Updated: Dec 11, 2020
This is a literature review taken from my Case Study submitted to UEL on 15th June 2020 as part of my MA in Counselling and Psychotherapy.
Working with transitioning clients and taking my thoughts around my work to supervision, it was clear that many LGBTQ+ clients may be under represented and even not understood by their counsellors as through supervision all of my supervisors didn’t have much first-hand experience of working with transitioning clients. Therefore, I used a literature review as a chance to explore what reading is available to counsellors to expand on the knowledge of working with gender questioning clients, especially for those counsellors who haven’t had experience of working or even knowing anyone going through this transition.
As I began to research for studies, articles and journals relating to people’s experience of counselling when questioning their identity and even counsellors approaches, it became clear that there is not enough research being done in this area and most of my research came from BACP articles from singular case studies of counsellors. There is a lot of debate about the history of the transgender movements and process within societies along with what can be done better within the mental health professions, but not much about what to do in the here and now with clients or how we can move forward as a profession to offer a safe space to people who do reach out at any stage of this transition.
It is true that the understanding of terms within the LGBTQ+ community are continuously developing and expanding, and so research has struggled to keep up with clients within this community. The BACP themselves didn’t make a change to their Ethical framework to include sexual orientation until the last 20 years and so gender dysphoria is still catching up in this regard too – though it is implied within the ethical framework that no harm or ‘correction’ of being should be forced upon clients. Even the terms used to describe the questioning and transition of genders has only recently changed from a ‘disorder’ to a ‘dysphoria’ in the DSM-52 to recognise that transgender isn’t a pathology but an identity (NHS, 2016).
As counsellors it is important to update our knowledge, understanding and own self-awareness of our gender, where we are with this and our sexuality. If we see ourselves as cisgendered & heterosexual when working with someone with gender dysphoria who may be gay, bisexual, asexual, etc. then we need to try to understand how the client may feel in this scenario and address the potential power imbalance in the room as early on in the relationship as possible (BACP article, 2013). It needs to be recognised within mental health professions that ‘coming out’ whether this is with gender identity or sexuality is a repeated event with different people in the individuals life that needs to be considered and evaluated as to whether this will cause harm – therefore this is a scary and uncertain time shrouded in fear of rejection for most (BACP article, 2016).
All that has been mentioned above, aligns with Erikson’s model of development (1968) – An individual is likely to suffer when there is a crisis of optimal identity which can lead to poor mental health and well-being. It is well documented however that clients who are questioning their identity or sexuality are among the clients being most at risk of self-harm, suicidal ideation, substance abuse along with high levels of anxiety and depression (Maguen & Shipherd, 2010; Shipherd et al., 2010) as a result of low self-esteem and discrimination due to ‘social norms’ (Bockting et al., 2006; Wylie et al., 2007: Livingstone, 2008).
Looking at the data around gender identity and sexuality within school, the Stonewall report (2017) found that 92% of trans young people in UK schools had thoughts of suicide in comparison to only 25% of the general population. This is also true that these feelings have come about due to reasons mentioned such as bullying, social exclusion, feeling isolated and even a lack of acceptance within the family. A BACP article in 2019 reported that there has been a proportionate 552% increase in the amount of clients reporting issues of gender identity showing that there is a need for increased awareness and knowledge within the counselling profession and the mental health profession on a whole.
Prejudice and harmful
The lack of knowledge and understanding can be more harmful to clients that is realised; Gagne et al. (1997) found that Male to Female transsexuals often felt pressurised by their counsellors into wearing femme wear or coming out to family members without considering the harmful impact this could have economically (where people have lost jobs), emotionally (rejection and harassment) and psychologically (they may not have been ready for this stage of their transition). In addition to this Fagan et al. (1994) found that there are some counsellors who have the belief that “transsexual people are fundamentally homophilic but cannot consciously accept their sexual orientation”.
This suggests that it’s not only about changing counsellors understanding and knowledge around gender dysphoria, sexual identity and any other LGBTQ+ terms that they have not yet researched, but to also address the prejudice and ideas that counsellors hold towards people going through these dilemmas. Carroll et al. (2002) suggests that “We do not think any of us in the majority who fit into the normative gender categories of male and female can imagine the paradoxical situation of being very obvious and yet invisible at the same time” again referring back to the power that the counsellor holds in the room.
A BACP article written in 2017 suggests that, before working with anyone from the LGBTQ+ community or who may have gender dysphoria, a substantial amount of self-reflection into beliefs and prejudice is carried out otherwise these can creep into the counselling room when working with the client.
How can we work with clients in transition?
Jackson (2017) suggests that working with individuals questioning their identity can be very complex as it is often intertwined with other factors such as personal beliefs, experiences, age, race, religion, culture etc. and that this topic is often underrepresented in counselling and psychotherapy training and education. There is also mention that, as discussed, it has take a substantial amount of time for the medical and law institutions to recognise that questioning gender identity isn’t a disorder and so there is a feel of doubt but also urgency that something more needs to be done within the mental health institutions to recognise what we can do better when supporting these individuals.
It can be seen that quite often there is a mismatch of needs for individuals questioning their identity leading to an internal crisis; Bridgman (2017) believes that often being there for a client offering a space for them to be ‘heard, acknowledge and validated’ is quite often all they are looking for, at least as I believe in the beginning.
The most promising study I found was by Wester et al. (2010) which looked at how counsellors could use GCR (Gender role conflict theory -O’Neil et al., 1986) specifically with MTF (Male to Female) clients and how this can be used as an approach to understanding the process that an individual questioning their gender identity may go through and how we as professionals can help hold that process in the counselling room. In addition other psychologists & research counsellors have suggested that a directive but holistic approach to the individuals journey called “cognitive flexibility” is recommended when working with transgender clients allowing them to explore their own narrative (Ettner, 1999; Carroll et al., 2002).
