The Importance of Trans-Affirmative Therapy
By Dr. Lior Ben- Avraham, MSW, DSW, RCSW
This week we mark Trans Awareness Week, which ends with the Trans Day of Remembrance. Here at the Psychological Health & Safety Clinic, we remember and honour those trans individuals who have faced transphobia or lost their lives due to hate and discrimination. As a therapist who has worked extensively with the trans community, I know many trans folks still don’t have access to good mental health services. In honour of this week, and of my trans friends and clients, I will share some personal stories about the journey that brought me to specialize in trans-affirmative therapy. As well as some thoughts about fostering trans-inclusive practice.
A word about terminology (because language is important). Although many terms exist in the literature, I will use the word transgender, or trans, as an umbrella term for any individual whose gender identity and/or gender expression differs from the gender they were assigned at birth (including but not limited to trans women, trans men, and non-binary people).
Why is trans-affirmative therapy necessary?
Transgender individuals still face enormous threats to their dignity and safety. Despite efforts to improve their security and welfare, throughout their lives they continue to face discrimination, microaggressions, and victimization. Manifestations of such behaviours occur everywhere, from the workplace to restrooms.
Many studies establish that transgender individuals in Canada are significantly more likely to experience violence than their cisgender counterparts. Another study speculated transgender individuals are “the most targeted hate crime victim group in Canada” (Perry et al., 2014).
The risk of violence is even greater for transgender people who are part of ethnic minorities. One study surveyed Indigenous transgender individuals in Ontario and found 73% of respondents suffered “violence due to being trans” (Scheim et al., 2013).
Unsurprisingly, then, these harms contribute to disparate rates of suicide, anxiety, trauma, and depression among transgender individuals. The data is clear: trans people across all demographics and ranges of experience have high levels of attempted suicide. A 2014 study by the Williams Institute reported that 46% of trans men and 42% of trans women had attempted suicide (Herman et al., 2014).
Yet, mental health services have not fully responded to the needs of transgender people.
Unfortunately, growing evidence shows that trans people experience more concerns about engaging in therapy than their cisgender counterparts. This is due to a lack of providers who are trained in providing services to LGBTQ2+ individuals, and the limited availability of trans-inclusive counselling services.
In light of this disturbing data, it’s imperative that professional counsellors who work with trans folks serve as social-change agents by developing specific competencies, attitudes, and skills to help this population. I hope sharing my personal narrative and my work experience will encourage some therapists to learn more about affirmative therapy, and some trans folks to seek the help they need with skilled professionals.
How did I start my work with trans folks?
My personal experience
As with most people, my personal experiences are the foundation of my passion for the work I do. My commitment to the practice and research of clinical social work originated from my relatively unique background and life experiences. A son of parents in an uncustomary intrareligious marriage, my ‘coming-out moment’ was not a single event but a continuous journey of rejection, survival, resilience, and acceptance. Indeed, sharing my sexual orientation with my parents was a traumatic and emotionally devastating experience.
However, this background, and living with overlapping identities, has given me a keen understanding of the lived experience and barriers facing LGBTQ2+ people, including trans individuals. While I identify as cisgender, and do not purport to have experienced the difficulties that trans folks face, I’ve connected with many trans people because we all suffered as a result of transgressing gender norms.
Over time, it became clear that I must transform my lived experiences into a strength to engage, empower, and mentor populations that endure vulnerability.
My work experience
My path led me to focus my clinical practice on groups who have multilayered social identities and complex psychosocial conditions. That’s why I completed my practicum training at the Ali Forney Center in New York, the largest provider dedicated to homeless LGBTQ2+ youth in the U.S. A significant number of my clients there were trans individuals, and I learned a great deal from them. They were often kicked out of their homes and shunned by their families. They faced considerable discrimination, often compounded by racism and poverty.
Almost a decade later, I worked at Three Bridges in Vancouver, in the Trans Specialty Care clinic, providing gender-affirming counselling to transgender individuals from Metro Vancouver.
Although my work in these places was different, in both I felt honoured and privileged to help these clients in their journey to better lives. I got to witness the resilience and courage of my clients as they endeavour to live fully despite and beyond the limitations and challenges of their lives.
I turned my barriers into an advantage, and I am deeply committed to using my experience and knowledge to help others to fulfill their human potential and build satisfying lives.
What is trans-affirmative therapy?
Trans-affirmative clinical practice refers to a non-pathologizing approach to clinical practice that accepts, respects, and validates all experiences and expressions of gender (Austin & Craig, 2015). Trans-affirmative practice rejects the male-female binary and instead fosters a trans-inclusive culture at the onset of the therapeutic relationship. Good trans-affirmative therapy requires constant learning on trans literacy. That means staying up to date on changes in terminology and about trans-affirming health care. Sometimes, it requires the clinic, or website, to change its forms; for example, making sure there is a place to include pronouns.
As a trans-affirmative therapist, I focus on creating a trusting environment for my clients to safely share, understand, and explore their experiences. At the same time, I understand that trans people experience a host of issues beyond those related to gender identity and expression.
A person-centred approach—emphasizing empathy and unconditional positive regard for the client—allows clients to feel secure in the client-therapist relationship and comfortable to explore their sexual orientation and gender identity and expression. I use strength-based and empowering trans-affirmative language while speaking with clients, and never make assumptions about any aspect of their lives.
Trans-affirmative practice must acknowledge and facilitate conversation about the oppressive contexts that transgender clients often experience in our society and the healthcare system. We identify clients’ unique resiliencies, such as embracing self-worth and self-esteem, connection with a supportive community, cultivating hope for the future, and being a positive role model for others.
How we move forward
I believe the “next frontier” is to help the counselling field integrate transgender-affirmative training for healthcare providers. The transgender community still faces challenges in access to all-inclusive mental health services. I’ve often seen good counselling services make a significant positive change in clients’ lives.
Trans Awareness Week is a good time for clients to start their journey toward better lives and for therapists to think about how to better integrate services for transgender communities.
Austin, A., & Craig, S. L. (2015). Transgender affirmative cognitive behavioral therapy: Clinical considerations and applications. Professional Psychology, Research and Practice, 46(1), 21-29. doi:10.1037/a0038642
Herman, J., Haas, A., & Rodgers, P. (2014). Suicide Attempts Among Transgender and Gender Non-Conforming Adults. UCLA: The Williams Institute. Retrieved from https://escholarship.org/uc/item/8xg806
Perry, B., Perry, B., Dyck, D. R., & Dyck, D. R. (2014). “I Don’t know where it is safe”: Trans Women’s experiences of violence. Critical Criminology (Richmond, B.C.), 22(1), 49-63. doi:10.1007/s10612-013-9225-0
Scheim, A. I., Jackson, R., James, L., Sharp Dopler, T., Pyne, J., & Bauer, G. R. (2013). Barriers to well-being for Aboriginal gender-diverse people: Results from the Trans PULSE Project in Ontario, Canada. Ethnicity and Inequalities in Health and Social Care, 6(4), 108–120. http://doi.org/10.1108/EIHSC-08-2013-0010
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