Several years ago, I worked with a trans* woman in the NHS. Looking back, I was naive and ill-equipped, but lucky – she was patient and educated me, answered my curious questions and generously forgave insensitive language. Having now embarked on research into trans people in therapy, I realise I committed many of the common ‘missteps’ with this client group, such as education burdening (expecting the client to use some of their therapy time to fill in my knowledge gaps), gender inflation (having an exaggerated focus on gender, excluding exploration of other aspects of life) and gender generalising (making assumptions in psychotherapy that all trans individuals have the same needs).1 I was able to provide a good enough experience of therapy for her and she seemed to benefit from our sessions. But this was not good enough for me.
Getting it right matters, because trans people face poor mental health2 and high rates of suicide,3 a result of living in a society that pathologises and devalues them. Trans people are subjected to disproportionate rates of harassment and violence, as well as housing and workplace discrimination.4 Perhaps in response to such treatment, trans people seek therapy at high rates,5 more than other LGBTQ+ people, who have more therapy than their heterosexual counterparts.6 It is therefore highly likely that therapists will have professional contact with trans people and, according to research by Abbie Goldberg and colleagues, experiences with therapists and other mental health providers have the ‘potential to reflect and exacerbate the stigma trans people encounter in society, or to offset and buffer such stigma’.7
The situation is further complicated by the seemingly intractable debate around the rights of trans people currently taking place in the UK, particularly where these rights intersect with the rights of cisgender women.8 The lives and bodies of trans people seem to be a curiously British preoccupation, a ‘debate’ taking place over the heads of the people it directly impacts. In California, where I currently live, trans rights are unambiguously enshrined in law, all-gender toilets are ubiquitous and trans people feel accepted in their communities. But in the UK, the transgender ‘issue’, as it is reductively named, yet positively reclaimed by the author Shon Faye in her manifesto The Transgender Issue: an argument for justice,9 has rendered trans people a political football, their lives debated over their heads by people in positions of power.
BACP and several other UK therapy bodies have pledged their support to the Memorandum of Understanding on Conversion Therapy (MoU),10 which firmly denounces any practices aimed at converting a person’s gender or sexuality, overtly or otherwise. As the MoU explicitly points out, an exploration of gender can be part of therapy, but an agenda or theoretical basis that centres only cisgender, heterosexual people as the healthy norm should not. However, some therapists have contested the ban on the grounds that it stifles clinical freedom and puts therapists at risk of litigation.
At the time of writing, we have just witnessed a ‘double U-turn’ from the UK Government on conversion therapy. It started with a leaked document that suggested the Government was looking into ‘non-legislative measures’ instead of – as had been promised – banning such conversion practices by law. After a public outcry, the Prime Minister announced that such practices would be made illegal, but only for gay people, specifically and cruelly omitting trans people. Jayne Ozanne, a prominent campaigner against conversion practices and a member of the Church of England’s General Synod, called it ‘by far the most significant betrayal of trust that the LGBT+ community has experienced in years’.11
We cannot underestimate the impact of this heightened political climate on trans people, which is another reason why, as Igi Moon, a non-binary psychologist and academic says, ‘every therapist needs to be very honest with themselves about how they feel about…people who are transgender’.12 But just how competent are we to work with this client group? Despite training relatively recently (I qualified in 2011), I learned nothing about working with trans people during my course, even though there was a two-week LGBTQ+ and sexualities module. The shocking realisation of my own lack of knowledge in this area led me to wonder how other British cisgender therapists felt about working with trans clients, and how many of them would be aware when their attitude could be classed as anti trans. I decided to focus part of my doctorate research13 on the UK’s current debate over trans rights to assess if this preoccupation and related transphobia have filtered into the UK therapy profession, given that research suggests therapists in other parts of the world are largely and increasingly supportive of trans people.14
As a gay man growing up in Yorkshire in the 1980s and 1990s, I understand what it is like to feel ‘less than’, an outsider within a heteronormative culture. Name-calling, bullying and the threat of physical violence, fear of (and actual) disownment and being seen as perverted or pathological were the norm. Previous generations suffered even more, but thankfully gay people have increasingly enjoyed more acceptance. Trans people – and particularly trans people of colour – are one of the most marginalised groups of today, thrust into the spotlight of debate by those unsure how to feel about this increasingly visible group that threatens their notions of binary and constant genders and comfortable norms.
