatment: personally, professionally, and systemically
- How you operate around privilege and oppression inside and outside of the therapy room
- The history of settler colonization, enslavement, and genocide; white Western education, research, training; and lingering medical and mental health care trauma
- The ways in which you continue to benefit from and engage in the perpetuation of those systems that have caused harm or, for those who belong to historically marginalized communities, the ways in which you have internalized the impact of those systems
As you continue to move through this work, you will uncover the countless ways in which colonization is woven into the fabric of our personal and professional lives, which has a direct and ongoing impact on the oppression of marginalized communities. Those in power may seem to benefit in terms of resources and capitalism. But the psychological, emotional, and intergenerational impact of colonization affects everyone, not just TGNB, BIPOC, and other marginalized communities. We all will benefit by working toward racial, gender, and body liberation, as well as striving for decolonization through supporting Black and Indigenous communities to reclaim their ancestry, values, land, and rights.
“If Black women were free, it would mean that everyone else would have to be free since our freedom would necessitate the destruction of all the systems of oppression.” – Taylor, 2017 (in How We Get Free: Black Feminism and the Combahee River Collective)
In the next and final installment of this series, I will further discuss actionable ways to begin transforming your work with TGNB clients. I want to reiterate that this work is multifaceted and is not meant to focus on completing a list of “to-dos.” Rather, it is an opportunity to reflect on your practice and the ways in which you can continue to do better and to help heal the harm caused by our ancestors and our modern-day systems.
Please see below for an extensive list of resources created by TGNB folx and/or BIPOC* who expand on these topics. Another resource list will be provided at the conclusion of my next article as well.
*Note: For the purpose of this article, TGNB indicates transgender and gender nonbinary populations. The use of BIPOC sometimes represents Black, Indigenous, and People of Color (i.e., non-white people), and at other times it represents Black and Indigenous people of color primarily (Code Switch episode, Meraji & Escobar, 2020). When discussing BIPOC communities in this article, I am referring to the Black, Indigenous, and other communities of color who experience ongoing marginalization and oppression in relation to the colonized history of the Western world, including the intergenerational impact from their ancestors.
Resources for decolonizing your clinical work
- binaohan, b (2014). decolonizing trans/gender 101. biyuti publishing.
- Strings, S. (2019). Fearing the Black body: The racial origins of fat phobia. New York University Press.
- Taylor, K-Y. (2017). How we get free: Black feminism and the Combahee River Collective. Haymarket Books.
- Monyee´, T. (Host). (2020 – Present). Shaping the shift. [Audio podcast]. Producer unknown. https://shapingtheshift.com/podcast
- Quiana & Misty. (Hosts). (2020 – Present). Healing while Black podcast. [Audio podcast]. Producer unknown. https://healingwhileblackpodcast.podbean.com/
- Wilbur, M. & Keene, A. (Hosts). (2019 – Present). All my relations. [Audio podcast]. Producer unknown. https://www.allmyrelationspodcast.com/
Electronic print & audiovisual resources:
- Colorado Funders for Inclusiveness and Equity (COFIE). (2010). The four I’s of oppression. Adapted for use by the Chinook Fund. http://www.coloradoinclusivefunders.org/uploads/1/1/5/0/11506731/the_four_is_of_oppression.pdf
- jackson, k. & Shanks, M. (2017). Decolonizing gender: A curriculum. [Zine] https://www.decolonizinggender.com/
- Mase III, J. (2018, Aug 15). Platypus poem: Zone of rarity [Video]. YouTube. https://www.youtube.com/watch?v=mnNguCYwx1U&feature=youtu.be
- Meraji, S.M. & Escobar, N. (Hosts). (2020, September 30). Is it time to say R.I.P. to POC? [Audio podcast episode]. In Code Switch. NPR. https://www.npr.org/2020/09/29/918418825/is-it-time-to-say-r-i-p-to-p-o-c
- Okun, T. (n.d.). White supremacy culture. Dismantling Racism. https://www.dismantlingracism.org/uploads/4/3/5/7/43579015/okun_-_white_sup_culture.pdf
- PBS. (2015). A map of gender-diverse cultures. https://www.pbs.org/independentlens/content/two-spirits_map-html/
- Plummer, D.L. (2020, June 5). Not a racist? Then let’s be better antiracist. https://www.dlplummer.com/blog/not-a-racist-then-lets-be-better-antiracist
- Spector, M. (2020, Sept. 9). Helping Queer Clients Become Their Own Liberators. The Affirmative Couch. https://affirmativecouch.com/helping-queer-clients-become-their-own-liberators-liberation-psychologys-critical-contribution/
- Tedx Talks. (2015, June 30). Tedx Georgia State – Anneliese Singh – Trans liberation is for everyone. [Video]. YouTube. https://www.youtube.com/watch?v=-onhIoDRMdM
- The Martín-Baró Initiative for Human Rights. (n.d.). About Ignacio Martín-Baró. The Martín-Baró Initiative for Human Rights. http://martinbarofund.org/about/ignacio/
General Websites & Social Media Accounts:
- Brown, A.M. (writer/thought leader/podcaster, she/they) (n.d.). Adrienne Maree Brown. [@adriennemareebrown]. [Instagram profile, Website]. http://adriennemareebrown.net/
- Cargle, R. (public academic & writer, she/her). (n.d.). Rachel Cargle. [@TheGreatUnlearn, @TheLovelandFoundation, @Rachel.Cargle]. [Website, Instagram profile]. www.rachelcargle.com
- Mase III, J. (poet & educator, he/him). (n.d.). J Mase III. [@jmaseiii]. [Instagram profile, Website]. www.jmaseiii.com
- Menon, A.V. (author/speaker/performer, they/them). (n.d.). Alok V Menon. [@alokvmenon]. [Instagram profile, Website]. www.alokvmenon.com
Decolonization. (2020). By MarleyAyo, LLC. [Definition]. In Thea Monyee´ presents: The Blacker the brain – Free to heal – Decolonizing our practices. www.marleyayo.com
Morgensen, S. L. (2012). Theorising gender, sexuality and settler colonialism: An introduction. Settler Colonial Studies, 2(2), 2-22. https://doi.org/10.1080/2201473X.2012.10648839
Peramo, M. (2018, July 17). Transphobia is a white supremacist legacy of colonialism. Medium. https://medium.com/@Michael_Paramo/transphobia-is-a-white-supremacist-legacy-of-colonialism-e50f57240650
Singh, A. (2016). Moving from affirmation to liberation as psychological practice with transgender and gender nonconforming clients. American Psychologist, 71(8), 755-762. https://doi.org/10.1037/amp0000106
Tuck, E. & Yang, K.W. (2012). Decolonization is not a metaphor. Decolonization: Indigeneity, Education, & Society, 1(1), 1-40. https://www.researchgate.net/publication/277992187_Decolonization_Is_Not_a_Metaphor
Learn more about transgender and gender nonbinary affirmative therapy with addyson tucker, PsyD (they/them)
LGBTQIA+ Affirmative Mental Health During the Pandemic
The stress and anxiety wrought by the COVID-19 pandemic may be universal–so many of us face fears of the virus itself, not to mention job loss, illness striking our loved ones, and myriad missed social, professional, and financial opportunities–but all of us experience these differently. Just as everyone’s mental health needs are unique, therapy is not one size fits all. LGBTQIA+ clients in particular need to work with therapists who can understand and validate the unique experiences impacting their emotional wellbeing. Although no one is immune to the detrimental psychosocial effects of the pandemic, LGBTQIA+ clients can face some identity-specific challenges that make affirmative therapy especially crucial at this time.
Affirmative Psychotherapy & Unsupportive Families During the Lockdowns
These include extended time with family of origin and overall decreased social interaction. Pandemic-induced social isolation can hit LGBTQIA+ individuals harder, as many queer and trans people have strained relationships with their families of origin and thus rely heavily on friendships and chosen families for support. Being stuck in toxic family environments due to the pandemic, and enduring sustained lack of contact with friends, can constitute a dangerous combination for any client. LGBTQIA+ people living with family members who don’t respect their gender identity or sexuality may find their mental health negatively affected. This experience can also contribute to dysphoria and has been linked to substance abuse (Newcomb, 2019).
Affirmative Therapy & Lack of Social Connections During COVID-19
Further, lack of social connection is linked to suicidality, for which LGBTQIA+ populations are already at higher risk (Kaniuka, 2019). Prolonged feelings of loneliness can be self-perpetuating; when we feel disconnected, we might start to doubt our ability to connect with others, and we avoid opportunities for socializing out of fear. Happily, ongoing therapy sessions with a therapist who “gets it” and makes us feel seen can serve as a form of connection and help break the cycle of isolation. As we know well, the therapist’s office should be the one place in which clients don’t have to worry about appearing awkward or facing judgment. It can serve as a safer space in which a client can brush up on rusty social skills and build confidence.
Finally, more free time and solitude can make space for greater self-reflection, which may in turn bring up complex emotions in clients just discovering their sexuality and/or gender identity. It’s important for therapists to welcome discussions of these realizations with curiosity and validating support, whether we fully understand them or not. Other difficult topics that can emerge during extended periods of solitude and self-reflection–the trauma related to minority stress that so many LGBTQIA+ people face, for instance–may be challenging to navigate on one’s own but can provide rich fodder for the virtual therapy room as well.
Training in Affirmative Therapy
Simply put, now more than ever, LGBTQIA+ clients need therapists who can treat them without bias. They may be coming into sessions with a lot of self-doubt about their gender identity and/or sexuality. They may have wanted support before now, but perhaps did not feel confident approaching a provider due to the double stigma of being LGBTQIA+ and having a mental health condition. If you are an affirmative provider who is welcoming a client like this into your practice, congratulations on ensuring a safer space. Taking the time to get training in best practices for working with LGBTQIA+ communities makes you an invaluable resource for clients and a genuine lifeline during this unbelievably challenging time.
