Counseling Transgender and Gender Nonconforming Youth

Description of Transgender and Nonconforming Youth

When counseling youth who identify as transgender, trans, or gender nonconforming (TGNC), counselors must first understand the diverse ways in which clients might experience their gender identity and expression. Trans identities are characterized by the experience of one’s gender identity (i.e., internal sense of gender) and/or gender expression (i.e., self-presentation) differing from norms associated with their assigned sex at birth (ASAB; Bolger & Killerman, 2018). TGNC youth might identify within the gender binary (e.g., woman, transgender woman, trans woman, trans feminine person, man, transgender man, trans man, trans masculine person) while others might identify outside of binary notions of masculinity and femininity (e.g., GNC, nonbinary, genderqueer, agender, bigender, gender neutral). Additionally, some TGNC youth might or might not elect to transition in a variety of ways including social, legal, and physical/medical (Brammer & Ginicola, 2017; Chang, Singh, & dickey, 2018). 

Due to the exclusion of gender identity in many population-based surveys, research is limited regarding the percentage of youth who identify as TGNC within the United States; however, some researchers have estimated that between 1.3% and 3.2% of youth identify as TGNC (Wilson & Kastanis, 2015). Authors of a more recent population-based study within each U.S. state estimated that 0.7% of youth between the ages of 13-17 years identify as transgender (Herman, Flores, Brown, Wilson, & Conron, 2017). 

For information on terminology, pronouns, and Safe Zones, see: https://thesafezoneproject.com/

Mental Health Considerations

Violence and marginalization account for extremely disproportionate mental health concerns and experiences when compared to cisgender peers (Katz-Wise, Ehrensaft, Vetters, Forcier, & Austin, 2018). Presenting concerns include significantly elevated overall negative psychological states (Kosciw, Greytak, Zongrone, Clark, & Truong, 2018; Wilson, Chen, Arayasirikul, Raymond, & McFarland, 2016), depression (Katz-Wise et al., 2018; Wilson et al., 2016), self-harm (Katz-Wise et al., 2018), post-traumatic stress disorder (PTSD; Wilson et al., 2016), and suicidal ideation (Katz-Wise et al., 2018; Wilson et al., 2016).

Specifically, Reisner et al. (2015) compared mental health outcomes of TGNC youth and cisgender youth in a community setting, finding TGNC youth to be approximately 2.5 times more likely to experience depression and anxiety, almost three times more likely to experience suicidal ideation and to attempt suicide, and almost four times more likely to engage in non-suicidal self-injury. In a 2017 GLSEN School Climate Survey, TGNC youth reported experiencing lower self-esteem, grade point average, and sense of belonging compared to cisgender students. They were also more likely to be absent from school due to victimization and were less likely to pursue college when compared to cisgender peers (Kosciw et al., 2018). These findings are unsurprising as TGNC students consistently reported the highest levels of feeling unsafe and experiencing verbal and physical harassment, physical assaults, and school policy discrimination based on gender identity and expression as compared to cisgender peers (Kosciw, Greytak, Giga, Villenas, & Danischewski, 2016; Kosciw et al., 2018). Furthermore, in the 2015 U.S. Transgender Survey, respondents reported experiencing verbal harassment (54%), physical assault (24%), and sexual assault (13%) as an attack on their gender identity while they were students in K-12 schools, and 17% reported discontinuing their K-12 education due to experiences of severe discrimination and mistreatment (James et al., 2016). Hence, it is essential to consider that presenting concerns and symptomology for TGNC youth may be in response to systemic oppression and violence, as opposed to intrinsic pathology (Goodrich & Luke, 2015).

To increase safety and systemic support for TGNC youth in schools, access GLSEN’s Safe Space Kit: https://www.glsen.org/safespace

Identification/Assessment Strategies

Using assessments in counseling with TGNC youth requires counselor awareness of cisnormativity within assessments normed on cisgender populations, as well as applicability of assessments to TGNC youth, specifically. Counselors refrain from using assessments that were not normed on TGNC populations, as well as assessments normed on lesbian, gay, bisexual, and queer populations who do not identify as TGNC (American Counseling Association [ACA], 2010; Goodrich et al., 2017). When electing to use assessments, counselors recognize systemic barriers experienced by clients and implications of inappropriate use regarding psychometrics of the assessment and interpretation of results. 

Intake Paperwork

Often, depending on client age, a client or their guardian’s first interaction with counseling begins with completing intake paperwork. It is imperative that intake materials reflect a trans-aware counseling space by addressing gender in an affirming and conscious manner. Counselors can build inclusive paperwork by asking about gender instead of ASAB and using blanks, as opposed to predetermined and binary checkboxes, when asking questions about gender (Harper & Singh, 2014). Furthermore, to increase client self-determination, counselors can provide space for clients to self-identify their correct name and pronouns (e.g., they/them/theirs, she/her/hers, he/him/his, ze/hir/hirs, a client’s name, or others) (Chang et al., 2018; Goodrich et al., 2017; Vance, Ehrensaft, & Rosenthal, 2014). On intake paperwork, counselors are not required to ascertain a client’s “legal name” if it differs from the name they use (Chang et al., 2018); doing so could force a client to use a name that does not fit the identity, inciting trauma.