I am aware that my marginalisation does not mean that I am an expert on anyone else’s marginalisation, and that there will be criticism of this research (and this article) in its centring on cisgender people, which it does; I wanted to understand cisgender attitudes so that they can be examined and improved. I also acknowledge that I am another white, cisgender male researching trans lives, wielding a narrative privilege not afforded to many trans people. However, because of my history, I feel a duty to hold the ladder behind me, rather than pull it up now that I have achieved some degree of safety, as a small minority of gay people do.
In consultation with trans therapists and researchers, I devised a questionnaire that would capture both quantitative and rich qualitative data. It was responded to by 576 qualified cisgender psychotherapists and counsellors from all the core modalities – mainly psychodynamic, integrative and person-centred. Half had been in practice for 10 years or more, 78% identified as female, 75% were over the age of 45, 87% were white and 72% identified as heterosexual. London and the South East were over-represented, but respondents took part from all parts of the UK. I used a random sampling of UK postcodes and sent email invitations to the first 10 therapists in the area listed on membership body directories. The response rate was high – one in five – signalling a strong desire to engage with this subject.
The quantitative data point to UK therapists being generally supportive of trans people, despite feeling that they are lacking in knowledge and education. Three-quarters of people had either sought, or planned to seek, further training around gender identity, and three-quarters of therapists had worked with a trans client. Most (78%) said they would take an affirming stance when working with trans clients, and 86% agreed with a ban on conversion practices. Only eight per cent felt that a total ban on conversion therapy had the potential to limit their work with trans people. But the themes that came out of the qualitative text show the extent of the confusion that many therapists are currently grappling with around trans issues in relation to their professional practice.
Many pointed out the unfairness of a debate happening over the heads of trans people: ‘I hate the idea that what is happening in the media can be described as a debate. I believe that people’s lives are not there to be debated, ever.’ But it’s also something that people feel they can turn away from, as if watching a political panel show. As one respondent put it: ‘It feels like a minefield, so I have removed myself from the debate and not surprisingly those kinds of clients don’t find their way to me.’ Another said: ‘The debate is toxic and polarised, and I fear that if I express an opinion that doesn’t go with the majority thinking on this issue, I could face professional ostracising or malicious complaints.’ It’s an understandable response, but one that prevents further thinking about how trans individuals are affected, rendering them invisible.
Getting it wrong
Overtly anti-trans views were relatively rare, but shocking nonetheless when they were expressed, especially when bolstered by psychological theories that pathologise trans people, demonstrating that, as in general society, some members of the UK therapy profession hold views that could be seen as anti trans. Indicative of the media debate, the focus on trans women and public toilets was a common refrain, with very little mention of non-binary people or trans men. The general tone of the data around the ‘political minefield’ theme was one of paranoia, lack of safety and anger, or avoidance and distancing from the ‘toxic debate’.
Many therapists admitted to feeling out of their depth and, due to the political climate, were nervous of missteps or getting things wrong: ‘I know my heart would be to support them in any way I could, but I can be clunky with words. I just don’t want to accidentally do harm.’ Shame at being ill-equipped was a big factor in many responses, along with a desire to rectify this: ‘A bit nervous, shows up my ignorance, I feel I can’t keep up with all the new thinking on this. It made me feel like an incompetent professional.’
Others were surprised and grateful for the opportunity the survey offered to explore their feelings and ignorance, with many saying it had given them ‘food for thought’. Some expressed an immediate desire to seek further training and work on their own biases and prejudices: ‘[The survey] rocked my assumptions of myself as a broad-minded and knowledgeable human being. This has been like having a splinter put under my skin, I don’t think I will stop thinking about it’; and ‘I found it unsettling at times because it’s nudged me into realising that although I want to be more informed, I haven’t done the leg work yet!’
While some practitioners were unsettled by what they see as the rapid changes around gender identity, a majority of therapists conveyed curiosity in their responses and were reflexive about internal conflict and honest about their earnest struggle. As this respondent commented when asked about how they felt about the use of the term ‘cisgender’: ‘Interesting internal response to this – “I am being rebranded”. But actually, in terms of equality and celebrating diversity, I have no problem with identifying as cisgender.’
Several responses revealed the conflict of cisgender women who seemed to really empathise with and want to support trans people, while concerned that the ‘hard-won rights of women’ might be eroded. The data show a desire among many therapists to work towards a more intersectional feminism while acknowledging a pull to a historical fight for (cisgender) women’s rights. This earnest struggle encapsulates a real desire to want to understand and support, despite personal inner conflict.