Learn more about working with LGBTQIA+ Clients
Alessi, E. J., Dillon, F. R., & Van Der Horn, R. (2019). The therapeutic relationship mediates the association between affirmative practice and psychological well-being among lesbian, gay, bisexual, and queer clients. Psychotherapy (Chicago, Ill.), 56(2), 229–240. http://doi.apa.org/getdoi.cfm?doi=10.1037/pst0000210
Feder, S., Isserlin, L., Hammond, N. Norris, M., & Seale, E. (2017). Exploring the association between eating disorders and gender dysphoria in youth, Eating Disorders, The Journal of Treatment and Prevention, 25:4, 310-317, DOI: 10.1080/10640266.2017.1297112
Johnson, K., Vilceanu, M. O., & Pontes, M. C. (2017). Use of Online Dating Websites and Dating Apps: Findings and Implications for LGB Populations. Journal of Marketing Development and Competitiveness, 11(3). Retrieved from https://articlegateway.com/index.php/JMDC/article/view/1623
Kaniuka, A., Pugh, K. C., Jordan, M., Brooks, B., Dodd, J., Mann, A. K., … & Hirsch, J. K. (2019). Stigma and suicide risk among the LGBTQ population: Are anxiety and depression to blame and can connectedness to the LGBTQ community help? Journal of Gay & Lesbian Mental Health, 23(2), 205-220.
Newcomb, M.E., LaSala, M.C., Bouris, A.,Mustanski, B., Prado, G., Schrager, S.M., & Huebner, D.M. (2019). The Influence of Families on LGBTQ Youth Health: A Call to Action for Innovation in Research and Intervention Development. LGBT Health, 6:4, 139-145. DOI: http://doi.org/10.1089/lgbt.2018.0157
“Grant me the serenity to accept the things I cannot change, the courage to change the things that I can, and the wisdom to know the difference.”
In 12-step treatment settings, the Serenity Prayer often makes an appearance at the beginning or end of a group session in substance abuse treatment. Drawn from the Christian tradition, reciting this prayer is intended to unite group members, reminding them to make the small choices every day that will help them maintain their sobriety from substance use. Some things, like developing healthy coping skills, are within the client’s control. With access to resources, a supportive sober community, and for many, clinical treatment, recovery from substance abuse can and does happen.
But what about those things that are outside of our clients’ control? For many LGBTQIA+ people, factors like homophobia, transphobia, family rejection, and discrimination complicate the recovery process. These systemic forces weigh on our clients along with the pressures of finding a support network, managing basic needs like shelter and food, and learning new coping skills for cravings and mental health symptoms. While recent years have seen an increase in resources allocated for people in recovery, navigating this system can be challenging. It can also be isolating as an LGBTQIA+ person to successfully start treatment for substance abuse, only to arrive on day one and be the only queer and/or trans person in the room. How can a client find sober support when they feel singled out? And how can they mitigate the overtly Christian themes of 12-step and other sober communities as a queer and/or trans person?
Affirmative Substance Abuse Treatment
As treatment providers, it is important for us to practice cultural humility and establish competence in LGBTQIA+-affirming therapy in our substance use treatment. The 2018 National Survey on Drug Use and Health revealed that in sexual minority adults–those who described themselves as lesbian, gay, or bisexual–37.6% reported marijuana use in the past year, compared with 16.2% in the general population (Drugabuse.gov). This suggests that it is likely that many of your clients identify as part of the LGBTQIA+ community, and will be looking to you to cultivate an environment that is both affirming of their identities and informed about how substance abuse may impact their community differently. While this process of learning and unlearning is a lifelong commitment to growing your clinical practice, starting to research and reflect is a great place to start.
Barriers to Accessing Affirmative Treatment
Using a barriers model to accessing treatment, there are several elements that may deter LGBTQIA+ clients from seeking services. First, to reiterate, substance abuse treatment is often heavily rooted in Christianity. While many in recovery find comfort in finding a higher power and drawing strength from their faith community, for others, the church has historically been a place of harm and rejection. The idea alone of going to an Alcoholics Anonymous meeting in the basement of a church might feel like walking into the lion’s den. AA and other 12-step groups also often use literature like the Big Book and daily devotionals that have been criticized for their gendered language and heteronormative themes. This may lead LGBTQIA+ clients to feel as though they do not fit into the recovery community.
Similarly, many treatment programs themselves are gendered. From settings such as sober housing to residential treatment, as well as within intensive outpatient programs (IOPs) and partial hospitalization programs (PHPs), many groups are gender segregated. Veteran treatment providers may remember the original logic for this decision as preventing group members from starting romantic relationships while in treatment, or perhaps to give clients a “safe place away from the opposite sex.” We know now that this line of thinking is flawed: it erases the existence of same-sex relationships.
While many treatment programs do recommend that clients refrain from starting new relationships while they are in the vulnerable period of early recovery, it is naïve to think that two members of a women’s discussion group could not start dating. Additionally, that “safe place” we are trying to establish for our clients must also take into account gender-expansive identities. How can we properly serve our transgender and non-binary clients if we only offer women’s and men’s treatment programs? If you are at the level of executive leadership in your agency, asking these questions is a good place to start in establishing accessible and equitable treatment provision.
LGBTQIA+ Communities & Substance Abuse Treatment
It is also important for clinicians to understand how substance abuse can impact different populations within the LGBTQIA+ community. Since the 1970s, for example, the vasodilator inhalant “poppers” has been a club drug popular among gay men, as it can produce a euphoric effect and relax smooth muscle in the body, making sex more pleasurable (Hall et al., 2014). Other club drugs, like methamphetamines and cocaine, have been commonly used among gay and bisexual men as well (Hazelden Betty Ford, 2016). Similarly, when considering substance use in social settings, research indicates that lesbians and gay men are less likely to abstain from alcohol use than their straight counterparts, with lesbian and bisexual women reporting more frequent heavy drinking (Green & Feinstein, 2013).
Further, it is worth noting that for LGBTQIA+ clients, seeking substance abuse services is an issue of access to healthcare. According to Faces and Voices of Recovery, a 2017 survey by the National Institute on Drug Abuse (NIDA) found that 77% of respondents identifying as gay, lesbian, or bisexual, and only 57% of those identifying as transgender, have access to affordable healthcare (Pennelle, 2019). While many substance abuse treatment agencies are funded by state programs like Medicaid, and do not require that clients have health insurance, others do require coverage. Still more are private-pay only, and can get quite expensive. For someone who is contemplating starting treatment, finding out that they are not able to afford it or that a state-funded program has a long wait list can be enough to push them back to a state of precontemplation.
As we know that substance abuse affects the LGBTQIA+ community at higher rates, and that it can impact various LGBTQIA+ populations differently, service provision may seem like a daunting task. Whether your role is as a case manager, a therapist, or a program director, there are a number of resources that you can offer to your clients as they start their recovery journey. While the best place to start is by making changes within your own agency, you may also want to review community resources. One place to start is calling 211, a nationwide service provided by the United Way. Whether you call or go online for information, a trained resource navigator can help you to identify LGBTQIA+ specific resources like sober support group meetings, sober housing, and more. Keeping in mind that many queer clients may not feel comfortable going to traditional 12-step meetings, an alternative to consider is SMART Recovery. This program uses a non-denominational approach to promote sobriety using science- and evidence-based interventions, and may appeal to clients seeking a peer support group without religious overtones. Another option may be looking into support groups or other resources through your local LGBTQIA+ center, or services on campus at your local college or university.
Changing the Things We Can As Therapists
Revisiting the idea of the Serenity Prayer, we as clinicians do not have to accept the things we cannot change in the substance abuse treatment community. There are real, tangible actions we can take to make services more equitable and accessible for our LGBTQIA+ clients. Whether you are part of executive leadership or a newly hired clinical staff member, you can and should educate yourself about how substance abuse impacts your queer clients. Remember: recovery can and does happen. It is up to us to help identify and remove institutional barriers, and help our clients get what they need to do it.
Affirmative Organizational Development Consulting for Substance Abuse Treatment Centers
The Affirmative Couch offers affirmative organizational development consulting for substance use treatment centers who want to create a safe, welcoming environment for all patients who walk through their doors.
Our consulting team joins your clinic and gathers information to identify ways in you can become more affirmative in your services for LGBTQIA+ community members. We provide a needs assessment and a community narration evaluation to begin exploring the gaps in service delivery to these communities and how this lines up (or doesn’t) with the mission and values of your organization. Our technical report will review our findings from these tools, offer next steps, and provide the foundation for your ongoing training with The Affirmative Couch.
Through this empowered approach, you will have everything you need to make systemic change in all areas of your treatment center from your paperwork to administrative procedures and from staff training and transforming organizational culture. We are here to answer questions to enhance your learning on your journey to becoming an affirmative treatment center.
If you want to learn more, schedule a call with us to discuss your needs!
Learn More About Addiction and LGBTQ Clients
Butler Center for Research. (2016, January 1). Substance Abuse Factors Among LGBTQ Individuals. Retrieved October 11, 2020, from https://www.hazeldenbettyford.org/education/bcr/addiction-research/lgbtq-substance-abuse-ru-116.
Green, K. E., & Feinstein, B. A. (2012). Substance use in lesbian, gay, and bisexual populations: an update on empirical research and implications for treatment. Psychology of addictive behaviors : journal of the Society of Psychologists in Addictive Behaviors, 26(2), 265–278. https://doi.org/10.1037/a0025424.
Hall, T. M., Shoptaw, S., & Reback, C. J. (2015). Sometimes Poppers Are Not Poppers: Huffing as an Emergent Health Concern Among MSM Substance Users. Journal of Gay & Lesbian Mental Health,19(1), 118-121. doi:10.1080/19359705.2014.973180
National Institute on Drug Abuse. (2020, August 25). Substance Use and SUDs in LGBTQ* Populations. Retrieved October 11, 2020, from https://www.drugabuse.gov/drug-topics/substance-use-suds-in-lgbtq-populations.
Pennelle, O. (2019, August 16). LGBTQ+ Recovery Resources. Retrieved October 11, 2020, from https://facesandvoicesofrecovery.org/blog/2019/08/16/lgbtq-recovery-resources/.