I initially started off wanting to find ways for counsellors working with transgender clients, or those in the initial stages of questioning their gender, to be able to understand and adapt their approach in order to hold the client in a safe and contained way, however as I started researching this review found that there still isn’t enough research out there to be able to do that.
As it has been discovered, the LGBTQ+ community are underrepresented in the counselling and psychological research sector, especially when it comes to transgender clients. It can be seen that there is a massive increase in the amount of clients coming forward reporting issues of gender dysphoria however the knowledge and understanding of counsellors needing to meet these clients in an effective way doesn’t seem to match up, almost as if there is a lag in research being done in this area compared to what’s happening in the real world.
I wanted to leave this review with research and comment that I feel sums up this area lacking in understanding – it is recommended by Laird (1999) that when working with clients with gender dysphoria, we should “behind her own cultural biases and pre-understandings, to enter the experience of the other” (p.75), but also that we as therapists should be advocates for clients bringing their stories and experiences to us in the political arena and to professional literature so that we can develop the understanding and awareness of our peers.
BACP children, young people and families journal, 2019. Gender identity and suicidal ideation. [online] Available at: <https://www.bacp.co.uk/bacp-journals/bacp-children-young-people-and-families-journal/september-2019/gender-identity-and-suicidal-ideation/> [Accessed 12 June 2020].
Bardlow, J., Bartram, F., Gusap, A. and Jadva, V., 2017. School Report: The Experiences Of Lesbian, Gay, Bi And Trans People In Britain’S Schools In 2017.. [ebook] UK: Year of Stonewall. Available at: <https://www. stonewall.org.uk/ system/files/the_ school_report_2017.pdf> [Accessed 12 June 2020].
Bockting, W., Knudson, G. and Goldberg, J., 2006. Counseling and Mental Health Care for Transgender Adults and Loved Ones. International Journal of Transgenderism, 9(3-4), pp.35-82.
Bridgman, 2017. Gender Mosaic. Private Practice, [online] Available at: <https://www.bacp.co.uk/bacp-journals/private-practice/winter-2017/gender-mosaic/> [Accessed 12 June 2020].
Carroll, L., Gilroy, P. and Ryan, J., 2002. Counseling Transgendered, Transsexual, and Gender-Variant Clients. Journal of Counseling & Development, 80(2), pp.131-139.
Denny, D., & Green, J., 1996. Gender identity and bisexuality. In B. Firestein (Ed.), Bisexuality: The psychology and politics of an invisible minority. Thousand Oaks, CA: Sage. pp. 84–102
Erikson E., 1968. Identity: youth and crisis. New York: Norton
Ettner, R., 1999. Gender loving care: A guide to counselling gender-variant clients. New York: Norton
Fagan, P. J., Schmidt, C. W., & Wise, T. N., 1994. Born to the wrong sex [Letter to the editor]. The New Yorker, pp. 7-15.
Gagne, P., Tewksbury, R., & McGaughey, D., 1997. Coming out and crossing over: Identity formation and proclamation in a transgender community. Gender & Society, 11, pp. 478–508.
Jackson, C., 2017. Putting gender on the agender. Therapy Today, [online] Available at: <https://www.bacp.co.uk/bacp-journals/therapy-today/2017/december-2017/putting-gender-on-the-agenda/> [Accessed 12 June 2020].
Laird, J. (1999). Gender and sexuality in lesbian relationships: Feminist and constructionist perspectives. In J. Laird (Ed.), Lesbians and lesbian families: Reflections on theory and practice. New York: Columbia University Press, pp. 47–89.
Livingstone, T., 2008. The relevance of a person-centred approach to therapy with transgendered or transsexual clients. Person-Centred and Experiential Psychotherapies, 7(2), pp. 135-144
Maguen S & Shipherd J.C., 2010. Suicide risk among transgender individuals. Psychology and Sexuality, 1(1), pp.34–44.
NHS. 2016. Gender Dysphoria. [online] Available at: <http://www.nhs.uk/conditions/gender-dysphoria/Pages/Introduction.aspx> [Accessed 12 June 2020].
O'Neil, J., Helms, B., Gable, R., David, L. and Wrightsman, L., 1986. Gender-role conflict scale: College men's fear of femininity. Sex Roles, 14(5-6), pp.335-350.
Private Practice, 2016. We need to talk about gender. [online] Available at: <https://www.bacp.co.uk/bacp-journals/private-practice/autumn-2016/we-need-to-talk-about-gender/> [Accessed 12 June 2020].
Shipherd J.C., Green K.E. & Abramovitz S., 2010. Transgender clients: identifying and minimizing barriers to mental health treatment. Journal of Gay and Lesbian Mental Health, 14, pp. 94–108.
Therapy Today, 2013. Listening to transgender voices. [online] Available at: <https://www.bacp.co.uk/bacp-journals/therapy-today/2013/october-2013/articles/listening-to-transgender-voices/> [Accessed 12 June 2020].
Wester, S., McDonough, T., White, M., Vogel, D. and Taylor, L., 2010. Using Gender Role Conflict Theory in Counseling Male-to-Female Transgender Individuals. Journal of Counseling & Development, 88(2), pp.214-219.
Wylie, K., Hainsworth, K. and Ryles, S., 2007. The Support Needs of People Awaiting a Primary Assessment at a UK Gender Reassignment Programme. International Journal of Transgenderism, 10(2), pp.91-98.