What best supports trans clients?

Therapists routinely engage in conversations about how to best support their clients. This means keeping up with research, consulting with peers, and paying attention to what our clients stated needs are.

I recently attended training about unpublished research that highlighted complex issues for those who have chosen to detransition. A significant piece of this work focused on unpublished research MacKinnon, K.R., Khan, N., Newman, K. Exposito-Campos, P., Marshall, G, Gould, W.A., Pullen Sansfacon, A., Rackliff, K., Lam, J.H.S. (under peer review). Gender fluidity and detransition: Results of a cross-sectional online survey of sexual and gender minorities living in the US and Canada.

Four categories were highlighted, with category A experiencing the most regret about transition and category D experiencing the least regret. It seems that research is working towards the ability to predict who benefits from gender affirming care, but we aren't there yet. So what do we do with this gap in information?

The importance of client autonomy

My school focused heavily on the importance of client autonomy. We were told that regardless of the type of therapy we focus on we will have clients who we disagree with. The decision ultimately remains with the client. Domestic violence was often used as an example. You may have a client whose spouse you view as a threat to their safety. You may create a safety plan and discuss various options, but your client may choose to stay with someone violent towards them.

This goes against a therapists instinct that people want to be safe. Some people choose to live in complex realities that don't make sense to their therapist. This is why we are constantly challenged to be aware of our biases to minimize the impact our bias has on our clients. This is the nature of being a therapist.

What concerns me most about this issue is when people come to therapy with unrealistic expectations. Clients come in with beliefs and statements like "Gender affirming care is the only thing that cures gender dysphoria." When I hear something like that I wonder where that belief came from. The research isn't that clear cut and in my profession I'm not allowed to make blanket statements like that. I can't even claim that CBT cures depression because that would imply that my client should expect it to work for them. I can say research has shown that CBT is an effective treatment for depression. I can't even claim that I'm effective at providing such treatment because I don't have any research that shows my provision of CBT helps my depressed clients.

I've had over 60 hours of training in supporting trans clients. I believe that hearing broad perspectives helps challenge bias. In the gender affirming training I had I would hear off hand comments about how sometimes a person has other mental health issues going on and they don't recommend transition for those people until those mental health issues are addressed. This made me curious about what they were referencing because they didn't seem to think it necessary to elaborate on what issues we should bring up to clients.

What I refer to as traditional therapy approaches focus on client autonomy and encouraging exploration. Dr. Isabelle Hénault said when clients asked her questions like "Am I trans?" she would say "Maybe, yes, maybe no. Let's explore." This sense of exploration is very much the type of exploration that makes my job enjoyable. I'd say that my main difference is I don't think there is a way of determining if someone "is" trans or if they will benefit from gender affirming care.

As therapists there is a way of assessing if someone has a mental health condition like gender dysphoria, but that is separate from a person's identity. Identity typically isn't considered something that needs clinical treatment unless it's based in a cognitive distortion like "I'm bad." "I'm a failure." "I'm not good enough."

The things I treat largely focus on helping people understand why they experience distressing emotions and thoughts. How can they communicate better and pursue their goals? These are things that research has a lot of good information on and can benefit a wide range of people.

I also wonder if as a society, even though we talk more about mental health, if we are enabling poor mental health. John Rosemond highlights

Thirty-four percent of students at Amherst College are registered as having a disability and thus entitled to one or more “accommodations,” including being allowed more time on tests and being granted various other forms of lowered academic standards. The corresponding figure at Stanford is 40 percent. The average for four-year colleges and universities nationwide is 21 percent. The figure for two-year community colleges is 4 percent. The more prestigious the institution, the greater the percentage of students with “disabilities.” Fascinating.

This makes me wonder how many of these students are being treated for their various mental health conditions. Have we become more focused on diagnosis and accommodation rather than treatment? Proper treatment of mental health issues is a difficult task. The first challenge is accurate assessment.

Why assessment is important for support

Key point: Assessment is standard practice for any significant medical intervention involving psychological factors.

Mental health assessments before major medical interventions are not about ‘allowing’ or ‘denying’ care. They are a standard part of healthcare designed to ensure that a patient understands the implications of treatment, has the capacity to consent, and receives support for any co-occurring issues. This is known as informed consent.

In Ontario where I began my clinical work there is no mental health evaluation needed for social or hormonal transition. Some surgeries may require a mental health signor, but my regulatory body is currently not included as being approach to sign off on these surgeries. This means by definition I'm not involved in decisions regarding a person's ability to transition. Any work I do to support a trans person has to do with what else is happening. Very often a big piece of this is how their parents respond and helping their parents understand why transition is important to the client.

Other areas that we commonly offer support are decreasing rumination, managing unhelpful emotions, resolving perfectionist tendencies and social anxiety. These are treatment areas that benefit from mental health support and are separate from a clients choice to pursue gender affirming care.

Many have concerns that mental health practitioners are gatekeepers for acquiring gender affirming care. If gender affirming care is mental health care then it makes sense to have mental health providers as gatekeepers in the same way you have to talk to a mental health provider to get an anti-depressant. If it's not mental health care then it does not make sense to have mental health providers as gatekeepers.

I don't think we have enough research to say conclusively that gender affirming care provides mental health benefits to anyone who wants to access it. As such I don't consider it a mental health intervention. What I often see from clients is transition makes them more fixated on their dysphoria causing them to feel worse. It's as if by taking one step towards transition the goal posts are always moved further, and are forced to acknowledge that their dream of being like the opposite sex can never be realized.

Andrea Chu states

I feel demonstrably worse since I started hormones....Like many of my trans friends, I've watched my dysphoria balloon since transition...I was not suicidal before hormones. Now I often am....I still want this,all of it. I want the tears; I want the pain. Transition doesn't have to make me happy for me to want it. Left to their own devices, people will rarely pursue what makes them feel good in the long term.

My primary concern is that current informed consent models are not adequately informing people of alternative treatment options and the lack of long term information that we have regarding research. Research typically focuses on gender affirming care as the primary treatment. The only research I'm aware of that focuses on therapy as primary treatment is Singh D, Bradley SJ and Zucker KJ. (2021) A Follow-Up Study of Boys With Gender Identity Disorder. Front. Psychiatry 12:632784.doi: 10.3389/fpsyt.2021.632784

We need research that evaluates the impact of specific mental health interventions that allow people to freely choose whether to pursue transition during the time of the study. At our clinic we are working towards providing mental health support in a consistent way so that we can participate in research that can help us better understand what mental health interventions provide the best support for resolving dysphoria, improving relationships and addressing other mental health needs regardless of whether a person chooses to transition.

When we provide clients with the best information we have we allow them to make informed decisions that hopefully provide them with the long term results they desire.

If you think this is the type of mental health support you're looking for you can request an intake to learn more about how we offer support.