Partners in Transition: Helping Transgender Clients

Robyn Chauvin was happily married in the early 1990s. Having spent time in counseling, she had given up drugs and alcohol, was studying to be a music therapist and was working with patients in a psychiatric hospital. But she knew there was one more change she needed to make. “I got very clear that I was not going to pretend to be male anymore,” Chauvin says.

Born looking like a male, Chauvin had lived her life as a man, fell in love and married a woman — but she knew something was wrong. “The one unhappy thing was my gender identity,” Chauvin says. “I grew up in New Orleans, and my idea of male-to-female transsexuals was strippers and hookers. That was what I thought it would have to be. I never imagined it was a possibility for me, and then I got to a point where it felt like an imperative.”

Chauvin describes going through years of deep self-hatred and low self-esteem, with associated depression and substance abuse, before deciding she could no longer pretend to be someone she was not. But deciding to transition to female also would require enormous sacrifices, including a divorce, the concern of possibly resigning her position at the psychiatric hospital and securing significant financial arrangements to pay for her eventual surgery. After going public with her decision, Chauvin found herself welcomed and accepted by the hospital staff and eventually went on to study counseling at Naropa University in Boulder, Colorado. Today, she is a licensed professional counselor (LPC) and music therapist in private practice with offices in Boulder and Denver. She sees adult clients who are dealing with what she describes as “garden variety neuroses,” including gender identity and divorce. “Not to sound too existential, but I think everybody is dealing with gender identity issues,” Chauvin says. “The idea of a gender identity is false.”

Many in the counseling profession are exploring Chauvin’s assertion. The Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC), a division of the American Counseling Association, approved competencies for counseling transgender clients in 2009. The competencies emphasize a wellness-, resilience- and strength-based approach to working with transgender clients, while also acknowledging the multiple oppressions experienced by many in this population.

An April 2011 research brief published by the Williams Institute on Sexual Orientation and Gender Identity Law and Public Policy at the UCLA School of Law said an estimated 3.5 percent of U.S. adults identify as lesbian, gay or bisexual, whereas an estimated 0.3 percent of U.S. adults — or about 700,000 people — are transgender. Meanwhile, a February 2011 study by the National Center for Transgender Equality and the National Gay and Lesbian Task Force (NCTE/NGLTF), titled “Injustice at Every Turn,” revealed that trans people face pervasive discrimination and report staggering rates of attempted suicide.

These findings suggest that you are quite likely to meet a transgender person in your lifetime, and if they turn up in your counseling office, they are likely to have experienced significant ostracism and pain. The good news is that healing can start within the therapeutic alliance. But counselors must be aware of the uncommon factors that might affect these clients, as well as the ways they experience common mental health issues, just like any other client.

Thomas Coughlin, an LPC and ACA member at Whitman-Walker Health (formerly Whitman-Walker Clinic) in Washington, D.C., explains this further. “The needs of this community range from the very basic — i.e., adequate and safe shelter, food, personal safety and protection against discrimination and violence, sometimes from the very agencies in place to protect us — to gender consolidation, navigating romantic relationships and/or ‘coming out’ concerns.”

Pointing to the recent NCTE/NGLTF report, Coughlin notes that individuals in this community often experience “cumulative discrimination” in which they are personally affected by at least three events rooted in bias and discrimination. “It is clear to see how one’s mental health may be impacted,” he adds.

Heather L. Chamberlain agrees. A licensed mental health counselor and self-described “gender specialist” in private practice in Seattle, she applies narrative and feminist theory to her work with transgender clients. “Anyone who is transitioning their gender identity is necessarily involved in rewriting their story and evaluating the impact of systemic obstacles on their past, present and future development,” she explains, noting that she has focused her education and training on gender issues from the outset.

