Gender-Affirming Clinical Skills: Part 1

gender, nonbinary, gender-affirmingby Worner Leland, MS, BCBA, of Upswing Advocates

Whether someone thinks a lot about their gender or has never given their gender identity much thought, everyone has a gender identity.

Cisgender means: having a gender identity that matches the gender assigned to one at birth (from the Latin prefix “cis” meaning “on this side of”). Transgender means: having a gender identity that is different than the gender assigned to one at birth (from the Latin prefix “trans” meaning “on another side of”). Additionally, transgender is an umbrella term that encompasses many gender identities, including non-binary, trans, transwoman, transman, agender, genderqueer, two-spirit, and third-gender, just to name a few. This list is by no means comprehensive, and additionally as our language is shaped by our verbal communities, new and more precise language to describe one’s experience is always being added.

Like so many things in life, gender can be conceptualized along a spectrum. Just as there is tremendous variability in gender across people, gender can vary for an individual across time or context. Some people may experience very stable gender across time, some people may sense one big shift in their experience of gender, and some may experience gender fluctuation.

It is important to understand that cisnormativity – an assumption that everyone aligns with the gender assigned to them at birth – severely marginalizes transgender people. According to the 2015 U.S. Transgender Survey Report, transgender people experience pervasive mistreatment and violence, and severe economic hardship and instability. These have deeply harmful effects on transgender people’s physical and mental health.

As a clinician, it is important to build competency in transgender care, but it may be difficult to know where to start. Here are some gender-affirming clinical skills you can incorporate into your practice.

Get to know the difference between gender and sexuality.

Before serving transgender clients, it is important to be knowledgeable about the specificity of what gender identity is, and is not. Gender identity is different than gender expression which is different than sex. These are different than sexual attraction. Sexual attraction is different than romantic attraction.  It is complicated, and people’s experiences of each are totally unique. It can be incredibly hurtful to be vulnerable and share experiences about gender, only to have them either conflated with or incorrectly correlated with experiences of sexuality or romantic attraction or gender expression. It is important as clinicians to be fluent with language, and to understand the difference between each of these terms and experiences.

Shake off that binary.

Similarly, you can increase your trans competence by becoming more fluent with the myriad of terms people use to describe their gender identity. It is important to acknowledge that language shifts, and that people use similar terms in different ways. Always let a client ascribe their own labels if they care to, and understand that many of those labels exist outside of a binary. While some transgender people identify as transmen or transwomen (or equally fairly, just as men or women), other transgender people do not experience a gender that aligns with the term “man” or “woman”. Don’t assume that a client is confused, or simply “on their way” to a more binary gender. Honor whatever gender you client is, and whatever pronouns they use.

Don’t make your clients educate you.

If you are unclear about terminology used by a client, do not make them educate you. Make a quick note of the term used, and proactively educate yourself outside of the session time, before the next session. Also, be mindful of the boundaries of your competence. If you have little experience with the complexity of transgender issues, immediately seek out education, the supervision of a colleague who may have more expertise, or refer the client to someone who would be a more appropriate provider if needed. As clinicians, we want to be mindful to do no harm to our clients. Providing clients with access to the most competent services possible reduces potential harm.

Let your client be the expert on their experience.

Above all else, it is vital to let a client tell you who they are. Gender identity is a deeply personal experience, and the only person capable of defining this is the individual. Ask questions. Listen intently. Do not interrupt or talk over clients when they are describing their gender experience. Remember the information disclosed to you, and follow through consistently using language that the client uses to describe themselves. Address your client using their preferred name and pronouns. If you make an error, apologize succinctly and move forward.

It is also important to be aware that much of the transgender community’s experience with mental health professionals has been in a gatekeeping role. Prior to the DSM-5, incongruity of gender identity was still listed as a disorder. Although the DSM-5 now focuses on the concept of Gender Dysphoria, with a focus on distress around gender incongruity, this perpetuates a medical model of care for transgender people, with an attached diagnosis. For many, seeking psychotherapy services is a requisite part of being able to move forward with medical aspects of transition. Embrace an informed consent model of gender-affirming care. Do not require performance of gender norms from a client. Believe them when they tell you who they are, and center their wants and needs.



Worner Leland, MS, BCBA, is the Director of Development and Promotion at Upswing Advocates, a nonprofit organization that provides sliding scale coaching, groups, trainings, and research opportunities that focus on the LGBTQIA community. Worner is also an Adjunct Faculty member at The Chicago School of Professional Psychology.

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