The age factor
Perhaps not surprisingly, my research revealed generational differences. Some older therapists reported feeling ‘bewildered’ or apathetic about trans issues. Those nearing retirement mentioned their age as a factor in their lack of knowledge or motivation to learn more, and were dismissive: ‘I’m close to retiring and have decided not to make too many changes.’ Others revealed a sadness or guilt that they might have missed an opportunity: ‘Guilty that I may have avoided finding out more about trans people.’
Many responses suggested that younger and more recently trained therapists have more empathy for this client group and a real desire to work with them: ‘It has left me wanting and welcoming (within my heart) the opportunity to work with more trans people’; and, ‘I feel a deep empathy for this client group. I feel that there are not enough experienced therapists comfortable or knowledgeable about [them].’ Another said: ‘Therapists need to critically examine their own privilege, which is afforded by intersections of class, education, gender, gender identity etc, as well as the power imbalance that is present (visible or not) in the therapeutic relationship.’ This suggests that new and subsequent generations of therapists may be more trans-allied than their older colleagues.
Affirmation vs conversion
Several responses suggested a split along modality lines, with humanistic therapists seemingly more comfortable with an affirmative stance than more psychoanalytically aligned therapists, who expressed concern that the essence of their work – exploration – is inhibited by the MoU: ‘[I have] fear of serious repercussions or even litigation should I somehow inadvertently be seen to be “converting” a client by simply exploring their underlying issues,’ said one respondent. There was confusion about the wording of the MoU and the differences between affirmation, exploration and conversion, resulting in conclusions, in some, that could be seen as anti-trans, such as: ‘The focus of my psychoanalytic work would not be conversion but acceptance of biological reality. In my view that is not conversion.’ Others were able to find a workable balance between affirmation and exploration: ‘Therapeutic communities give primacy to giving a sense of belonging, that is to accept differences without pathologising. Group analysis seems to accept trans identity as developments in the social matrix with meaning both for the individual and the group they belong to.’
Some of the psychoanalytic community expressed confidence in working from an affirmative and exploratory stance, with the data suggesting that those who are anti trans and at risk of enacting conversion therapy are outliers. But many were simply confused – frightened, even – about how they can work with this population safely and effectively within their modality. My guess is a number will simply avoid working with trans people.
An interesting note was that many therapists from a psychoanalytic background assumed an expertise to work with anyone, despite a lack of specific training or even knowledge. However, the risk of litigation by ‘accidentally’ conducting conversion therapy was also a very real fear. In practice, and as a psychodynamic therapist myself, exploration and affirmation can exist side by side – the reason this is seen as anathema seems rooted in the personal, unprocessed and perhaps unconscious biases of some therapists. I wonder if the research revealed the extent to which psychotherapy is still entrenched in its white, cis-normative and heteronormative origins, seeing people who fall outside of this as ‘deviant’?
Getting it right
I was heartened that, overall, my research suggests that most UK therapists have positive attitudes towards trans people and a desire to ‘get it right’, although there is a great deal of anxiety and shame around the potential to get it wrong. Transphobia does exist, which is a worrying find among therapists, although in small numbers and it seems that those therapists unfit to work with trans people are likely to avoid this client group.
Overall, the research suggests that UK therapists are progressive and supportive of trans people, want to work with them, and indeed do, and only a minority hold views that could be seen as anti-trans. But a general misunderstanding of affirmative therapy seems to have entered the profession. Some respondents appeared to understand it as a scripted verbal affirmation of a client, whereas it more accurately describes a stance, similar to the psychoanalytic stance, mostly unspoken but felt, and used in tandem with challenge and exploration once trust is earned and a client feels contained. Exploration is not conversion, and the fear that has been whipped up around this has left many therapists feeling vulnerable and paranoid. Having said that, this final quote speaks to the general sense of hopefulness for trans people seeking therapy from good, knowledgeable therapists, unafraid of affirmation and exploration: ‘Our job is to go deeper, to understand why “this truth” now, this account of themselves – to move beyond polarities to a deeper, more soulful understanding of the self that they are and are becoming as they journey through the world.’