Chamberlain has found that these clients initially present to counseling with marked depression and anxiety. “It is a terrifying prospect to disclose the self-discovery that one’s anatomy and inner experience do not align,” she says. “People fear rejection, loss of employment [and] loss of family, friends and intimate relationships. Initial goals for treatment often include support in coming out, strategizing about how to manage the obstacles and challenges they anticipate in their transition experience and mitigating depressive and anxiety-related symptoms.”

“Often, there are issues surrounding low self-esteem, as many people have spent years living with a gender presentation that they know to be wrong for them and have developed significant self-loathing as a result,” Chamberlain continues. “People who are further along in their transition sometimes have trauma issues to process, perhaps as a result of hate crimes, rejection from family or termination of employment. The risk of suicide for these clients cannot be overstated. The challenges they face are immense and, sometimes, quite overwhelming.”

Chamberlain cautions that one challenge in working with the transgender population comes in the form of witnessing the extreme injustice and marginalization these clients are forced to endure. However, she notes that the work is highly gratifying as well. “I have yet to work with a transgender or gender-variant client who is not intelligent, insightful, creative and incredibly tenacious in one way or another,” she says. “There aren’t words to describe how incredible it is to witness the transformation of a person who comes to you sad, fearful and overwhelmed into a confident, beautiful, successful human being whose outer self aligns with their inner experience.”

Thomas Tsakounis reports a similar experience. An ACA member in private practice, Tsakounis is the executive director of A Quiet Journey Counseling & Associates in Silver Spring, Maryland, where he works with a variety of clients, including lesbian, gay, bisexual and transgender (LGBT) individuals, same-sex couples and families. “Witnessing the shift from nonacceptance to acceptance is one of the most rewarding experiences,” he says. “[Although] oftentimes it doesn’t happen in one session but is more a transition, the work is life altering.”

Tsakounis finds that working through deeply embedded social, cultural and religious views often presents the most daunting challenge. “It is my belief that since many of these views are imparted to youngsters early in life, deviating or breaking free from these belief systems is more challenging as a young adult or adult,” he says. “These deeply steeped views result in challenges in empowering the client to see themselves in a different light.”

Counselor as gatekeeper

Transgender clients present to counseling for a variety of reasons. Counselors may find themselves working with someone who is fully confident at the end of her transition or a person for whom even speaking the word “transgender” may be a new experience.

When a trans person decides to pursue gender reassignment surgery, they are often required to have a mental health evaluation and a letter of support written before receiving hormones or being evaluated for surgery. Coughlin describes this as playing the role of gatekeeper, or being the one with the power to determine if the client gets to live an authentic life.

“When I was doing intakes, I would sometimes be the first person [the client had] ever shared their feelings with. They come in with symptoms of depression or anxiety, and it takes a while to get to the gender stuff,” he says, adding that, as a health center, Whitman-Walker Health addresses the mental health factors alongside the physical health issues that clients are facing.

Coughlin says it is critical that counselors educate themselves on gender identity topics because they are often on the front lines of helping trans people find resources. “We are put in a tremendous position of power to say if [these individuals] can get ‘the surgery’ [gender reassignment surgery],” he says. “They can come in skeptical or unsure. This has been a marginalized community that has dealt with marginalization and discrimination by health care providers, [so they] may come in very distrustful of us.”

Chauvin suggests that counselors attune themselves to situations in which a trans client enters treatment with resentment toward the medical establishment and use that as a way to explore similar resentments and frustrations the client has experienced over a lifetime. She also recommends that counselors be prepared to help these clients if they are facing financial crisis as a result of losing a job or career when they begin to transition. She notes the example of one of her clients who had been running an engineering firm but lost her job and had to become a massage therapist after making the transition to female. But at the center of this process, Chauvin emphasizes, is the same existential question that any other client may face: Who am I in the world?

