According to the resolution on transgender, gender identity, and gender expression nondiscrimination (APA, 2008), transgender individuals are at risk for discrimination from clinicians as well as the general public. When a transgender adult seeking physical transition contacts a psychotherapist's office, the person is often under the impression that psychotherapy is needed. The clinician may also share this assumption. Unfortunately, this is erroneous. There is no known empirically demonstrated effective psychotherapeutic treatment to change gender identity. There is also no empirically validated measure for assessing gender identity.
When one consults the Standards of Care (SOC) of the World Professional Organization for Transgender Health (WPATH, 2001), it becomes obvious what is recommended in this situation. Knowing the client requesting hormone replacement therapy for three months is suggested. This can involve an initial mental status exam, interviews with significant others, and referrals to support groups or other transgender individuals who can become a “big” sister or brother. I typically see an individual three times over this period. I may answer questions
that concerned or confused family and friends may have. I also provide a letter for the client to carry in their wallet, describing what the individual is seeking to do for anyone, including law enforcement, who may be confused, or worse, ready to discriminate against the individual.
The SOC are international guidelines and do not carry legal status, but a clinician not following them or lacking knowledge of their existence, could be viewed as not working in a “reasonable and customary” manner with these types of clients, which exposes one to legal liability. In a worst-case scenario, the uninformed clinician may be viewed by the client as a threat. In 1998, a psychotherapy trainee in San Diego was murdered by a transgender client, who felt the approach taken to their transition was less than satisfactory. Sadly, it appears that the supervisor of this trainee was not following the WPATH guidelines (Nangeroni, 1998).
Even when SOC documentation is utilized, it can be negated by the clinician's, often unconscious, pejorative approach to the client (Bettcher, 2009). For example, a tall transgender woman may be told she “will never pass” or a small transgender man may be criticized for his passivity. Unknowingly, clinicians may act as “gender police.” These same clinicians would quickly admit that they would not question the gender identity of a tall nontransgender woman or a less than assertive man. Given the valence gender carries (e.g., one is still asked the sex of their child when pregnant) the clinician is likely acting out their countertransference on the client.
A clinician’s lack of awareness of unrecognized inappropriate use of gender-based pronouns and expectations can compromise the trust of transgender adults seeking psychotherapy, or worse, be harmful to their desire to seek psychotherapy in the future (APA, 1992). At least since the time of Carl Rogers (1951), the need for unconditional positive regard has been seen as the cornerstone of the psychotherapeutic bond.
The clinician's primary role in assessing transgender adults seeking physical transition is to evaluate the capacity to provide informed consent (Berg & Appelbaum, 2001, Faden, Beauchamp, King, 1986). At some future point, after a relationship has been established with the clinician, the client may seek psychotherapy to assist with the potential myriad of losses (e.g. job, family, income) and possible hate crime victimization. If the trust has not been established between the client and clinician, then clearly this would hamper the client from entering into psychotherapy and may taint their view of psychotherapists in general (Rachlin, 2002).
One method of assessing the capacity to provide informed consent for hormone replacement therapy or surgery is to perform a mental status exam and request that the client write a letter to the prospective physician describing what treatment or procedure they are seeking. The letter will also contain statements demonstrating awareness of the potential positive and negative consequences of the desired intervention. This approach helps to negate some of the valence of the clinician being the “gatekeeper” and allows the adult client to take responsibility for their request. The clinician then writes a letter of endorsement that the client has demonstrated the ability to provide informed consent.
In the case of minors, medically delaying puberty until one is an adult may be the goal. The legal guardians along with the minor would then follow this same approach with the clinician to demonstrate the capacity to provide informed consent. In the case of a client seeking surgery, the WPATH SOC suggests that two clinicians, who are not working together, provide an opinion of the individual’s ability to provide this informed consent. Sometimes, the surgeon’s office may contact either clinician to verify that each wrote a letter of endorsement. It is recommended, when possible, that the surgical candidate has lived as the desired gender for at least a year. In the case of some transgender men, this may not be physically possible until after completing a mastectomy.
Given there is currently no formal graduate level training in applied psychotherapy specializing in gender identity issues, it is incumbent upon the clinician to familiarize themselves with the various hormone replacement regimens and surgical options. Some health care insurance plans are now beginning to cover medical treatments. If one has mental health coverage, then this can also be used. The WPATH listserv provides a wealth of consultation opportunities on an international and multidisciplinary scale. The WPATH conference, which is held around the world every two years, is an excellent chance to talk to seasoned health care providers in this field.
A great many transgender individuals are wary of psychotherapists, often because they complain of knowing more about their concerns than do the clinicians. They already face discrimination in housing, employment, ability to marry, and legally change their birth certificates in some states, so it is vitally important that psychotherapists become allies to assist them on their courageous journeys to integrate their identities with their physical bodies (Fuhrmann, 1998).