If necessary for insurance purposes, one can honor a client’s correct name by asking the youth or parent for their insurance card and avoiding making a client vocalize a name that does not align with how they identify. By asking for client pronouns on intake materials or in person, counselors can also avoid using incorrect pronouns or misgendering clients. Furthermore, asking for pronouns from all clients and sharing one’s own pronouns can demarcate a counselor as aware, affirming, and safe in their non- assumption of a client’s gender identity.

Initial Psychosocial Assessment

During the initial counseling session, counselors facilitate client access to empowerment by asking clients to self-identify and share presenting concerns related or unrelated to TGNC identities. Counselors recognize that there is no singular, linear narrative for all TGNC youth, necessitating the creation of a therapeutic alliance in which clients create personal paths that align with their sense of self and facilitate their survival and thriving. Relatedly, a trans-affirming counselor will be aware that TGNC youth are multidimensional individuals who might experience multiple minority identities and refrain from assuming that a client’s presenting concern is related to gender identity and expression merely because they identify as TGNC (ACA, 2010; Goodrich et al., 2017). Integrating an unassuming lens in this initial session, counselors holistically assess client needs, barriers to care, strengths, and resiliencies by operating from an intersectional framework that validates the impacts of TGNC youths’ multifaceted identities.

An intersectional framework entails understanding how clients experience privilege and oppression as shaped by their diverse identities, including but not limited to: gender identity and expression, sexuality, race, ethnicity, nationality, socioeconomic status, immigration status, language, spirituality, religion, ability, size, and age. Relatedly, age considerations are critical in work with youth who do not possess the same access to agency and autonomy as non-minor clients. Therefore, discussion of informed assent (Goodrich et al., 2017) and consideration of possible support or harm within family systems is critical to facilitating access to affirming clinical care. For example, considering a client’s discussion of their gender identity in session, counselors recognize that each individual’s outness journey and timeline differs and must be honored. Responsive counselors uphold confidentiality, taking measures to avoid outing a TGNC client to family, verbally or in case notes (Finnerty, Kocet, Lutes, & Yates, 2017; Griffith et al., 2017). If clients consent and voice readiness to disclose their identity to others, counselors can offer support as determined by the clients.

Transition-Related Assessment

Some TGNC youth pursue gender-affirming transition socially, legally, and/or medically. If a TGNC youth client aims for social or legal transition, the counselor, with an awareness of the World Professional Association for Transgender Health (WPATH) Standards of Care, can inform the family and youth of resources and support them in these transitions. Relatedly, counselors use the WPATH Standards of Care as a guide for support rather than an absolute mandate for care (ACA, 2010; Goodrich et al., 2017). If a client seeks medical gender-affirming transition as they near puberty, the counselor has a responsibility to inform the family of benefits and considerations related to transition, assess for diagnoses that could affect transition, and offer connections to integrated care resources (ACA, 2010; Chang et al., 2018).

Furthermore, some physicians and insurance agencies require counselors to write one or two formal letters supporting a youth’s medical transition, depending on the type of medical intervention (Chang et al., 2018; dickey, Karasic, & Sharon, 2016). Letters detail information such as: client information (i.e., name, pronouns, birth date, intersectional identities, ASAB); relevant gender history, milestones, and readiness for transition; current gender identity and expression; physical and mental health; substance use; systems of support; family relationships; coping skills and resiliencies; capacity to give informed consent; relevant diagnoses; future plans and transition-related expectations; and clinician credentials, qualifications, and recommendation for gender-affirming care (Chang et al., 2018; Coolhart, Provancher, Hager, & Wang, 2008; Goodrich et al., 2017). The counselor should collect this information from the youth and consult the family for additional needed information (Vance et al., 2014), refraining from asking intrusive questions and reporting unnecessary information (Chang et al., 2018). In completion of transition-related assessments and letters, counselors can seek continuing education and use resources regarding best practices and guidelines, such as those included in the resource below. Additionally, affirming counselors without experience in these procedures will best support TGNC clients by pursuing supervision and consultation from or referring clients to counselors who specialize in counseling TGNC youth.

Supporting TGNC individuals in transition-related name and identity document change procedures: https://transequality.org/issues/identity-documents-privacy

Counseling TGNC clients, including assessment recommendations and letter writing:

Chang, S. C., Singh, A., & dickey, l. m. (2018). A clinician’s guide to gender-affirming care: Working with transgender and gender nonconforming clients. Oakland, CA: New Harbinger Publications, Inc.

