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Fear, anger and anxiety — these are just some of the feelings Jessica Jarman’s transgender clients are dealing with right now. And for good reason. 

Thus far in 2023, nearly 500 anti-LGBTQ+ legislative bills have been introduced at the state level. This includes a bill introduced in Jarman’s state of South Carolina that would force teachers to report any child who is trans and “out” students to their parents.

Jarman, a licensed professional counselor (LPC) in South Carolina who specializes in trauma, has previously had to report a father to the state’s Department of Social Services because he became abusive after finding out his child was transgender. According to Jarman, police arrived at the home and blamed the child, telling her that if she would just stop pretending to be a girl, then her father wouldn’t get angry andthey wouldn’t need to come back. Jarman worries that situations like these could become the norm should the bill pass. 

“Those poor kids are terrified,” Jarman says, “because right now they’re the ones being targeted most by our government. So they’re watching their ability to live being stripped away. … [It’s] just a very scary time.” 

Other states have introduced more severe legislation. For example, Florida Gov. Ron DeSantis recently signed into law several anti-LGBTQ+ bills, including a bill (SB 254) that bans gender-affirming medical care for minors and would allow the state to temporarily remove a child from their home if they receive gender-affirming treatments or procedures and a bill (HR 1069) that restricts teachers, faculty and students from using their pronouns of their choice in public schools and prohibits teaching about sexual orientation and gender identify through the eighth grade.  

According to a study by the Trevor Project, around 86% of trans and nonbinary young people in the United States say that listening to lawmakers debate transgender rights has negatively affected their mental health. This population is more likely to attempt suicide and to develop anxiety, substance use disorders and eating disorders than are their cisgender peers. 

Demographic differences 

Transgender individuals of all ages will face negative repercussions because of these laws. Several states are seeking to pass laws that would imprison doctors for providing any form of gender-affirming care — regardless of the patient’s age.

 “If you are trans and you have undergone a medical treatment that involves removing your testes or removing your ovaries and now they’re not going to let you have hormone therapy, … what’s that going to look like? Your body can’t go back to producing the hormone that you’re born with, and what’s that going to do?” asks John Thomas, an LPC located in Virginia who specializes in gender identity and sexual development. 

The Williams Institute estimates that approximately 1.6 million people age 13 and older identify as transgender in the United States, with trans adults making up about 0.5% of the country’s population. With laws that prohibit doctors from giving gender-affirming care, many of these people will no longer have access to hormone therapy, which can have a negative impact on their physical health and force them to make extremely painful decisions.

Jarman, who is genderqueer, mentions having some difficult conversations recently with transgender clients during counseling sessions. Jarman says they ask, “Is now the time to go back into the closet? I’m not very far out. Is this safe?”  

“[It’s] a devastating conversation to have because as much as I want to say there’s a good answer … there’s not,” Jarman says. 

Other factors also can affect someone’s decision to come out. Transgender people of color face extra struggles when navigating the world compared with white transgender people. The Williams Institute reports that about 0.5% of white people identify as transgender. Meanwhile, adult persons of color who identify as transgender make up 0.5% to 1% of their race’s population.

“We live in an incredibly racist society,” says Okichie Davis, a LPC with a private practice based in Philadelphia. “There is a certain power and access that comes from being white that shifts the experience that white trans people [have] in relationship to trans people of color.” 

For example, Black trans women face some of the highest levels of intimate partner violence in comparison with trans people of other genders and races. All trans people of color are more likely to experience extreme poverty in comparison with their cis or white peers, says Davis, who holds a certificate in affirmative therapy for transgender populations. 

These factors can play into a client’s desire or ability to seek gender-affirming care. Of course, the most prominent issue that many trans people struggle with when seeking care is location. 

Accessing care 

It is important for counselors to recognize that the issues facing transgender and nonbinary people are unique and real, Davis says, especially now that states are passing more anti-trans legislation.  

Professional counselors can tackle some of the issues transgender people are facing by using the same tools they would with other clients dealing with trauma. At the same time, there is a severe shortage of LGBTQ+ affirming and knowledgeable counselors. So gender-affirming counselors often have extensive waiting lists. And these counselors are typically located in major cities, which means people living in more rural areas can’t easily access their services, Jarman adds.  

Then there is also the issue of the cost of care itself. 

“The lack of universal health care in this country is an incredible barrier ... to seek[ing] mental health care,” Davis says. They explain that trans and nonbinary adults are more likely to experience poverty than their cis peers, so they have less money to seek out care in the first place. “As long as that financial barrier exists, everyone who is marginalized in this society is going to have a harder time accessing care,” they add. 

Davis, a nonbinary woman, says it has only been in the past few decades that mental health care for transgender individuals has become more affirming, rather than pathologizing trans identities. It is important that the profession doesn’t take a step back, they assert. 

Davis adds that the providers doing the most affirming work tend to be transgender or nonbinary themselves. It’s often a struggle for them to get into the field in the first place, they explain, because they face systemic barriers such as cost and stigma regarding their gender identity. 

When working with transgender clients, all the rules that clinicians use with other clients still apply. But there are additional things to keep in mind. “The counselor may be the only witness to a client’s truest self, and in that space, the counselor can help them explore how they can balance authenticity with safety,” Thomas says. 

Of course, there are obvious actions that counselors shouldn’t take, such as engaging in conversion or reparative therapy, which denies a person’s identity and gender. Being transgender is not a mental illness, Davis emphasizes. It is not something that needs to be “fixed.” What these clients need instead is support in dealing with the trauma inflicted on them by society, Davis says. 

Whether it is with cognitive behavior therapy, dialectical behavior therapy, existential therapy, person-center Rogerian therapy or any other approach, counselors should aim to focus on all facets of their clients’ lives, Davis adds. 

A counselor’s responsibility 

The important thing to remember is that the issues trans clients are bringing into session are real, Davis stresses. Davis says they have often had clients whose previous providers would not recognize the severity of what the clients had gone through. 

“They [the counselors] are telling them to think more positive thoughts, and there’s a sense of detachment from the very real fact that a lot of our clients who are marginalized … are directly under attack,” Davis says. “Their physical lives, their physical safety are in jeopardy.” 

 “If you are not acknowledging the realness of the attack on trans clients right now, you are not in a position to really support them,” Davis stresses. 

Aside from asking more counselors to become openly gender-affirming providers and offering their services pro bono or for a discount (if possible), Davis and Jarman advise counselors to get politically involved. 

Offering crisis management services for LGBTQ+ organizations that are protesting transphobic laws or involving themselves visibly during these events is a good way for counselors to show their support, Jarman says. She adds that she rarely sees other counselors who say they are gender-affirming and serve transgender clients show up to public protests, which she finds disheartening.

 “I think the biggest thing I would ask from any therapist would be [to] be an ally,” she says. “Any therapist that uses the terminology affirmingly, please show up. At the state house, please show up. At the community events, please show up.” 

Samantha Cooper is a staff writer for Counseling Today. Contact her at scooper@counseling.org.  

The views expressed in Counseling Today are those of the authors and contributors and may not reflect the official policies or positions of the editors or the American Counseling Association.