CHAPTER 16

Role of the Mental Health Professional

According to the “Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People” (TGNC), set forth by the World Professional Association for Transgender Health (WPATH),1 mental health professionals may serve TGNC people and their families in a various ways, depending on individual needs. The roles include assessor or evaluator, counselor, psychotherapist, educator, and advocate. Psychological assessment or evaluation typically covers three domains: gender dysphoria, mental health, and psychosocial adjustment. Based on this assessment or evaluation, counseling and psychotherapy follow an individualized treatment plan. Counseling may include assisting TGNC individuals and their families in making an informed decision about interventions to affirm gender identity. These interventions may include changes in gender role and expression, voice therapy, hormone therapy, and/or surgery. Psychotherapy may include exploration of gender and sexual identity but also treatment of mental health concerns. TGNC people may be extra vulnerable to mental health concerns because of the stress associated with being differently gendered and the social stigma attached to gender nonconformity. Mental health concerns, whether or not related to gender nonconformity, may also exacerbate the psychosocial challenges TGNC people face as they explore and seek to affirm their gender identity. Education may include providing information and facilitating access to community resources so that TGNC people and their families can make informed choices and can benefit from peer support. It may also include educating the environment (for example, schools, workplaces, organizations, and institutions) and policy makers about gender diversity and the needs of TGNC people. Finally, mental health professionals can play a key role in advocating for transgender rights on an individual, interpersonal, and sociocultural level. This may include supporting changes in identity documents, advocating for sexual and reproductive rights, and supporting antidiscrimination legislation.

Competency in mental health care for TGNC people and their families varies based on the mental health professional’s role. All mental health professionals should be culturally competent in transgender care. Cultural competence can be defined as the process in which the health professional continuously strives to achieve the ability to effectively work within the cultural context of the patient.^1,2 This includes awareness of one’s own biases and prejudices, knowledge about the patient’s belief system and worldview, the skills to conduct a cultural assessment while avoiding stereotypical judgments and assumptions, cultural encounters with patients from diverse backgrounds, and the desire to engage in the ongoing process of building cultural competence. In transgender care this includes ensuring a clinic environment that reflects gender diversity in posters, brochures, registration and intake forms, the use of preferred names and pronouns, and access to all-gender bathrooms. It also includes open communication between provider and patient about gender identity and gender affirmation to the extent that it is relevant to the presenting concern. Clinical competence in the assessment and treatment of gender dysphoria goes a step further, because it requires specialty training and supervision.¹ In addition, mental health professionals working with TGNC children and adolescents should have training in developmental psychology. Moreover, mental health care for TGNC people and their families is best provided in consultation with providers of other disciplines (for example, medicine, education, and social work) involved in the patient’s care.

Assessment of Gender Dysphoria

Gender dysphoria refers to discomfort with the sex and gender role assigned at birth. Gender dysphoria is also a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5),3 where it is defined as a marked incongruence between a person’s experienced/expressed gender and assigned gender of at least 6 months’ duration and requires that the patient present with at least two of the following:

A strong desire to be rid of his or her primary or secondary sex characteristics (or in young adolescents, to prevent the development of the anticipated secondary characteristics)

A strong desire for the primary or secondary sex characteristics of the other gender

A strong desire to be of the other (or some alternative) gender

A strong desire to be treated as the other (or some alternative) gender

A strong conviction of having the typical feelings and reactions of the other (or some alternative) gender

In children, the desire to be the other gender must be present and verbalized. For the diagnosis to be applicable, the incongruence must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Mental health professionals must recognize that some patients and transgender community members may take umbrage to the idea that their gender identity issues deserve a DSM classification. This is a response that the clinician should be prepared for and able to deal with thoughtfully, professionally, and empathetically.⁴ Although some patients may enter the therapeutic relationship with a mature grasp on their gender identity, others may be less clear and have questions about their gender identity. Mental health professionals should explore with compassion and cultural competence the gender with which the patient identifies and avoid any assumptions before proceeding with a formal assessment and treatment of gender dysphoria.

The main approach to the assessment of gender dysphoria is the clinical interview. TGNC adolescents or adults are asked to describe their gender identity, how they feel about their current gender role and expression, how they feel about their body (particularly their primary and secondary sex characteristics), and what if any changes they have made or would like to make in gender identity, gender expression, and/or sex characteristics. Subsequently, a history of their experience with gender identity is obtained. TGNC children are asked whether they feel like a boy, girl, or other gender (for example, boygirl). Parents of TGNC children and adolescents are interviewed about their perceptions, observations, and the reports received about their child or adolescent regarding their gender identity, gender expression, and sexual development. For many of these domains, structured questionnaires have been developed that are either self-administered or interviewer-administered. These include the Gender Identity Interview for Children,5 the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults,^6,7 and the Utrecht Gender Dysphoria Scale.⁸

The assessment of gender dysphoria also includes other key components of sexual identity and sexual development. Most patients presenting with gender dysphoria report normative development of primary and secondary sex characteristics before gender-affirming medical interventions. However, some children born with ambiguous genitalia develop gender dysphoria. Many patients with gender dysphoria report a history of childhood gender role nonconformity (for example, feminine boys and masculine girls), and yet a substantial number of patients (particularly among those assigned male at birth) were not gender role nonconforming in childhood. Thus gender identity and gender expression are two distinct components of sexual identity that are not necessarily congruent. Sexual orientation, another key component of sexual identity, is also distinct from gender identity. TGNC adolescents and adults may be attracted to boys or men, girls or women, or both, as well as to other TGNC individuals. In assessing the patient’s sexual development, all these components should be considered, along with other aspects of sexuality, such as sexual fantasy, sexual expression, attachment, and love. The development of gender identity and gender dysphoria should be understood in the context of overall sexual and human development.