Rapp, R. C., Xu, J., Carr, C. A., Lane, D. T., Wang, J., & Carlson, R. (2006). Treatment barriers identified by substance abusers assessed at a centralized intake unit. Journal of substance abuse treatment, 30(3), 227–235. https://doi.org/10.1016/j.jsat.2006.01.002
Keywords: queer, LGBTQ, LGBTQIA, impostor syndrome, impostor, cognitive behavioral therapy, CBT, core beliefs
I thought I identified one way, but now I’m not sure. What if this really was just a phase?
I’m afraid I won’t like all of the changes medical transition will cause to my body. What if I’m not really trans?
Can I still be bisexual if I’ve never dated someone of the same gender?
Our clients seek therapy for a variety of reasons, but commonly, they are struggling to mitigate their own core beliefs with external influences. These may include family, friends, partners, or society at large–for LGBTQIA+-identified folks, how we see ourselves can often conflict with how the world interprets us. This type of invalidation can lead to self-doubt for many people, even making them question whether they are frauds or impostors. As therapists, our goal is to help clients identify and challenge their negative core beliefs, to challenge these external influences and find internal validation.
The theory of Impostor Syndrome originates from a 1978 paper from Georgia State University that examined the phenomenon in more than 150 “high-achieving women” (Clance & Imes). The authors found that in their psychotherapy practices, women often presented with “scholastic honors, high achievement on standardized tests, praise and professional recognition from colleagues and respected authorities,” yet did not report “an internal feeling of success” (Clance & Imes, 1978). Rather, these clients felt like “impostors,” as though they were given undue praise or accolades they did not deserve.
In recent years, Impostor Syndrome has entered the lexicon as a common experience among millennials. A 2013 article by Weir at the American Psychological Association examined the experiences of graduate students and suggested that for many, there is “‘confusion between approval and love and worthiness. Self-worth becomes contingent on achieving.” This attitude is compounded by factors like gender, sexuality, disability, class, and race, with impostor feelings being a strong predictor of future mental health problems among college students of color (Cokley et al., 2013).
Similarly, impostor feelings often pop up in psychotherapy with millennial clients, particularly those with one or more marginalized identities. In our culture, certain roles or industries are often referred to as a “boys’ club”–as these spaces were built by and designed for white, heterosexual, cisgender men, anyone who varies from this norm can feel like they don’t belong. Higher education is just one example of a much more global dynamic.
For LGBTQIA+-identified people, impostor feelings are often less about achievement and more about community. Many people find comfort in the use of labels or identity words–such as gay, lesbian, bisexual, transgender, genderqueer, gender non-binary, and more–to describe themselves and their sexuality and gender. For someone who is just starting to explore their identity, finding a community of people who have been where they are can be healing and fulfilling. But what if none of the labels fit quite right? Or what if your experience differs from that of your friend, or even of your partner?
Though it is often said that “comparison is the thief of joy,” human beings are prone to noticing the similarities and differences between themselves and others. It can feel isolating to know that how you identify differs greatly from someone else. But this is where we as therapists can employ cognitive behavioral therapy to help our clients change their thinking and develop their senses of internal validation.
One example might be a therapist working with a client who identifies as a cisgender woman and a lesbian. At the first appointment, the client shares, “I’ve only dated women since coming out in college. Lately I’ve noticed myself looking at men differently than before, and it’s confusing. If I’m attracted to guys, am I still a lesbian?”
From what this client is saying, she sees the problem as confusion about her identity. It is worth exploring with the client what being a lesbian means to her, and furthermore, what it would mean if she were to identify differently. Often, this is where impostor feelings start to surface: if I’m not this, then what? I must have been faking. I don’t really belong here.
Using the framework of cognitive behavioral therapy, clarifying the client’s core beliefs about herself can be helpful. These are deeply held feelings that are central to our being, and that influence how we see and interact with the world. Core beliefs can be positive or negative, such as “I am worthy” or “I am unworthy,” “I am safe” or “I am unsafe,” “I am good enough” or “I am not good enough.” For this client, the core belief underlying her impostor feelings may be related to belonging, or feeling like she does not belong in her community of friends–or safety, from feeling like she is on the outside.
After isolating a client’s core beliefs, one CBT intervention that can be utilized would be fact-finding, asking the client to provide as many pieces of evidence as they can why their belief is true or untrue. Using our same example, if this client’s impostor feelings trigger the core belief that she does not belong in her community because she is questioning her identity, the therapist and client can list a number of examples of evidence to the contrary.
“Well, my friends will still be my friends no matter what. They have always supported me. That wouldn’t change,” the client offers. “And even if I did have a boyfriend someday, that wouldn’t make me straight. I wouldn’t think that about somebody else in my position.” By talking through this fact-finding process, the client is starting to challenge and reconstruct her core belief of belongingness. It may also be helpful to have a client write down thoughts, beliefs, and evidence in a journal between sessions. This can be a helpful reflective exercise and also encourage clients to use their coping skills outside of therapy.
Core belief work is not always easy, nor is it a quick fix for impostor feelings. Therapy sometimes makes things worse before they get better, and clients can sometimes unearth deep-seated issues in therapy that take time, effort, and dedication to work through. That does not make their effort any less valuable, however, and small changes in the client’s self-perception should be noticed and praised. There may be certain situations or stages of life in which a client feels old impostor feelings starting to emerge again. When they do, it is important for the client to remember that they have control over their own thoughts and feelings, and that they can reconnect with their positive core beliefs.
Learn more about working with LGBTQIA+ Clients
Clance, P. R., & Imes, S. A. (1978). The Impostor Phenomenon in High Achieving Women: Dynamics and Therapeutic Intervention. Psychotherapy: Theory, Research and Practice, 15(3), 241-247.
Cokley, K., Mcclain, S., Enciso, A., & Martinez, M. (2013). An Examination of the Impact of Minority Status Stress and Impostor Feelings on the Mental Health of Diverse Ethnic Minority College Students. Journal of Multicultural Counseling and Development,41(2), 82-95. doi:10.1002/j.2161-1912.2013.00029.x
Weir, K. (2013). Feel like a fraud? GradPSYCH, 11, 24. doi: https://doi.org/10.1037/e636522013-001
By now, we are all experiencing the impact of the ubiquitous trauma and stress surrounding COVID-19 in some way. What might have started with a distal awareness of the problem quickly snapped to a reality that the world will forever be changed by this virus. You might have also noticed the varying “stages of grief” through which our clients and we ourselves are shifting, the unfortunate stage of denial being the one that has caused the most irrevocable damage to the world.
On the one hand, many may find the universality of this experience comforting–it is rare that everyone on the planet understands the same thing to some degree. The current situation presents a valuable opportunity for emotional validation and a sense of common humanity (i.e., increased self-compassion due to awareness of the common human experience of suffering). It often takes personal experience and connection to a situation to increase empathy and compassion, and we are seeing a lot of that right now.
On the other hand, I wish there was this strong of an empathic connection and worldwide response to problems like climate change, the murder of black and brown bodies, and the impact of capitalism on class disparities. Interestingly, each of these intersects with the effects of COVID-19, especially the disparity of the impact on (and deaths of) black folks in our country.
No matter how we process and move through this situation, many feel its impact as a trauma. While we work to validate our clients’ experiences and help them make sense of something entirely unprecedented, it is also important to remember that this situation impacts different people very differently. The disparities affecting various marginalized populations are amplified during this time. It is crucial to acknowledge the potentially devastating impact on the LGBTQIA+ community, especially on transgender and gender nonbinary (TGNB) individuals, many of whom are no strangers to trauma and grief. More background on this can be found in The Affirmative Couch’s course Gender Minority Stress and Resilience in Transgender and Gender Nonbinary Clients.
How our LGBTQIA+ clients might experience a compounded impact of grief and/or trauma related to COVID-19:
Physical distancing in unsafe and/or unaffirming living situations due to quarantine
- College students who were suddenly asked to leave campus
- Those in domestic violence or other abusive home environments
- People who have not disclosed or come out to their families/housemates
Social isolation due to the pandemic
- Being physically distant from one’s chosen family or an affirming environment (e.g., at a university)
- Being unable to explore communities or experiences that might be affirming, such as closed, limited, or postponed LGBTQIA+ centers and Pride month activities
Lack of resources to access safe space and online support for LGBTQIA+ Clients
- Limited resources to pay for stronger Internet connection, or lack of multiple devices
- Lack of privacy or safe space to seek online support or therapeutic help
- Food, housing, or job insecurity during this time
COVID-19 factors specific to TGNB people
- Canceled or postponed lifesaving gender-affirming surgeries
- Barriers to beginning gender-affirming hormones, monitoring bloodwork, and receiving preventative affirming healthcare
- Risk of misgendering via phone/video and distress/dysphoria of seeing one’s face via video conference
- Inability to affirm one’s gender expression due to lack of support and/or awareness of other household members
- Limited or no access to gender-affirming haircuts (i.e., hair can make or break someone’s experience of dysphoria on a given day)
- Increased body insecurity and disordered eating in response to the fatphobia strengthened by this crisis; you can read more about this in my article At the Intersection of Fat & Trans
How therapists can help our LGBTQIA+ clients during the coronavirus crisis:
The impact of each of these concerns is amplified for those with intersecting marginalized identities related to, for instance, race, class, ability, and mental/physical health status. To make matters worse, many of our clients experience anticipatory grief for the continued losses ahead as well as for the uncertainty of when things will “return to normal.” Here are some ways in which we might help our LGBTQIA+ clients, especially members of the TGNB community, to navigate this situation and find ways to practice self-compassion, gratitude, and hope.
Supporting LGBTQIA+ Clients with boundaries during the pandemic
This is not an “opportunity” for people to do the things for which they don’t usually have time. “Productivity porn” is shame-inducing for many who are experiencing this situation as a trauma. It is okay to limit time spent on consuming the news and social media. To paraphrase an important sentiment, this is not just remote work. You are at home during a pandemic crisis and attempting to work.