Rebecca Ouer, a social worker in Dallas, is currently writing a book titledSolution-Focused Brief Therapy With the LGBT Community: Creating Futures Through Hope and Resilience to help educate clinicians. Her philosophy is to make room for the client to fully define himself or herself. “If a client looks to you like a typical male and sounds like what you have always known as a male but wants to be called ‘Nicole’ and referred to by female pronouns, as their therapist, you must get past any and all reservations you have about societal norms and completely respect your client’s definition of themselves. If you cannot do that, you should not be working with this community,” Ouer states. “Do not question their definitions; just respect them and ask them questions about the hopes that they have for their lives.”

Coughlin himself transitioned around 2000, when he says the medical community still struggled with how to help trans people. “The field around transgender people has just totally transformed [since then],” he says. “Way back then, we were still considered to be in this pathology that needs to be corrected. Still [today] people see it as an affliction, a disorder, a tragedy — and it’s not. I come at it from a strengths-based place. Coming into my office is an amazing feat [for these clients]. Trying to become more authentic and more themselves … it’s not a horrible thing. With some family members, this is a courageous thing to go through, so my focus is on how can I help and be of support to you?”

Counselors who are not transgender themselves still can be helpful to clients facing gender identity issues. Tsakounis suggests that counselors consider exploring sensitivity training to help them “separate the myth from the truth.” He adds that coming out often is a long, painful and confusing process. “Seeking support may seem simple and straightforward, but there is a certain degree of courage involved,” he says. “Clients who present to counseling have reached a point where they simply don’t have the answers they seek, and despite their concern about judgment and anonymity, they make the decision to engage professional help.”

For counselors looking for a starting point in their work with these clients, Tsakounis recommends recalling Carl Rogers and the concept of unconditional positive regard. “I am always reminded that whether it is an LGBTQ client or anyone else seeking a counselor/therapist, the bottom line is that when you erase all the labels, what sits before you is a peer — a person who wants to be accepted, listened to and supported. In the end, their sexual identity is a small, very small, part of that human being,” he says. “Offering a safe space where there is no judgment and providing unconditional positive regard [are two] of the most valuable gifts you can give to someone who has known nothing but the contrary their entire life.”

A host of interventions

The diversity of ways a transgender client presents to counseling may be equaled only by the variety of interventions used with this population. Caroline Gibbs, an ACA member, is the founder and director of the Transgender Institute in Kansas City, Missouri, where the model of treatment extends beyond talk therapy. Gibbs explains that the institute’s offerings are multifaceted to truly support transgender people through all phases of their transition. Services include individual and group therapy, one-on-one vocal coaching, mentoring programs, insurance navigation assistance and physician referral, as well as clinical consultation for therapists desiring support as they help transitioning clients. The institute also offers classes on makeup application and hairstyling, Gibbs says, because many trans women are highly interested in learning about these skills and need a safe space to explore them.

“We have a fashion stylist … [and] we have a finishing school for people who want to learn how to sit properly at a table and how to make their way around society. We do vocal feminization, and, of course, we do therapy,” she explains. “99.9 percent of the patients who come here say, ‘I want to blend in. I want to be a woman in this society, and I want to live my life.’ They may choose to be an advocate for their community in the future, but most often they are very sure they just want to blend in.” Gibbs adds that female-to-male transsexual clients may find it easier to blend in faster because testosterone treatments provide physical and vocal changes within three to six months.

Gibbs often starts by inviting clients to write an autobiography, which, she explains, can feel easier than having to vocalize their feelings. “Sometimes people are so anxious they will not talk in therapy,” she says. “They are so afraid to say ‘I’m transsexual,’ so they write out their sessions.”

Gibbs mentions the example of a male-to-female transsexual client who grew up in a household of brothers and with a masculine father who profoundly discouraged her from doing anything feminine. “All she wanted was to play with Barbies,” Gibbs recalls. “So what she did was take her GI Joes and, at 4 or 5 years old, cut out paper dresses and pinned them to the GI Joes. She remembered that when writing the autobiography.”

At the same time, Gibbs says, “I think that the power of a future-focused conversation with this community cannot be overstated. I never spend time talking about my clients’ childhood or delving into the details of their dysphoria unless they ask me to or bring those things up on their own.”

