Treating Gender Questioning Clients for Clinicians

When I initially obtained my bachelors in nursing in 2007 I don’t recall learning about transgender individuals at any point in my four year program. During my Master’s program I think we had some discussions around the LGBT community in generalized terms but nothing specific to therapy with clients who are gender questioning. I graduated in 2012, and started practicing as an psychiatric nurse practitioner in 2013. At some point I had my first transgender patient on the inpatient psychiatric unit I worked on. Inpatient treatment is very different than outpatient. Inpatient is focused on stabilization and it’s not the place to go into deep gender work. Transgender or non-binary clients were usually there for a primary depressive or bipolar illness that was or was not related to their gender identity. Our focus was on stabilizing symptoms of depression or bipolar disorder, not on gender identity.

Along the way I slowly transitioned to outpatient medication management and transgender clients slowly and naturally made their way onto my caseload for medication management. Medication management has an element of detachment from the primary gender work. For medication management we still focus on symptoms that can respond to medication- depression, anxiety, etc. I always have the discussion about gender identity and how body image, hormone therapy, surgery accessibility, etc. is contributing or not to dysphoric or mood symptoms but it’s really focused on symptom management.

During these years I started to educate myself. I found gender work even in the removed role of managing medication, to be interesting and rewarding. These clients are vulnerable and brave, and I very much enjoyed the work with them. But I knew my knowledge was lacking and I started to have gender questioning people asking me to do individual therapy in addition to medication management.

I did not take on a client who was newly questioning their gender until I felt competent enough to provide quality care. I went to conferences, I read books, I talked to people. I talked to clinicians professionally. I talked to transgender individuals who I knew personally and professionally and with a great deal of sensitivity I asked them if they would tell me what worked for them and what didn’t when interacting with mental health providers. I asked what they would look for in a healthcare provider. I asked my LGBT group their good and bad experiences with healthcare providers. I read studies dating as far back as the 80’s. I ate up and continue to eat up information. I also got supervision. When I started therapy with my first gender questioning client I felt I had a solid base of knowledge and a solid support net of people to call if anything came up that I didn’t know how to handle.

What I discovered is that I still loved doing gender work, and even more so as the individual therapist not just providing medication management. I’ve described gender work to people as this- being the most neutral person imaginable for my client. Gender work is unique in therapy. Because the goal of individual therapy for someone with depression is to help them feel less depressed. Same with anxiety or PTSD symptoms. The goal is to reduce symptoms. But with gender work the therapist should not be guiding a person toward one gender or another.

The therapist can be a blank slate providing a safe space for a person to explore their own gender identification without judgement and without the boundaries of the binary societal view of gender. It involves exploring self image, self esteem, sexual orientation, mood, persistent thoughts, family systems, what gender means to them, what gender feels like to them, how gender can be a spectrum and that their journey can be whatever they want it to be. I’ve found that so much of the work for gender clients is providing them their own empowerment in defining their own sense of self.

As a health care provider there is generally a sense that we should present this front that we know what we are doing. I agree with that to a degree. I think to be a good health care provider we also need to know what we don’t know and be comfortable with that. I would not do individual therapy with a young child questioning their gender because I do not have the training or experience to provide competent care. I did not do individual therapy with children prior to branching into gender work, so I don’t have a foundation for that age group in general.

For a young adult or adult questioning or newly transitioning I do feel comfortable providing individual therapy and medication management. But I didn’t just wake up and feel that way. Gender work is a sub-specialty and should be treated as such. It required me to challenge myself as a provider but it has been incredibly rewarding to see clients through this intimate and courageous journey.

I would advise any clinician with interest in this area to not just start marketing yourself as a gender specialist. Really do the work. Start with one client. Do that work well. Learn from it. Take on another. Build slowly, and never stop learning and asking and seeking supervision from others with more experience. Pick a number of CEU’s per year that you will commit to gender education. As a psychiatric nurse practitioner we are required to do 25/year, I commit at least half to gender continuing education. And at the end of each day identify your limitations and don’t be afraid to refer a client out if you do not have the skillset. Clients are not educational opportunities they are people, and they deserve the best care possible for what they are going through.

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