Providing validation for LGBTQIA+ clients
Acknowledge to your clients that employing all self-care strategies possible still may not help beyond simply keeping them afloat during this time. Surviving a traumatic experience takes an extreme emotional and physical toll, and it’s okay if clients’ eating habits and bodies change, if they sleep more than usual, and if they struggle to get work done.
Helping LGBTQIA+ Clients Develop Self-compassion
I can’t emphasize enough how important it is for our clients to be mindful and self-compassionate. Whatever thoughts, feelings, and behaviors emerge during this time make sense given the impact of collective traumas. Even if someone acts in a way that is inconsistent with their values, they are still worthy of self-nurturance and connection. You can learn more about these concepts through The Affirmative Couch’s course Helping Transgender and Gender Nonbinary Young Adults Develop Self-Compassion.
Finding and Celebrating little moments of joy and gratitude with LGBTQIA+ clients
- Ask clients to reflect on a vulnerable moment where they were able to nurture themselves or others
- What was one show/movie/podcast/song that made them smile or laugh?
- What is one thing they’re looking forward to in the upcoming week?
- What are three things about the past week for which they felt most grateful?
- Direct them to some of the many inspirational, hopeful, and positive ways in which people have been expressing themselves and creating via social media.
Finding meaning and connection
- Can clients volunteer virtually? Reach out to someone who is more isolated? Offer to drop off groceries for an elderly neighbor?
- What creative talents might be employed to help others?
- Engage clients in storytelling and/or writing–expressive writing exercises like these can be particularly useful–to help work through their feelings
- If they have financial resources, what organizations might benefit from their support?
- Connect virtually with supportive others, especially in spaces that are queer- and trans-affirming. Balance their socializing with meaningful conversation and moments of fun
- Help your clients explore whether local or statewide LGBTQIA+ organizations are running online groups and support spaces, and/or offering other forms of connection
Looking for Hope for the future (i.e., not focused on a specific time when things return to “normal”)
- Who is the first person a client can’t wait to hug again?
- What restaurant are they excited to go to first?
- For students, how will it feel to step back onto campus again?
- What is the first event/trip/appointment they’re looking forward to rescheduling?
A final note: These points are important for clinicians to keep in mind as well. We need these reminders now more than ever. Most of us are not at our best right now, and it is foolish to pretend to our clients that we are. This is a time for us to hold that we are all human, and that authenticity models for our clients why it is important to be less hard on themselves for struggling. At the very least, consider reading this “Dear Therapists” blog post.
Berinato, S. (2020, Mar 23). That discomfort you’re feeling is grief. Harvard Business Review. Retrieved from https://hbr.org/2020/03/that-discomfort-youre-feeling-is-grief
Thebault, R., Tran, A.B., & Williams, V. (2020, Apr 7). The coronavirus is infecting and killing black Americans at an alarmingly high rate. The Washington Post. Retrieved from: https://www.washingtonpost.com/nation/2020/04/07/coronavirus-is-infecting-killing-black-americans-an-alarmingly-high-rate-post-analysis-shows/?arc404=true
Patton, S. (2020, Apr 11). The pathology of American racism is making the pathology of the coronavirus worse. The Washington Post. Retrieved from: https://www.washingtonpost.com/outlook/2020/04/11/coronavirus-black-america-racism/
Tucker, M. (2019). Gender minority stress & resilience in TGNB clients. Retrieved from: https://affirmativecouch.com/product/gender-minority-stress-and-resilience-in-transgender-and-gender-nonbinary-clients/
Tucker, M. (2019) At the intersection of fat & trans. The Affirmative Couch. Retrieved from: https://affirmativecouch.com/at-the-intersection-of-fat-trans/
Ahmad, A. (2020, Mar 27). Why you should ignore coronavirus-inspired productivity pressure. The Chronicle of Higher Education. Retrieved from: https://www.chronicle.com/article/Why-You-Should-Ignore-All-That/248366
Tucker, M. (2019) Helping TGNB young adults develop self-compassion. The Affirmative Couch. Retrieved from: https://affirmativecouch.com/product/helping-transgender-and-gender-nonbinary-young-adults-develop-self-compassion/
Pennebaker, J.W., Blackburn, K., Ashokkumar, A., Vergani, L., & Seraj, S. (2020). Feeling overwhelmed by the pandemic: Expressive writing can help. The Pandemic Project. Retrieved from: http://exw.utpsyc.org/#tests
Katy (2020, Mar 21). Dear therapists. Navigating Uncertainty Blog. Retrieved from: https://navigatinguncertaintyblog.wordpress.com/2020/03/21/dear-therapists/
Learn more about affirmative therapy with addyson tucker, PsyD (they/them)
As we approach winter and prepare for “hibernation,” diet culture and fatphobia often kicks into high gear. Family meals, holiday parties, and New Year’s resolutions surround us, regardless of whether we celebrate, and become fertile ground for fat shaming. The “holiday season” is already hard enough for many LGBTQIA+ folx*. It can also be an exceptionally dangerous time of year for fat folx, as well as those who experience disordered eating. (Note: See my previous article, At The Intersection of Fat & Trans, for further descriptions of fatphobia and weight stigma).
*Folx is an alternative spelling of folks, meant to represent inclusivity in a way similar to terms such as womxn and latinx.
Did she just say fat?
Yes, you read that correctly. “Fat” is not a bad word, though it’s often wrapped in a framework of shame. How often do those with larger bodies get unsolicited weight management or weight loss advice? When a person says, “Ugh, I’m so fat,” how quickly do we jump in to dismiss their experience and try to make them feel “better”? Our response to a friend who has lost a significant amount of weight (e.g., “wow, you look great!”) differs significantly from the response to a friend who has gained weight (e.g., “I’m concerned about your health”). The messages we get from diet culture, the media, and most other humans is that fat=lazy, bad, ugly, and unhealthy, versus thin=fit, good, desirable/attractive, and healthy.
But surely queer and trans communities are less fatphobic?
Unfortunately, members of LGBTQIA+ communities have not quite embraced fat liberation yet. Many activists and theorists have spoken to fatness as a queer and feminist issue, as well as discussing fatphobia in the queer and trans community (e.g., Mollow, 2013). For example, consider trans and nonbinary folx who feel pressure to shrink their bodies to avoid being misgendered, gay men who indicate “no fats, no femmes” on their dating profiles (Conte, 2018), and queer women who are called fat bitches or fat dykes when they turn down someone’s advances.
As in most intersectional social justice work, the impact is often worse for people of color (Strings, 2019). For further reading, please see Fearing the Black Body by Sabrina Strings (2019). Mollow writes, “Anti-racist, feminist, and queer activists must make fat liberation central to our work; we need to explicitly and unequivocally reject the notion that body size is a ‘lifestyle choice’ that can or should be changed” (for further reading, please see The Bizarre and Racist History of the BMI; Your Fat Friend, 2019).
What should I keep in mind for my clinical work?
During the holidays, people are bombarded with messages on how to avoid weight gain, ways to “eat smart” during holiday meals, and what workouts are most effective to keep one’s body at its “best” (read: smallest). If all else fails, resolution season arrives with plenty of reduced-fee gym memberships, exercise programs, and diet plans. Many gatherings with family and friends are centered around food. Unfortunately, those in our immediate circles often believe our food intake and how our bodies have changed since they last saw us are fair game for dinner conversation. This behavior is almost always a wolf in sheep’s clothing–fat shaming and food policing thinly veiled by “I care about your health.” It also often connects to the commenter’s insecurity and their own internalized fatphobia or beliefs about what their body should look like, what they should be eating, etc.
While these experiences happen to people of all shapes and sizes, this kind of commentary is more frequent and insidious for fat folx, as most people are conditioned to believe that we are less worthy if we are fat or at risk of becoming fat. LGBTQIA+ people, who already approach the holidays feeling worried about various family dynamics, lack of acceptance, and/or outright homophobia/transphobia, might need support to develop a game plan. (Note: Please also check out earlier pieces written about this topic by Chastain, 2014a; 2014b; Mollow, 2013; Murphy, unknown; Raven, 2018; and Rutledge & Hunani, 2018.)
Here are some possible topics to address fatphobia with your clients:
1) Make a choice about attending, if optional
With my LGBTQIA+ clients, we first consider whether going to visit certain family members and/or attending various holiday events is physically and emotionally safe. If not, could they spend the holiday with chosen family? If there is no ideal alternative or the person is sure they want to go, I empower their decision and encourage them to approach the situation with a grounded sense of self, giving themselves permission to step back and engage in self-care as needed; see #6 below.
2) Define boundaries and potential consequences
This part is crucial. Boundaries are as simple as what is okay and what is not okay. Help your client identify their boundaries and the potential consequences if those boundaries are crossed. Make sure they feel comfortable following through with these (e.g., don’t threaten to leave if it’s not a feasible option). For example, “What I’m eating is fine. Please stop commenting on my food choices. If it happens again, I’m going to excuse myself from the table.” Encourage them to practice the boundary setting in advance, preparing for best versus worst case scenario with particularly difficult individuals. Finding the humor, even if they’re the only one in on the joke, can sometimes help. You might check out Oh, Boundaries (Oh, Christmas Tree) Song Adaptation (Chastain, 2016).
3) Pregame conversations
Once the client knows what their boundaries are, they might consider reaching out to trusted family, friends, or the event host in advance. For example, they could send a text or blind copy email that says, “Hi family, just a reminder that I am working on loving my body at all sizes and practicing intuitive eating. My body has also changed slightly since I started taking hormones, so please do not make any comments about my food choices, my body, or my weight when I am home next week. Appreciate your understanding – see you soon!” This gives those individuals an opportunity to prepare and learn more rather than responding defensively in the moment. If this approach may not be well received by everyone in attendance, could the client identify one or two trusted folx who will have their back if the conversation turns to weight and body talk?