What needs to change
As a profession, we can’t ignore our knowledge gap on trans identities. It is clear that current trainings are inadequate in preparing therapists to work with gender diversity and that many therapists feel ill-equipped to do so. Training courses need to move beyond outdated difference and diversity modules towards an emphasis on intersectionality. It’s also important that trans people are visible in our profession, particularly on therapy trainings.
The respondents to my research confirmed that therapists are generally keen to understand and learn more, but that many are worried about how to find relevant trainings that are not intimidating or shaming. We need to overcome this fear to seek out appropriate CPD and ensure we are culturally competent and can offer a standard of care to this client group that meets our obligations under our ethical framework.
We need our membership bodies to clearly communicate to members that, as long as their psychological formulation for health is not based solely on the cis-normative and heteronormative, and that biases are explored and processed in personal therapy, there is no need to fear a conversion ban. As Dominic Davies, founder of Pink Therapy, has said: ‘The MoU does not ban exploring someone’s uncertainty or ambivalence at accepting their gender or sexuality. Our role as psychotherapists and counsellors is always to explore the client’s thoughts and feelings. However, the MoU means we need to work in an affirmative-exploratory way.’ It is my belief that we should be wary of a small but vocal minority of anti-trans individuals attempting to confect a panic in the profession, under the guise of a ‘they are banning exploration’ argument.
A trans-aware practice that acknowledges the particular difficulties and minority stressors that trans people face, as well as the missteps that can occur in therapy, is vital. Assuming that a core training equips you to work with any identity is harmful if therapists are not prepared to at least do basic work outside of their own experiences. Trans people of colour are particularly (and paradoxically) both discriminated against and invisible, and work must be done to acknowledge and rectify this in ongoing practice, discussion and research.
We need to be mindful that we don’t contribute to the toxic ‘moral panic’ debate around trans identities, just as it is hoped we would not debate the existence or rights of gay or black people. As one participant put it: ‘I think it is important to note that trans people’s mental health is impacted by so many people debating their very existence.’
Having said all of this, it is, of course, for the trans community to state what they need – these are suggestions from a cisgender researcher, studying cisgender therapists. I invite other cis therapists to step up and learn how to properly support trans clients and look forward to seeing more trans therapists represented in Therapy Today.
* Trans can serve as a term that refers to everyone who is not cisgender (identifying with the gender assigned to them at birth) including non-binary and genderqueer people (gender identities that can not be categorised as masculine or feminine).
Next in this issue
1. Mizock L, Lundquist C. Missteps in psychotherapy with transgender clients: promoting gender sensitivity in counseling and psychological practice. Psychology of Sexual Orientation and Gender Diversity 2016; 3(2): 148-155.
2. Weir C, Piquette N. Counselling transgender individuals: issues and considerations. Canadian Psychology 2018; 59(3): 252-261.
3. American Psychological Association guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist 2015, 70(9): 832-864.
4. James SE et al. US transgender survey 2016. Washington, DC: National Center for Transgender Equality. 5. Budge SL, Moradi B. Attending to gender in psychotherapy: understanding and incorporating systems of power. Journal of Clinical Psychology 2018; 74(11): 2014-2027.
6. Olfson M, Marcus SC. National trends in outpatient psychotherapy. The American Journal of Psychiatry 2010; 167(12): 1456-1463.
7. Goldberg AE et al. Health care experiences of transgender binary and nonbinary university students. The Counseling Psychologist 2019; 47(1): 59-97.
8. Rustin S. My hope for a more open discussion of women’s and trans rights is fading. The Guardian, 2021; 13 October. bit.ly/3jiLRgt
9. Faye S. The transgender issue: an argument for justice. London: Allen Lane; 2021.
10. Memorandum of Understanding on Conversion Therapy in the UK: collaborative publication. BACP 2021, 2 December. bit.ly/3E1hLaY
11. Stewart S et al. Boris Johnson ditches plans for ban on LGBT conversion practices. Guardian 2022; 31 March. bit.ly/3LQ2QmB
12. Jackson C. The big interview: Igi Moon. Therapy Today 2021; 32(5): 23-25.
13. Mollitt PC. Exploring cisgender therapists’ attitudes towards, and experience of, working with trans and non-binary people in the United Kingdom [unpublished doctorate research]. Metanoia Institute 2022.
14. Willoughby B et al. Who hates gender outlaws? A multisite and multinational evaluation of the genderism and transphobia scale. International Journal of Transgenderism 2010; 12(4): 254-271.