Lambda Legal offers a guide to assist in identity document changes: http://www.lambdalegal.org/sites/default/files/transgender_booklet_-_documents.pdf

Gender Dysphoria in the DSM-5

Related to gender-affirming transition procedures is the diagnosis of gender dysphoria. In the fifth edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the American Psychiatric Association (APA, 2013) specifies separate criteria for the diagnosis of gender dysphoria within children and within adolescents and adults. The revision of gender identity disorder in the fourth edition of the DSM, and the continued inclusion of diagnostic criteria related to gender identity and expression in the DSM-5, is a topic of much debate, as iterations of the DSM have relied on and propagated heterosexist and cissexist assumptions (ACA, 2010; Chang et al., 2018; Goodrich et al., 2017; Sennott, 2010). Current diagnostic criteria include distress and/or impairment due to the incongruence between one’s gender identity and expression and the ASAB and associated primary and secondary sex characteristics (APA, 2013). Although this diagnosis is often used to justify or facilitate gender-affirming medical interventions related to transition, there is controversy over its existence in the DSM-5. Many argue that it facilitates continued pathologization of TGNC clients within a cisnormative framework (Chang et al, 2018; Goodrich et al., 2017; Sennott, 2010). Importantly, distress and dysphoria can result from systemic oppression and gender policing experienced when gender identity and expression do not align with gendered societal expectations. It is imperative to note that not all TGNC youth will experience dysphoria, and expectations for the concept of gender nonconformity are socially and culturally variable (Brammer & Ginicola, 2017). Thus, counselors must recognize that this diagnosis “is only relevant when a client wishes to access medical treatments related to the transition process and is required by insurance” (Goodrich et al., 2017, p. 5).

Resource:

A book to support families of TGNC youth: Ehrensaft, D. (2011). Gender born, gender made: Raising healthy gender-nonconforming children. New York, NY: Experiment.

A book to support work with families of TGNC youth from the Family Acceptance Project: http://familyproject.sfsu.edu/sites/default/files/FAP_English%20Booklet_pst.pdf

Advocacy

Advocating for trans-affirmation and trans-liberation requires counselors to embody their advocate identity outside of the counseling space, recognizing the call to action within numerous sets of competencies and standards of care (ACA, 2010; Council for Accreditation of Counseling and Related Educational Programs, 2016; Goodrich et al., 2017; Griffith et al., 2017; Ratts et al., 2015). Counselors can advocate with TGNC youth in their communities and school systems to remove institutional barriers and educate officials on needs that will increase access to safety and success (ACA, 2010; Chang et al., 2018; Vance et al., 2014). TGNC youth and their families can engage school officials on policies surrounding bullying, trans-affirmative policies, and allyship within school administration (Harper & Singh, 2014).

Engaging in community and political advocacy surrounding TGNC communities’ needs can also affect systemic change (Chang et al., 2018). Furthermore, counselors can support youth in developing their own advocacy identities, resulting in increased self-efficacy, empowerment, and resiliency (Chang et al., 2018).

Resource:

For information on advocacy with and for TGNC youth in schools, see: https://www.glsen.org/

ASCA’s position statement regarding school counseling and TGNC youth: https://www.schoolcounselor.org/asca/media/asca/PositionStatements/PS_Transgender.pdf

Lambda Legal guide to FERPA considerations related to updating TGNC youth’s school records: http://www.lambdalegal.org/sites/default/files/publications/downloads/factsheet_ferpa.pdf 

Integrated Care

Facilitating access to integrated care or connecting TGNC clients and families to resources for holistic support (Peek & National Integration Academy Council, 2013) is another important counseling task. Counselors serving TGNC youth must take steps to vet referral sources, ensuring affirmative and aware practices prior to referral. Integrated care referrals can include trans-affirming providers such as pediatricians, endocrinologists, surgeons, vocal therapists, psychiatrists, social workers, addiction counselors, attorneys to assist with name and gender marker change procedures, financial planners to support medical transition needs, hair removal specialists, and school system officials (Brammer & Ginicola, 2017; Chang et al., 2018; Goodrich et al., 2017; Vance et al., 2014). Additionally, TGNC youth might benefit from participation in in-person or online TGNC youth support groups, arts and cultural programming, and social justice and advocacy groups, and they might desire connection with additional forms of support such as books, Internet resources, and social media platforms (Goodrich et al., 2017).

Resource:

Informed Consent for Access to Trans Health (ICATH): http://www.icath.org/ WPATH Standards of Care: https://www.wpath.org/publications/soc

Center of Excellence for Transgender Health best practices regarding mental health in primary care: http://transhealth.ucsf.edu/trans?page=guidelines-mental-health

Published: September 2019
Updated: September 2019