4) Address internalized fatphobia
One of the toughest parts of resisting fatphobia and diet culture is our cultural internalized stigma and belief that fat is bad. Help your clients see the roots of fatphobia in racism, misogyny, and oppression (that is, while remaining attentive and attuned to their experiences of internalized body shame). Firstly, remind your clients that no one has the right to comment on their body or food choices. If they struggle to comfort and care for themselves, you might ask them to imagine those external comments and internal shame narratives impacting a close friend or a young sibling.
Above all, food is not good or bad. That is to say, being fat is not bad, and body size is not a determinant of health, worth, or desirability. We can feel uncomfortable with certain parts and features of our body (hello, dysphoria) without harming or hating the parts of our body that help us to survive. Bodies experience natural fluctuations in weight throughout the year. People can make whatever choices they want about their bodies and food. That includes making decisions for themselves about whether to engage in diet behavior or body modification, as well as whether to embrace fat liberation, health at every size, and intuitive eating philosophies. It also might include examining their social media consumption to critically examine which accounts activate internalized self-judgment and shame while shifting toward those that engage in transformational and affirming conversations about bodies, fashion, and food.
5) Prepare ways to respond
Helping our clients advocate for themselves is an important component of recovering from diet culture and internalized fatphobia. LGBTQIA+ people have often been expected to perform in certain placating ways when interacting with hurtful others. “Too often we get the message that as [LGBTQIA+ people], it’s our responsibility to always be ‘on’–to always advocate for the cause, or to behave ‘properly,’ or to keep the peace. We’re told that it’s our job to endure demonizing sermons and degrading misgendering in the name of ‘dialogue’ or whatever. But we don’t have to.” (Murphy, unknown).
Therefore, when responding to fatphobic comments and questions such as, “Should you really have a second serving?” each person needs to think about what might work best for them depending on whether they’d like to shut the conversation down or potentially open it up for further dialogue.
Here are some examples of responses:
- Short & sweet, then continue to eat (e.g., “Yes, I should.”)
- Humor & sarcasm (e.g., “If I want to talk to the food police, I’ll call Pie-1-1”; Chastain, 2014)
- Firm boundaries (e.g., “I get to make my own food choices – it’s not okay for you to comment on them. Please stop, or I will leave the table.”)
- Authentic curiosity (e.g., “What made you decide to comment on what I eat?”)
- Reflect on diet culture (e.g., “Isn’t it interesting how shaming it is when we comment on others’ bodies and food choices?”)
- Self-reflection (e.g., “Those types of comments are really hurtful, and I know there are times I’ve commented on your food choices as well–I’d like us to stop doing that.”)
- Reframe and shift (e.g., “I wonder if you think those types of comments come from a place of caring. They actually make me feel shame and the desire to pull away from you. Let’s focus on catching up and enjoying our time together.”)
- Ignore and move through discomfort – It is always an option to decide not to respond, not to speak up, and to instead move through and take care of yourself in other ways. Sometimes this is the safest option emotionally and/or physically.
- A potential dilemma – It can be hard to meet family and friends where they are, especially when the conversations are painful. Making the decision to educate someone is always optional, as the other person should take responsibility for educating themselves (and this goes for various other social justice matters, such as racism). At some point, many of us have made value judgments and comments about others’ food choices or body size based on our internalized shame around diet culture and fatphobia. It can take some time and energy to adjust those patterns of thinking. Bottom line: there is a difference between healthy, respectful, and curious discourse versus harmful and fatphobic comments, questions, and behaviors. Hence, the need for boundaries.
6) Have an exit strategy (i.e. self-care plan)
In many cases, setting a firm boundary and following through with the consequence should be quite effective. However, sometimes these responses may do little or nothing to stop others from perpetrating harmful microaggressions and fatphobic judgments. In those cases, it is good for your client to have a plan for self-care, considering the following:
- Permission giving – If things don’t feel good, can they give themselves permission to be prepared to leave if necessary?
- Take space – go for a walk, play with the kids or pets, watch a movie, listen to music, etc.
- Get support – Does the client have a friend who “gets it” and can be available to call or text? Or can the client log onto social media and check out some of the dietitians, bloggers, clinicians, and influencers who focus on fat liberation and intuitive eating (see resource list at the end of this article)?
- Practice validation & self-compassion:
- Duality: It’s okay to care about someone while also being disappointed or hurt by their behaviors and comments.
- Remember: Setting boundaries is a healthy way to show our expectations of love and respect for people who matter.
- Forgive themselves: It makes sense that they are tempted to go along with the comments–it is hard to speak up against diet culture and fatphobia.
- Validation: Many LGBTQIA+ people struggle around this time of year with difficult family interactions; they are not alone.
- Self-nurturance: Clients can use affirmations such as, “I am worthy. I am enough. My body is worthy at all sizes. I deserve to be treated with respect and common human dignity. It’s okay to protect myself from fatphobic comments.”
How can I continue to learn about fat liberation and radical self-love to support my clients?
- Practice radical body love and fat acceptance–for yourself and others! It doesn’t mean you will successfully love all parts of your body all the time, but it sure will help.
- Consider anti-diet and intuitive eating practices all year round–they can be life changing.
- Actively reduce and aim to eliminate diet talk, which often serves to shame people and essentially teaches us to avoid at all costs becoming a “bad fat person.”
- Rather than praising bodies that have thin privilege or seem to have lost weight, consider finding other ways to let people know we appreciate them.
- Instead of using descriptors that are pathologizing (“overweight” suggests there is a lower weight that is normal/better/good), stick with actual descriptors that help us to understand (such as “fat”). When possible, check in with others about the descriptors that work for them and what words they prefer.
- Surround yourself with social media and images of fat people of all races and abilities, appreciating the beauty and diversity of the human body.
- “If previously you have ruled out fat people as potential sexual partners, rule them back in, and rule out ‘fatphobes’ instead” (Mollow, 2013).
- Make choices for your body that feel good for you, and only you. Give your body size permission to vary with time, hormones, and many other factors.
- Be mindful of where your clients are in terms of their readiness for discussions related to diet culture and internalized fatphobia; as with any other intervention, gauge helpfulness as well as observing their body language as you move through.
A final note for those of you who are already anti-diet and practicing fat acceptance: It takes so much courage to move through these conversations with our clients, friends, and family members who don’t quite understand (yet!). Keep doing this work, because it matters. You matter. Thank you for persisting.
Online & Social Media (Note: @ = Instagram handle):
@ragenchastain & https://danceswithfat.org/blog; @chr1styharrison & Food Psych podcast; @yrfatfriend; @recipesforselflove & book; @bodyposipanda; @mynameisjessamyn; @jazzmynejay; @livinginthisqueerbody; @mermaidqueenjude; @ihartericka; @thefatsextherapist; @decolonizingtherapy
NOLOSE – Originally the National Organization for Lesbians of Size – later expanded to include all genders. Has a queer fat-positive ideology. http://nolose.org
Strings, S. (2019). Fearing the black body: The racial origins of fat phobia. New York University Press. New York, NY.
Taylor, S. R. (2018). The Body is Not an Apology: The Power of Radical Self-Love. Berrett-Koehler Publishers, Inc: Oakland, CA.
Your Fat Friend. (2019). The bizarre and racist history of the BMI. Medium – Elemental. Retrieved from: https://elemental.medium.com/the-bizarre-and-racist-history-of-the-bmi-7d8dc2aa33bb
Learn more from addyson tucker‘s continuing education courses
Baker, Jes. (2015). How to stay body positive during the holidays: Master list. The Militant Baker. Retrieved from:http://www.themilitantbaker.com/2015/12/the-how-to-stay-body-positive-during.html
Conte, M. T. (2018). More fats, more femmes: A critical examination of fatphobia and femmephobia on Grindr. Feral Feminisms: Queer Feminine Affinities, 7.https://feralfeminisms.com/wp-content/uploads/2019/04/3-Matthew-Conte.pdf
Chastain, R. Blog – Dances with fat: Life, liberty, and the pursuit of happiness are for all sizes.
- Combating holiday weight shame. (2014a).https://danceswithfat.org/2014/11/20/combating-holiday-weight-shame/
- Dealing with family and friends food police. (2014b)https://danceswithfat.org/2014/11/24/dealing-with-family-and-friends-food-police/
- Setting holiday boundaries – in song! (2016).https://danceswithfat.org/2016/12/14/setting-holiday-boundaries-in-song/
- Dealing with diet season. (2018a).https://danceswithfat.org/2018/01/05/dealing-with-diet-season/
- Resources for surviving fatphobia at the holidays. (2018b).https://danceswithfat.org/2018/12/24/resources-for-surviving-fatphobia-at-the-holidays/
McKelle, E. (2014). Cutting fatphobic language out of your life. Everyday Feminism. Retrieved from:https://everydayfeminism.com/2014/04/cutting-fatphobic-language/
Mollow, A. (2013). Why fat is a queer and feminist issue. Bitch Media. Retrieved from:https://www.bitchmedia.org/article/sized-up-fat-feminist-queer-disability
Murphy, B. (unknown). 8 queer tips to get through the holidays. Queer Theology. Retrieved from: https://www.queertheology.com/queer-holiday-tips/
Raven, R. (2018). 6 ways to deal with fat-shaming during the holidays, from someone who knows what it’s like. Hello Giggles. Retrieved from:https://hellogiggles.com/lifestyle/health-fitness/6-ways-to-deal-fat-shaming-during-holidays/
Rutledge, L., & Hunani, N. (2018). Take it from dietitians: Holiday diet advice shouldn’t be fatphobic. Huffington Post. Retrieved from: https://www.huffingtonpost.ca/lisa-rutledge/holiday-diet-advice-weight-loss_a_23621979/
Tucker, M. (2019). At the intersection of fat and trans. The Affirmative Couch Out on the Couch. https://affirmativecouch.com/at-the-intersection-of-fat-trans/
November 20th has been known since 1999 as the Transgender Day of Remembrance (TDOR). On this date, across the world, ceremonies and vigils are held to remember transgender individuals we lost to murder and suicide in the past year. Often somber and emotionally triggering, TDOR allows the community to gather and honor individuals whose stories are often ignored or incorrectly told. As this day approaches, I often think of Marsha P. Johnson.