Mental Health

TGNC children, adolescents, and adults are at increased risk for mental health concerns, including anxiety, depression, nonsuicidal self-injury, suicidal ideation and attempts, symptoms of posttraumatic stress disorder, and substance abuse.^9–14 When patients present to a mental health professional with questions about their gender identity or complaints of gender dysphoria, it is the responsibility of the clinician to also screen for and assess comorbid mental health conditions. Before finally deciding to see a mental health professional, patients with gender dysphoria have often dealt with years of social stigma, microaggressions, and social isolation resulting from their status as a gender and/or sexual minority.¹⁵ TGNC individuals may also experience physical violence.¹⁶

In a U.S. national survey of transgender women and men, 44% reported depression and 33% reported anxiety.⁹ These high rates of psychological distress have been attributed to the social stigma attached to nonconformity in gender identity and expression.^9,13,20 According to the minority stress model,^21,22 TGNC people experience minority stress, which negatively impacts mental health. Minority stress processes include enacted stigma (actual experiences of rejection and discrimination), felt stigma (perceived rejection and expectations of being stereotyped or discriminated against), and internalized transphobia (discomfort with one’s own transgenderism as a result of internalizing society’s normative gender expectations).²³ Indeed in the U.S. national survey previously cited,⁹ participants reported high rates of housing discrimination (12%), sexual abuse or assault (15%), physical abuse (24%), employment discrimination (38%), and verbal abuse or harassment (70%). Protective factors included family support and identity pride, and peer support and community connectedness buffered the negative impact of enacted stigma on mental health.^9,24 Research is needed to better understand the mechanism of how stigma affects mental health and to develop tailored interventions.¹³ While exploring the history of the patient’s gender dysphoria, clinicians should be cognizant of the often hostile cultural environment in which their TGNC patients came of age. The cumulative impact of this negative culture and its rejecting and sometimes violent attitude toward gender nonconformity and the subsequent trauma can have a serious impact on mental health. When caring for patients with gender dysphoria, the clinician should be vigilant for psychiatric comorbidities and prepared to apply the appropriate assessment tools to diagnose them.

TGNC adolescents are also more likely to have autism spectrum disorder compared with the general population. In a clinical sample of 204 children presenting with gender dysphoria, 16 (7.8%) had autism spectrum disorder compared with 0.6% to 1% of the general population.9 Similar higher rates of autism spectrum disorder traits have been found in an adult clinical sample,¹⁷ and in clinical samples of children and adolescents with autism spectrum disorder, a higher prevalence of gender dysphoria was found compared with the general population.^25,26 The explanation for these findings remains unclear. However, mental health professionals working with TGNC patients should screen for autism spectrum disorder and incorporate the results in the care they provide.²⁷

A standard psychological evaluation can assess mental health and psychosocial adjustment. For TGNC children, adolescents, and adults, this evaluation should include an assessment of the impact of enacted stigma, felt stigma, and internalized transphobia on mental health and the resilience that they developed over time. Existing strengths and potential assets should be identified, which may include support from friends, family, and community. The evaluation should also include screening for suicidal ideation, substance abuse, and sexual risk behavior (for example, HIV risk behavior, hazards associated with sex work, and sexual violence), for which TGNC people have a heightened vulnerability. When indicated, a psychiatric consultation may be obtained (for example, in patients with symptoms of severe mental illness or when pharmacotherapy may be helpful to alleviate symptoms of depression or anxiety).

Given the disparities in mental health documented thus far, a comprehensive screen and assessment of identified mental health concerns resulting in a differential diagnosis is warranted for most individuals presenting with gender dysphoria. This will allow incorporating treatment of mental health comorbidities in an individualized treatment plan. Generally speaking, treatment is best provided in parallel, that is, mental health issues are addressed during the course of treatment of gender dysphoria. Effective management of mental health comorbidities will facilitate social changes to alleviate gender dysphoria, and progress with gender affirmation will improve self-esteem and self-care, foster a positive future outlook, and motivate the patient to sustain optimal adaptation.

Transgender Identity Development

Transgender identity development is a lifelong process.²⁸ In the context of social stigma attached to gender nonconformity, transgender identity development has been described as a coming out process.^29–31 Bockting and Coleman²⁹ describe five developmental stages:

1. Pre-coming out

2. Coming out

3. Exploration

4. Intimacy

5. Integration

Individuals do not necessarily go through these stages in this particular order. Rather, these stages reflect developmental tasks commonly observed in clinical practice. The pre-coming out stage is characterized by feeling different. TGNC children and adolescents who are outwardly gender role nonconforming (for example, a feminine boy or masculine girl) are recognized as such by the people in their environment and are vulnerable to enacted stigma, which may take the form of rejection, harassment, and abuse. In the face of this adversity, they develop early resilience with the help of supportive others (for example, family members, friends, school, and mental health professionals). TGNC children and adolescents who are outwardly gender role conforming often conceal their gender identity in an effort to avoid enacted stigma. However, concealment is often accompanied by felt stigma (anticipated rejection and fear of discrimination), which may take a different emotional toll and contribute to anxiety, depression, and substance use.

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