Gibbs says she believes clinicians can sometimes become curious about the wrong things with this community, such as the details of transition that might make clients uncomfortable. “I think that these clients need to be able to be in the driver’s seat of these therapeutic conversations,” she says. “They need to know that they are the empowered ones in our therapy rooms. They are the experts of their lives and of who they are. We are just the experts of the question-asking process to help them get to their preferred future.”

Other clinicians apply their own preferred treatment modalities when working with trans clients. Tsakounis says he frequently uses the Emotional Freedom Technique (EFT) with clients working through feelings of fear, disappointment, guilt, sadness, low self-esteem, anger, anxiety and frustration. A self-administered energy technique that draws on approaches rooted in alternative medicine, EFT helps clients release distress by tapping on various parts of their bodies. “EFT is very effective in helping a client process through feelings more efficiently, while at the same time bringing out some of the more deeply seated feelings,” Tsakounis says. “EFT empowers the client by giving them a simple, easy-to-access tool which they can use at any time.”

Chamberlain, meanwhile, has found success using acceptance and commitment therapy and dialectical behavior therapy techniques to help clients manage anxiety and enhance their coping and containment skills. She also recommends journaling and art therapy techniques to engage the creative mind and bibliotherapy and media therapy (in which counselors use movies and TV clips) to help clients feel less alone.

Coughlin notes that he doesn’t believe therapy is an absolute requirement for trans people. “I think there are people who are high functioning, and this is just a path of self-actualization. They know who they are and have to go this track to be connected to the medical options,” he says. “[For] others, I think really it’s about support in dealing with the other people in their lives, dealing with the coming-out process, societal pressure, loss of family support, being isolated [and] just how to connect. Trans folks are human. You can be trans and be depressed. It’s not necessarily causal.”

How to become a resource

Working with the trans population may demand more than conventional counseling skills. Coughlin, for example, sees much of his calling in this community revolving around advocacy and education for people outside the clinic. He notes that he often does a substantial amount of footwork to help clients find competent providers for mental health and other health care needs.

“It’s more than hanging a shingle and saying, ‘Sure, I’ll work with trans folks.’ We need to refer to people with experience,” he says, adding that word-of-mouth is often how he becomes aware of providers with skills in this area. “I just went to a workshop this morning about transsexuality, and it’s so much more than just ‘read these two books and start taking clients,’” Coughlin says. “You really have to dive in, talk to providers, join a peer group, go to a conference, go to Gay Pride [events and] find out all the resources. You have to have a wealth of information to do this work well.”

Chamberlain agrees and takes issue with how counseling education programs address work with the transgender community, charging that if and when the topic is even discussed, it barely scratches the surface of what is needed. She recommends that counselors attend conferences specific to gender issues, including the Philadelphia Trans-Health Conference and Seattle’s Gender Odyssey conference. She also suggests joining the World Professional Association for Transgender Health and becoming familiar with its most recent standards of care. “Beware of offerings that promise you certification as a ‘gender expert’ in a short amount of time,” she says. “No such certification yet exists. We become gender specialists through years of education, training, reading, involvement in the communities and working with our clients.”

Although Whitman-Walker Health specializes in serving LGBT clients, Coughlin admits that the emphasis often is on the lesbian and gay clients rather than the transgender population. “A transgender person’s experience is going to be very different from a gay man’s experience. It’s important to do the work to see what the community is and who trans people are [to get] a sense of the complexity and diversity in that community, because it’s certainly not ‘one size fits all,’” he explains.

Coughlin’s advice for counselors is to stop thinking about gender the way they have in the past. “It’s a paradigm shift,” he says. “Gender is this fluid thing … more like a soup. … People are everywhere and anywhere in there, and that’s their right as people and human beings. And that’s our role as therapists — to allow them to be seen as they are and to know that when they aren’t able to present as themselves, to meet them where they are.”

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This article first appeared in the Feb 2015 issue of Counseling Today magazine.