Johnson, a transgender black woman, has long been credited within the queer and trans community for being the person who threw that first brick at Stonewall (Feinberg, 1996) and the creator of STAR, an LGBTQ+ youth shelter. Many don’t know that Johnson was an activist from early on in her life, fighting for gay rights and visibility instead of assimilation (Chan, 2018). After high school, she spent her days on the streets of New York, learning to survive and being repeatedly sexually assaulted and harassed (Chan, 2018). But the assault, harassment, and oppression she experienced due to her sexuality, gender identity, and skin color didn’t stop her for standing up for what she believed in. Knowing firsthand the discrimination the often-ignored transgender community suffered, she took an active role in ACT UP (https://actupny.org/), helping to speak out for HIV+ individuals and give a voice to people of color who were dying from the disease (Jacobs, 2016). Johnson was an inspiration to transgender individuals, especially to those of color. Her tragic death is frequently regarded as the first “notable” and documented murder of a transgender person in the United States.
In 1992, shortly after the New York City Pride Parade, Johnson’s body was found floating in the Hudson River (Feinberg, 1996). The cops ruled it a suicide, despite many people’s protests that Johnson was anything but suicidal and eyewitness reports that she was being harassed earlier during the day they believed she had died (Feinberg, 1996). The case was limitedly investigated and never solved. The media portrayed Johnson as a trans woman who was a sex worker and a drug user, leaving out the truths of her activism and every other aspect of her life (Feinberg, 1996); it is likely that had she been a cisgender white woman, media coverage would have been vastly different and much wider. Johnson’s voice, something she worked so hard to give herself while navigating major oppression in her lifetime, was taken away. Even worse, her killers were never found; to this day, minimal effort has been put into solving her murder.
You may be wondering what this has to do with psychology, and how Johnson’s death can show up for you, as a clinician, in the therapy room with your transgender clients. Well, it’s simple: the reaction of the public to Johnson’s death parallels how many transgender individuals feel about what their lives are worth to the rest of the world. It also relates to transgender people’s sense of whether others care about their safety. As a clinician who has worked in the community in varying capacities, I can attest to the fact that transgender people feel that their lives don’t matter. There is a constant threat of insufficient safety and feelings of protection, especially under the Trump administration when it seems as if transgender rights are under attack daily.
Almost every week I hear about another transgender individual, usually a trans woman of color, who has been murdered or found dead under mysterious circumstances. In many of these cases the killer is never found, or if they are, they are not named. The media often misgenders the victim, and very little coverage is given in the first place. My trans clients come to me with fear in their voices, wondering if they will be next just because they are living their authentic truths. Worse, and heartbreakingly, clients sometimes find that this fear is accompanied by wondering whether or not anyone would even care if they were gone, and if they deserve being killed due to being transgender.
Furthermore, clients have to navigate safety in many other aspects of life. Transgender clients have told me that they often don’t feel safe in their jobs and have a fear of being fired; what’s worse, nobody in their workplace will do anything to help when they are feeling threatened. I have heard about clients being assisted when buying shoes or clothing, and fearing that a salesperson will “find them out” and make a scene. Clients can fear for their safety in terms of secure housing and access to other social welfare services, the loss of which threaten their ability to survive.
So how can we, as clinicians, help with these fears? Certainly, the wrong thing to do is to try to make excuses for others or diminish the situation, because these fears are real. Also, if you are a cisgender therapist, there is no way to fully understand what your client is going through. It is best not to try to relate or use comparisons to other marginalized communities. I have heard of individuals telling their therapists about the fear of shopping, and the therapists suggesting in response to “shop online,” unsolicited advice that comes across as invalidating.
But then what is the right thing to do? First, validate the fear, which is constantly present. Ask questions. What does this fear look like to them? How does it show up in their lives? Secondly, address the fear and help empower your client to find ways to protect themselves. While we do not teach our clients physical self-defense techniques, we can certainly teach them mental defenses. Find positive self-talk and coping techniques when encountering non-life threatening yet mentally damaging situations. Third, help your client devise safety plans and locate resources. Is there someone they can call any time of the day, or put on alert when they are encountering any new or potentially triggering situation? Is there an emergency line they can reach that they know they can trust? Having access and knowledge to trans-affirmative resources can be life saving.
With all of that said, November is always a difficult month for the transgender community. Whether or not your client is aware of this fear on a daily basis, we cannot deny that the number of deaths we recognize during TDOR and the number of clients facing fear seem to increase annually. November is filled with a constant reminder to be vigilant and that the fight is far from over. As clinicians, we must recognize this and do everything we can to support our clients in the most affirming way possible.
Learn More about working with Transgender and Nonbinary Clients
Chan, S. (2018). A transgender pioneer and activist who was a fixture of Greenwich Village street life. The New York Times. Retrieved from https://www.nytimes.com/interactive/2018/obituaries/overlooked-marsha-p-johnson.html
Feinberg, Leslie (1996). Transgender Warriors: Making History from Joan of Arc to Dennis. Boston, MA. Beacon Press
Jacobs, S. (2012). DA reopens unsolved 1992 case involving ‘saint of gay life’. New York Daily News. Retrieved from: https://www.nydailynews.com/new-york/da-reopens-unsolved-1992-case-involving-saint-gay-life-article-1.1221742
By Rachel Jones, MA
NOTE: Throughout this article, I will refer to different gender identities including non-transgender women and transgender women. Every person has a gender identity, which is separate from the sex assigned at birth. Non-transgender or non-trans describes a person whose gender identity is the same as the sex assigned at birth–for example, someone who identifies as female and was assigned female at birth (GLAAD, 2019). Cisgender is another term used in replacement of non-trans, but it will not be used in this article for the sake of centering on transness and to avoid centering cisgender as the “norm” (GLAAD, 2019). Transgender or trans describes a person whose gender identity is different from the sex assigned at birth–for example, someone who identifies as female and was assigned male at birth (GLAAD, 2019). Distinguishing non-transgender women and transgender women throughout the article is solely for the purpose of pointing out perceived differences in a clear manner, and NOT to suggest that either term makes someone more of a woman than the other.
Women’s Equality Day
In the United States, August 26, 2019, will mark the 46th annual Women’s Equality Day. In the 1970s, President Nixon and the US Congress appointed August 26 to be Women’s Equality Day to commemorate the nineteenth amendment (Greenspan, 2018). In 1920, the United States government allowed women the right to vote, ratifying the nineteenth amendment that declared voting rights would not be denied on the basis of sex or gender (U.S. Const. amend. XIX). Today, millions of people across the country continue to advocate for women’s equality. However, a major aspect of mainstream feminism seems to be forgetting something pretty important. The battle for women’s equality has not been won if the only winners are white, non-transgender women. Mainstream feminism’s definition of a woman must be inclusive of transgender women, women of color, queer women, and other women in marginalized groups – otherwise, it is simply not feminism. In recent years, major feminist-driven events such as the Women’s March more explicitly and affirmatively include women of color and queer women in their mission, but transgender women continue to be blatantly left out of the major feminist discourse (Anti-Defamation League, 2017).
Similar to the experiences of non-transgender women vying for equal rights, transgender women experience dramatic disparities in civil liberties, legal protections, and cultural equity (Grant et al., 2011). Unlike non-transgender women, transgender women don’t have millions of privileged people fighting alongside them with the goal of equality. Instead, trans women are banned from women’s locker rooms, unprotected in public restrooms, left out of feminist manifestos, mocked by government representatives, and robbed of basic human rights to safety and respect. Many self-proclaimed feminists gleefully join their peers at Pride parades, yet express outrage when a trans woman hopes to share safe spaces.
A women-only space cannot be labeled safe if trans women are not allowed in that space–or are at risk of harassment or other hurts in that space. Equal pay for women has not been achieved if non-trans women receive higher wages than their transgender sisters. The quality of women’s healthcare has not been enhanced if clinicians are only trained to care for non-transgender women and their bodies. Misogyny has not been defeated if trans women are still being misgendered and pronouns are not respected or affirmed. Refusing to acknowledge trans women in the rulebooks of feminism makes it difficult to apply the narratives we work so hard to rewrite. Is the team really winning if half the players have been benched or disqualified?
Transphobia and Feminism
Transphobia is a driving force attempting to keep trans women out of feminism. While transphobia is often seen as a politically far-right driven attitude against transgender people, a popular subgroup of modern feminism has been loudly promoting transphobia across the country. This subgroup of radical feminism is often referred to as trans-exclusionary radical feminism or TERF and is considered a hate-group by many since its mission seems to promote transphobia and transmisogyny (Lewis, 2019). TERF ideology argues misogyny can only affect people with ovaries, uteruses, and vaginas, claiming trans women cannot be targets of misogyny (Dembroff, 2019). Furthermore, this group of radical feminists states trans women “by definition” are not “adult human females” and therefore “no trans woman is correctly categorised (sic) as a woman” (Stock, 2019). Other group members have acknowledged the decision to purposely misgender trans women, stating that using she/her pronouns for trans women is a “courtesy” they rarely extend (Bindel, 2019). Radical feminists have gone so far as to argue transgender women identify as female in order to “infiltrate women’s spaces” and assault or harass non-trans women (Kacere, 2014).
These infuriating and inflammatory messages spew misinformation and hate, and can lead to dangerous misunderstandings. No transgender woman casually goes through the costly and trying physiological, social, professional, and emotional transitions.Transitioning often is motivated by wanting to feel affirmed in one’s gender identity, avoiding repression, combating suicidal ideation or dysphoria. In fact, research shows approximately three-quarters of trans women who transition experience an increase in psychosocial well-being and quality of life (Hess et al., 2018). Transgender people do not transition for the sake of harming or harassing others, and it is upsetting that such a statement needs to be spelled out. Non-trans women experience blatant inequality in the United States, and there are many ways to address those inequalities while involving trans women. In fact, it is almost impossible to effectively approach feminist issues if the female population is being separated into trans and non-trans women.
