While it may seem that acceptance for the LGBTQ+ community is on the rise, there still remains a mental health crisis for many LGBTQ+ individuals, particularly for transgender and gender non-binary people (The Trevor Project, 2019). In addition, 33% of those surveyed by the National Center for Transgender Equality (2015) reported that they have had at least one negative experience with a healthcare provider ranging from verbal harassment to outright denial of care. Some individuals will not even tell a healthcare provider that they are transgender or non-binary due to the potential stigma, prejudice, and bias that can occur. In addition, according to the same survey, 37% of transgender women, 41% of nonbinary people assigned male at birth, 51% of transgender men, and 58% of non-binary people assigned female at birth have been victims of sexual assault in their lifetime. The rate of prejudice, discrimination, and assault increases for those that have intersecting identities. These are some startling statistics.
Research is limited on the transgender and non-binary population, particularly in the counseling field. However, from the research that has been completed, we see a pattern of transgender and gender non-binary individuals experiencing difficulty in obtaining care and individuals can face challenges even at gender-affirming places. Many may feel misunderstood by providers who approach them from a binary (i.e. male/female) perspective and they do not receive care that is sensitive to non-binary identities. Some individuals will even “borrow” a binary label to receive care, they may modify the healthcare that they were prescribed, or go without healthcare- both mental and physical- altogether. This can stem from feeling disrespected and frustrated as they sought and accessed healthcare in the past and feeling pressure to conform to a binary narrative throughout all healthcare interactions. In addition, many people assume that clients do not need sexual health services, such as pelvic exams or contraception, or that treating these individuals will be too complicated.
In general, there is a lack of sexual health advocacy for transgender and gender non-binary people. The need to affirm ones gender and expression can supersede other health concerns or seeking appropriate medical care. Furthermore, the effects of minority stress and rejection can interfere with someone navigating physical and mental healthcare, seeking appropriate healthcare, and negotiating healthy sexual interactions with a partner or partners. The fact that many providers lack appropriate knowledge or will flat-out turn clients away does not help with these concerns. In addition, the marginalization, bias, and potential abuse that these people can face can increase both physical and mental health risks. Moreover, economic and social disparity can lead to lack of access to care and lack of relevant sexual health information. Faced with job and housing discrimination, some transgender and non-binary individuals turn to sex work in order to provide for themselves and to survive.
In order to remain inclusive, abide by our various codes of ethics, and help transgender and gender non-binary clients navigate the different realms of their sexual health, there are several things we can do. Use gender-affirming language by asking the person to describe their pronouns and bodies under their terms and don’t use language that makes assumptions. If you are a sexuality educator, counselor, or therapist, include safer sex materials and information to include all bodies, not just cisgender ones. Counselors can also gain further education about gender diversity, educate colleagues, and advocate for more training. While some education about the client’s world will come from the client, do not expect all transgender and gender non-binary individuals to educate you and do the work for you. In addition, create an inclusive environment by having affirming posters and pamphlets, inclusive intake forms, gender neutral bathrooms (if possible), and inclusion of transgender and non-binary staff. Validate and identify yourself as an ally and be aware of your assumptions. Recognize that gender identity does not determine gender expression and gender identity does not equal sexual or affectional orientation. People may have sexual partners who are men, women, or both and recognize that relationships can include monogamous, open, poly, BDSM, and various other forms and sexual activity can include oral, vaginal, anal, and other types. Additionally, understand that there is no right way to transition and not everyone wants to transition.
In addition, we can do what counselors do best and that is establish a relationship with our clients. Listen and use a holistic approach. Acknowledge previous physical and mental healthcare experiences with an attitude of respect and from a place of advocacy. Regulate and pace disclosure and exploration of a client’s sexual history and approach trauma experiences slowly. If there has been any sexual trauma and assault, approach treatment from the position of the client’s identity, not just their anatomy. Increase your own awareness of the issues facing transgender and gender non-binary clients. If you have a client that has, or is currently, engaging in sex work do not stigmatize them, withhold sexual health and wellness counseling based on value judgments, and do not assume that all transgender and non-binary individuals are engaging in risky sexual behaviors. Also, use a comprehensive sexual health model that talks about sex, includes culture, gender, and sexual identity, sexual anatomy and functioning, sexual healthcare and safer sex, challenges and barriers to sexual health, body image, masturbation and fantasy, positive sexuality, intimacy and relationships, and spirituality and religion. Lastly, be open to discussing the effects of hormones and surgical procedures on sexual health such as shifting sexual attractions, changes in desire, functioning and activity, sensation changes, and any body and self-esteem issues that could arise for the client.
Finally, advocacy is an important part of who we are and what we do as counselors. Advocacy can include reporting discrimination and working to change, or eliminate, policies that hinder the lives and treatment of our clients. Such policies can include those that require transgender and gender non-binary people to undergo sex reassignment surgery before changing their gender marker on government documents (such as a birth certificate). People should be able to change their gender markers without requiring proof of surgery, or other invasive medical procedures, which is a violation of bodily autonomy, reproductive rights, and can lead to forced sterilization. In addition, transgender and non-binary sexual assault resources are difficult to find. Advocacy organizations for sexual assault and domestic violence typically cater to cisgender women. If there are safe male spaces, they typically focus on cisgender men. In addition, resources typically are gendered, particularly support groups, and there are high rates of discrimination in interactions with medical professionals, the court system, and the police in sexual assault and interpersonal violence cases. Some individuals are assaulted again by the professionals that are put in place to help and assist with these cases.
Overall, there is a great need for mental health resources, research, and advocacy work for the transgender and gender non-binary population. We, as counselors, can help to fill that need so that those who identify as outside of the gender binary can access the same right to appropriate sexual health and wellness as those who are cisgender. There are several resources and organizations to help with this process including ACA’s very own ALGBTIC division, the Association for Counseling Sexology and Sexual Wellness (ACSSW), and interest groups such as Sexual Wellness in Counseling (SWIC). Other non-counseling related resources include the National Center for Transgender Equality, The Trevor Project, World Professional Association for Transgender Health (WPATH), and the Center of Excellence for Transgender Health. Transgender and gender non-binary people have been around for quite some time and the need for appropriate sexuality counseling is there. Let us help fill that gap.
Resources
The Trevor Project (2019). National survey on LGBTQ youth mental health. Retrieved from https://www.thetrevorproject.org/wp-content/uploads/2019/06/The-Trevor-Project-National-Survey-Results-2019.pdf
James, S. E., Herman, J.L, Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The report of the 2015 U.S. Transgender survey. Washington, D.C.: National Center for Transgender Equality. Retrieved from https://www.transequality.org/sites/default/files/docs/USTS-Full-Report-FINAL.PDF
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Contributing Author
Lauren McLean is a counselor educator and licensed professional counselor specializing in gender, sexuality, and body image issues. You can follow her on Twitter @mcleaninsession, Instagram @mclean.in.session or LinkedIn @Lauren McLean.
This blog is brought to you by the Sexual Wellness in Counseling Interest Network. SWIC is comprised of a group of individuals who value the richness and complexity of human sexuality. Intentional efforts are made to advocate for sexuality education and training of professionals and students through a multi-dimensional approach. Sexual wellness elucidates the salience of sexual freedoms, rights, and expression while honoring the holistic exploration of the human existence. SWIC advances this sentiment by providing support and guidance to professionals and students that recognize the imperative nature of sexual wellness.
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