Culturally responsive mental health care for transgender and nonbinary individuals


Transgender and nonbinary (TNB) individuals who are seeking mental health care interface with a system that has a history of ignoring and overtly rejecting their need for support (Seelman et al., 2017). Substandard care, displays of provider discomfort, gender insensitivity, and verbal abuse have been documented (Roller et al., 2015) as leaving some individuals mistrustful of practitioners and unwilling to reach out when mental health services are needed (McCullough et al., 2017; Shipherd et al., 2010). Potentially less obvious, but still harmful, are experiences of microaggressions (Owen et al., 2019) - commonplace, everyday acts, whether intentional or not, that create hostile environments for marginalized people (Sue et al., 2008).

When TNB individuals have experiences with mental health providers that are humiliating (McCann & Sharek, 2016), or transphobic (Elder, 2016), stigma gets reinforced and experiences of marginalization can deepen (Spicer, 2010). This reinforcement of stigma is one of the most significant barriers to care and often results in disengagement with clinical services (Benson, 2013).

Provider education

Practitioners report feeling unprepared to work with TNB individuals, having had little formal or informal education regarding the population (Benson, 2013), leaving them with assumptions and biases about effective practice with TNB clients, an issue even more pronounced for TNB people of color (Noonan et al., 2018).

Frequently TNB clients have to teach providers about concerns regarding gender identity. Even basic content may be missing, such as the difference between sexual orientation and gender identity (Benson, 2013); common health concerns (Taylor et al., 2013); or the lack of legal protections (McCullough et al., 2017). Practitioners may fail to grasp the pervasive fear that can emerge as a result of transphobic experiences, including from medical providers. Further, neither practitioners nor provider educational programs are held accountable for the lack of practitioner knowledge and skills in providing competent services to TNB individuals (Shipherd et al., 2010).

It is also critical that practitioners understand what is not affirming for their clients. Unaware therapists are more likely to enact these behaviors, potentially rupturing the therapeutic relationship and causing harm (Mikalson et al., 2012). A well-meaning provider may erroneously believe that being kind is all that is needed to be affirming to TNB clients, failing to realize that subtle non-affirming interactions and microaggressions can be harmful.

Service approaches

Some concerns that TNB people bring to providers may be directly associated with gender identity status, transition, or life experiences as a TNB person, while other concerns may not. However, even seemingly unrelated concerns can be exacerbated by living in a transphobic world. Practitioners should neither assume that all concerns relate to the client’s TNB identity, nor assume that unrelated concerns are not influenced by experiences of invalidation through lived experiences.

One approach to balancing this tension is having familiarity with common trends impacting TNB-identified individuals, and being prepared to integrate this knowledge into practice. Giving thought to the best ways of inquiring about these common concerns prior to working with TNB clients - the skill of culturally educated questioning (Rodriguez & Walls, 2000) - can help clinicians feel more confident in their abilities to embody cultural humility (Hook et al., 2017). Remembering that the client is the expert on their lived experience, supporting the clients’ self-determination, and using strengths-based approaches can prevent stereotyping that may occur with familiarity of cultural trends.

Mental health concerns

As with cisgender adults, concerns that TNB adults bring to practitioners vary. Some are common issues, like mood disorders, self-esteem concerns, and trauma-related issues. Even with these more common concerns, the etiology may differ from similar concerns for cisgender clients, necessitating a different approach. Other concerns are unique to TNB clients and may include concerns about coming out or transition-related issues, requiring specialized knowledge.

Anxiety and depression

Prevalence of anxiety is two to three times higher among TNB adults than cisgender adults, with social anxiety disorder as the most common type (Harvard Medical

School, 2005; Millet et al., 2017). Similarly, depression is two to three times higher among TNB individuals (Adams et al., 2017; Reisner et al., 2016).

Factors associated with elevated rates of anxiety and depression include discrimination, violence, the stress of concealment, internalized transphobia, and fear of rejection (Bockting et al., 2013; Budge et al., 2013; Testa et al., 2015). TNB individuals in early stages of identity development may be at an increased risk for mood disorders (Testa et al., 2014), suggesting that this is an important time for involvement with affirming mental health services (Pflum et al., 2015).

For TNB individuals who desire them, gender-affirming medical interventions may act to reduce experiences of gender-related victimization by aligning one’s appearance with society’s binary gender norms (Butler et al., 2019). While research consistently finds a relationship between hormone therapy and reduced levels of anxiety and depression (White Hughto & Reisner, 2016), more complex patterns have emerged when examining other medical interventions such as chest surgery (Tomita et al., 2019).

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