Feminism Must Include All Women
Equal Pay. Although the nineteenth amendment was a major feat in the fight for equal rights, it was by no means the end of inequality for women in the United States. In 2018, women in the US earned on average 81.1 percent of their male colleagues’ weekly earnings (Hegewisch & Hartmann, 2019). When broken down by race and ethnicity, this gap became even bleaker. White women, Black women, Hispanic (sic) women, and Asian women earned 81.5 percent, 65.3 percent, 61.6 percent, and 93.5 percent respectively of their white male colleagues’ earnings (Hegewisch & Hartmann, 2019). Objectively, these disparities are alarming.
Workplace Discrimination. While precise numbers on transgender wage earnings are lacking, research findings on the experiences of transgender women in the workplace are nothing short of disturbing. More than one in three transgender women have lost a job due to gender identity or expression, and over half have been denied employment due to being transgender (Grant, et al., 2011). Furthermore, 32 percent of transgender people have been “forced to present in the wrong gender” to keep their job (Grant et al., 2011). Because of the lack of legislature protecting gender identity and expression in the workplace, transgender people experience unemployment and insufficient income at rates three times the national average (Grant et al., 2011). As feminists fight for equality in the workplace, it is vital to be aware of these experiences of transgender women in addition to the more widely publicized inequities of working non-transgender women. Due to the intertwined intricacies, we cannot fix one issue without facing the other. The fight for women’s rights and equality have been going on in the United States since its conception, and all women deserve advocacy.
School. 21 percent of school-age transgender girls are sexually assaulted at school because of their gender identity, and 22 percent had to change schools due to mistreatment (James et al., 2016). Over 20 percent of non-trans girls experience some form of harassment or bullying in school, and eight percent avoid attending school due to feeling unsafe (Hess et al., 2015).
Homelessness and Poverty. Over 20 percent of trans women of color reported homelessness in the past year due to gender identity, and many were denied access to shelters due to being transgender (James et al., 2016). For trans women of color, the rates of homelessness rise to around 50 percent (Human Rights Campaign, 2018). Non-trans women have higher poverty rates than men, and non-trans women of color have higher poverty rates of approximately 25 percent (Hess et al., 2015).
Sexual Violence. Five percent of all transgender people have been attacked by strangers and almost 40 percent of transgender women have been sexually assaulted at least once in their lifetime (James et al., 2016). Furthermore, trans women of color make up 80 percent of all anti-transgender homicides (Human Rights Campaign, 2018). Approximately one-fifth of non-trans women experience sexual violence or rape in their lifetime (Hess et al., 2015). For Native American and multiracial women, those numbers jump to one-third (Hess et al., 2015).
Hate Crimes. In addition to widespread transphobia and the disturbing inequities in many other areas, transgender women experience inequality, misogyny, and oppression perpetuated by an obscene lack of civil protections. Almost two-thirds of states have laws protecting non-transgender women against hate crimes, while less than half include biases against gender identity and transgender people in their legislature (Human Rights Campaign, 2018). In the United States, there are on average five hate crimes against transgender people for every single hate crime targeting non-transgender women (Federal Bureau of Investigation, 2017).
These statistics are not for the sake of creating a “who has it worse” narrative. Rather, they are presented to point out that transgender women need feminism and feminist support, too. There are intrapersonal and community-level implications for empowerment that come from having a strong network of peers who support and understand each other’s experience (Labonté & Laverack, 2008). In order to boost this empowerment through trans inclusionary feminism, non-transgender women must be willing to share some of the power they already have (Labonté & Laverack, 2008). If we create a hierarchy of women and ban certain women from safe spaces, the meaning of feminism becomes lost entirely.
How Clinicians Can Help Fight Transmisogyny
Therapists and doctors are not immune to transmisogyny; and following clear guidelines to affirm all patients can help prevent it. When running support groups for women, it is imperative to explicitly include transgender women. If trans women are not allowed in a women’s group, it promotes the warped narrative that trans women are not “real” women. The same goes for asking for a patient’s “real” name, the name the patient uses to introduce herself, the name she chose to affirm her gender identity, is her real name. The name on the patient’s original birth certificate does not automatically become her “real” name. Prioritizing what a piece of paper says over the patient herself is a perfect example of transmisogyny, and it is completely avoidable. Being a trans-affirming clinician requires an agreement that trans women did not “become” or “turn into” or “choose to be” women, but truly are women. When in doubt, trust the patient’s first-hand account, and affirm her identity as she defines it. Listen to women.
Including trans women in feminism is not a dramatic shift and requires nothing more of non-trans feminists than the ideals they fight to uphold: respect, equality, and reciprocal support. Trans women are women––it’s that simple.
Learn more about working with transgender and nonbinary clients
Anti-Defamation League. (2017). What the women’s march teaches us about intersectionality. ADL Blog. Retrieved from https://www.adl.org/blog/what-the-womens-march-teaches-us-about-intersectionality
Bindel, J. (2019). It’s time for progressives to protect women instead of pronouns. Quillette. Retrieved from https://quillette.com/2019/06/14/its-time-for-progressives-to-protect-women-instead-of-pronouns/
Dembroff, R. (2019). Trans women are victims of misogyny, too–and all feminists must recognize this. The Guardian. Retrieved from https://www.theguardian.com/commentisfree/2019/may/19/valerie-jackson-trans-women-misogyny-feminism
Federal Bureau of Investigation. (2017). Hate crime statistics: Incidents, offenses, victims, and known offenders by bias motivation. U.S. Department of Justice. Retrieved from https://ucr.fbi.gov/hate-crime/2017/topic-pages/tables/table-1.xls
GLAAD. (2019). Glossary of terms–transgender. GLAAD Media Reference Guide.
Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Keisling, M. (2011). Injustice at every turn: A report of the national transgender discrimination survey. National LGBTQ Task Force. Washington, DC: National Center for Transgender Equality.
Greenspan, R. (2018). On Women’s Equality Day, here are 3 things to know about the suffrage moment. Time. Retrieved from https://time.com/5372770/womens-equality-day-2018-facts/
Hegewisch, A., & Hartmann, H. (2019). The gender wage gap: 2018 earnings differences by race and ethnicity. Institute for Women’s Policy Research. Retrieved from https://iwpr.org/publications/gender-wage-gap-2018/
Hess, C., Milli, J., Hayes, J., Hegewisch, A., Mayayeva, Y., Roman, S., Anderson, J., & Augeri, J. (2015). The status of women in the states: 2015. Washington, DC: Institute for Women’s Policy Research.
Hess, J., Breidenstein, A., Henkel, A., Tschirdewahn, S., Rehme, C., Teufel, M., Tagay, S., & Hadaschik, B. (2018). Satisfaction, quality of life and psychosocial resources of male to female transgender after gender reassignment surgery. European Urology Supplements, 17(2), e1748. https://doi.org/10.1016/S1569-9056(18)32062-1
Human Rights Campaign Foundation. (2018). A national epidemic: Fatal anti-transgender violence in America in 2018. Washington, DC: Human Rights Campaign Foundation, Public Education & Research Program.
James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality.
Kacere, L. (2014). Why the feminist movement must be trans-inclusive. Everyday Feminism. Retrieved from https://everydayfeminism.com/2014/02/trans-inclusive-feminist-movement/
Labonté, R., & Laverak, G. (2008). Health promotion in action: From local to global empowerment. New York, NY: Palgrave Macmillan.
Lewis, S. (2019). How British feminism became anti-trans. The New York Times. Retrieved from https://www.nytimes.com/2019/02/07/opinion/terf-trans-women-britain.html
Stock, K. (2019). Doing better in arguments about sex, gender, and trans rights. Medium. Retrieved from https://medium.com/@kathleenstock/doing-better-in-arguments-about-sex-and-gender-3bec3fc4bdb6
U.S. Const. amend. XIX.
I am a fat, queer, able-bodied, neurotypical, white, and cisgender femme person (note: cisgender = my gender is congruent with the gender I was socially assigned). I’m well aware of societal expectations for the way my body should look, to express my gender consistent with white womanhood, and to engage in romantic and sexual relationships in a certain way. I also know that the bar for being seen, respected, and accepted for who I am would be sky high if I was a fat, autistic, disabled, polyamorous, transgender feminine person of color.
Most of the research conducted with people who are fat and/or trans has been with white, able-bodied humans, so any negative impact I discuss related to fat trans folks is likely even more detrimental for people of color and for those with chronic illness and/or disabilities. I write this as a person with privilege who aims to learn more, and educate others about systems of oppression and power, while also advocating for human rights and dignity. I am personally familiar with experiences of fatphobia and sexism, and I have a specialty in counseling trans and gender nonbinary (TGNB) people.
Weight Stigma, Fatphobia, & Microaggressions
When you see a slim person jogging down the road, do you think, “good for them!?” When a slim person walks along the beach in a bikini, do you think, “ugh, they shouldn’t be wearing that!?” When you notice that a slim friend has gained weight, do you say, “oh wow, you’ve gained weight? What are you doing?” I’m guessing most of us don’t, so why would it be OK for us to judge or comment on fat bodies? The short answer: it’s not OK. Basically never. Just like it’s never OK for us to comment on trans and gender non-conforming bodies.
The National Eating Disorders Association (NEDA, 2018) defines weight stigma as discrimination or stereotyping based on a person’s weight (also referred to as sizeism). Weight stigma is known to increase body dissatisfaction, which is a leading risk factor for disordered eating. NEDA clearly states, “the best-known environmental contributor to the development of eating disorders is the sociocultural idealization of thinness.” Many people who struggle with body image and disordered eating got messages along the way that shamed their bodies and/or food choices, suggesting they weren’t good enough just the way they were.
Fatphobia, the fear and/or hatred of fat bodies, is an extension of sizeism. Many of us have learned not only that thin is the ideal, but that being fat is to be avoided like the plague. We are constantly exposed to messages that thin = good and fat = bad (e.g., TV and movies, comments from our parents, health & wellness marketing, conversations with our friends, and health insurance companies offering wellness discounts). Brené Brown’s research found that a) appearance and body image and b) being stereotyped and labeled are two of the 12 most common triggers for shame (Brown, 2007). This hatred and fear of fatness becomes internalized and spreads like wildfire in the ways we talk about ourselves, evaluate ourselves compared to others, and judge others’ bodies and food choices. Three questions you might ask yourself to examine your weight bias are: 1) Do I engage in negative body talk? 2) How do I feel about bodies of different sizes? and 3) How do I feel about the concept of weight gain for myself? (Chastain, 2018).
We can’t talk about stigma and fatphobia without also talking about microaggressions, which Sue (2010) defined as “commonplace verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative insults to a target person or group.” The very nature of microaggressions is that they are often unintentional and unacknowledged slights, leaving the recipient to process those thousands of tiny moments that invalidate that person’s very existence.
For example, when someone says to a friend who has lost weight, “wow, you look great,” it is thinly veiled as a compliment that covers up the deeper diet culture judgment, “your body is more desirable now that it is thinner.” When someone watching you eat X food says, “I don’t eat X – it’s bad for you,” what it really suggests is, “be careful eating that food – you wouldn’t want to become fat and/or unhealthy. In fact, the conflation of weight with health and “concern for health” is one of the more common ways that people (especially health providers) justify weight-related microaggressions. Sadly, what often gets in the way of health for fat folks is the very structural oppression they face by those who believe people are unhealthy because they are fat (Lee & Pausé, 2016).
At the Intersection of Fat & Trans
When we talk about the above concepts in relation to fatness, they also hold true for other identities that experience oppression, e.g., race, gender, ability, sexuality, etc. TGNB folks experience transphobia, cissexism, cis-heteronormative expectations, and pressures to fit into (white) binary understandings of gender, i.e., what it supposedly means to be a man or a woman. Because TGNB people are often valued based on how well their bodies “fit in” to these expectations, it follows that they would also be held to standards of body size, shape, and weight. Adding weight stigma to the other pressures that a TGNB person experiences along with their own struggles with their body is like a shaken soda bottle of oppression waiting to explode.
Here are several ways that a TGNB person might experience the cumulative and harmful effects of sizeism and fatphobia in the context of their transness:
- A trans masculine person eats as little as possible to shrink his body and appear more androgynous by reducing the width of his hips & the size of his chest
- A nonbinary person hesitates to go to the gynecologist for worsening pelvic pain, because when they initially brought it up, the doctor said the pain was weight-related.
- A transfeminine person fears going out on a date, because she can’t blend enough with her large belly.
- An agender person has to search endlessly for affordable clothing that both fits their large body and also feels congruent with their gender.
- A genderqueer person wants to fly without drawing attention to themself, but they face ridicule when going through the security body scanners and then are looked at with disgust while walking down the airplane aisle due to their body size.
- A trans woman’s doctor does not refer her to get treatment for her Anorexia, because he reasons that restriction might help her to lose weight.
- A trans adolescent is extremely uncomfortable in their body due to the compounded effects of going through puberty as a fat person.
- A pregnant trans man gets mistaken for being fat and doesn’t get the emergency medical care he needs (note: an article was recently published about this exact situation at usatoday.com).
- A trans person arrives for their consultation appointment for gender affirming surgery, but the armchairs in the waiting room are too small for them to fit, the exam room table cannot hold their weight, and they soon find out that the surgeon has a maximum BMI requirement.
- A trans college student gets the courage to go to the gym and build muscle for his upcoming top surgery, but then is fat shamed by other students at the fitness center.
It is so crucial to be mindful of the ways in which weight stigma and fatphobia intersect with the policing of trans and nonbinary bodies. Don’t trans folks already have enough to worry about with their internal struggles to find peace and affirmation with their bodies? Why do we pile on societal constructions of what they should and shouldn’t look like, that they should and shouldn’t eat, and pressures to modify their bodies to be more feminine (i.e., thin and curvy in the “right” places) or masculine (i.e., thin and muscular)? Why do we expect TBNB people to not only modify their bodies to societal standards, but to do it without developing an eating disorder or increasing hatred toward themselves? We need to do better in making space for TGNB folks of ALL sizes, shapes, expressions, and food preferences. Everybody and every body is worthy of respect and human dignity.
The Greater Impact
The impact of sizeism and fatphobia are pervasive and insidious. For example, adolescents who are teased for their weight are 2-3x more likely to consider and attempt suicide (Eisenburg et al. 2003). TGNB folks, especially transfeminine people and people of color, are significantly impacted by the pressure to fit into gender appearance ideals (i.e., white, light skinned, thin, & young with straight hair; Patton, 2006) that reflect the binary norms of femininity or masculinity.
Here are some ways that TGNB people are impacted by these pressures compared to cisgender people:
- Increased body dissatisfaction and frequent body checking
- Risk of dissociation from or hatred of certain parts of their bodies
- Increase in disordered eating or weight and shape control behaviors, including binge eating, fasting, vomiting, and laxative use
- Weight loss to suppress secondary sex characteristics and/or
- For transfeminine people, to achieve the thin ideal
- For transmasculine people, to slow or stop the menstrual cycle
- For TGNB people with a high BMI, even greater rates of body dissatisfaction and disordered eating
- For transfeminine people, increased experiences of sexual objectification
- Greater risk of mental health struggles due to the stigma of being trans and/or fat
- e.g., desire for weight change increases reported history of suicide attempts and self-injury
- Risk of negative social consequences, stigma, and safety concerns when physical features are not in line with societal expectations for their gender
(Algers et al., 2010, Algars et al., 2012; Diemer et al., 2015, Gordon et al., 2016, Hepp & Milos, 2002; Jones et al., 2016; McGuire et al., 2016, Peterson et al., 2017; Sevelius, 2013; Vocks et al., 2009; & Witcomb et al., 2015)
It’s not surprising that trans folks are afraid to seek medical care from providers who often invalidate them while also imposing guidelines and hoops for them to jump through in order to seek some semblance of gender affirmation/congruence. When you’re fat, that fear increases. And don’t get me started on providers who recommend weight loss as a treatment for anything, regardless of gender. Would you pay to participate in a treatment program that had a 95-98% failure rate and led to most people going back to pre-treatment symptoms within 3-5 years? I hate to be the bearer of bad news, but if you have ever joined a weight loss program or gone on a fancy diet to lose weight, that’s exactly what you’ve done.
Though many TGNB people experience disconnect and dissatisfaction with their bodies, some reconnect with themselves and improve body satisfaction by altering their body, for example, through gender affirming surgery and hormones, body art/tattoos, and/or exercise. Gender affirming treatment, increased body satisfaction, and perceived social support from family, school, and friends help to reduce the risk of disordered eating (McGuire et al., 2016; Testa et al., 2017; Watson et al., 2017). Some find ways to reject the cultural ideals by creating their own unique gender expression, and those who have a more integrated gender identity are more likely to report social awareness, social acceptance, and body satisfaction (McGuire et al., 2017).
So What Can I Do?
Munro (2017) explains, “we live in a world that resists the notion of fatness as a facet of body diversity; as such, fat bodies are rarely represented in a positive light. Fatness is labeled as a disease and the treatment is eradication.” Social change movements for fat acceptance and body liberation are working to challenge and change this cultural mindset, but the journey is long and difficult – like transness, many are afraid of those who are different, those who do not fit the social norms, and those whose bodies challenge our internalized beliefs and fears.
Here are some ways I believe we can work to support our fat TGNB friends and fellow humans:
- Don’t comment on someone’s body parts, body size, food choices, or changes in weight. Ever. Check in when you’re thinking of complimenting someone – is there any chance that the compliment is a veiled microaggression?
- Practice empathy and compassion for others. Many TGNB and fat folks may struggle to love and accept their bodies, which can be a source of significant pain. “Empathy is the antidote to shame.” (Brown, 2007).
- While you’re at it, why not practice self-compassion and be mindful of the way you talk to yourself? “The act of giving yourself some grace is the practice of loving the you that does not like your body.” (Taylor, 2018, p. 114)
- Don’t assume that a TGNB person wants their body to be in line with binary constructions of femininity & masculinity. People have every right to exist in their bodies in whatever way works (or doesn’t work) for them.
- Dig into fat positive movements and literature (note: while there are some body positive (bopo) spaces that address fatphobia, not all bopo spaces are as fat accepting as they should be). Recommendations include:
- Ragen Chastain, https://danceswithfat.org/ blog
- Sonya Renee Taylor, The Body is Not an Apology book
- Rachel Wiley, Nothing is Okay book
- Christy Harrison, Food Psych podcast
- Alison Rachel, Recipes for Self-Love book & instagram
- Some awesome humans on social media: bodyposipanda; mynameisjessamyn; jazzmynejay; alokvmenon; ihartericka; po.rodil; ashleighthelion, and tessholliday.
- Be critical of the way that mass media portrays TGNB people, fat people, and TGNB fat people. Then, “dump the junk” (Taylor, 2018).
- Read up on intersections of transness with various identities, including size, health, race, ability, spirituality, sexuality, etc. so that your TGNB friends don’t need to teach you about their experiences.
- Check the privilege you carry in the world, whether you are cis, white, straight, able-bodied, healthy, wealthy, Christian, slim, etc. or any of the various intersections of these.
- Seek out medical and mental health providers who are fat positive and work from a Size Acceptance and Health at Every Size (HAES) perspective (Bacon, 2008; Chastain, 2012).
A Final Note
To those who are trans and fat, I see you. You are worthy, even when society doesn’t always communicate that to you. Everyone deserves to have love and compassion for the vessel that gets them through this world, even when you don’t like all parts of that vessel. You deserve to dress and express in ways that make you feel good about yourself and in clothes that fit your body, no matter what size you are. You deserve to access gender affirming care from providers who view fatness as a descriptor rather than an epidemic. You deserve to be gentle to yourself on good days, on bad days, and on in between days. There are people out there who will love and accept you at all sizes, in all gender presentations, and for all of the beautiful intersections that make up your identity. You are worthy.
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