H.L. “Lou” Himes, PsyD
Gender is a complex aspect of human development and identity, which forms in concert with, but independently from biological sex and sexuality. Yet, gender is often equated with biological sex and/or reduced to a simple rigid, binary construct which imposes separate, distinct sets of norms on those deemed men or women. More and more, with the help of good theory and the patience of our clients, mental health professionals are beginning to understand the true complexities of gender, the distinct developmental processes inherent in gender identity development, and the detrimental effects experienced by those whose experiences of gender do not fit neatly into an overly simplified gender-construct.
As trauma-informed therapists, it is becoming more common for transgender and gender-non-conforming (TGNC)1 individuals to find their way into our consultation rooms. Even in the best of circumstances (such as a young child expressing cross-gender identity to accepting and supportive parents), TGNC individuals cannot receive accurate mirroring of or attunement to their internal experience until they can first acknowledge and reveal (perhaps in unspoken ways) their identity to others (Fraser, 2009; McBee, 2013). This leaves TGNC individuals, particularly children, in a prolonged state of emotional isolation and “hiding.” Their dependence on caregivers, who may reject them, can force these vulnerable children to rely on dissociative processes to hide their identities from themselves and others. In short, the very fact that one is TGNC leaves an individual vulnerable to psychological distress and may result in trauma.
When a patient presents as both TGNC and DID, the level of complexity in the work grows exponentially. Therapists often need to be educated regarding TGNC issues in order to make important distinctions in treatment goals, allay patient fears, and to guide the work in a non-pathologizing manner. An understanding of the processes of dissociation, comfort with TGNC identities, and a basic level of knowledge regarding TGNC issues (e.g., terminology, cultural norms, and healthcare concerns) are imperative to meet the needs of these deeply vulnerable patients. This includes making oneself familiar with other organizations, such as The World Professional Organization for Transgender Health (WPATH), that focus on setting standards for health care professionals who work with TGNC individuals.
In order to address the needs of TGNC patients, some therapists may begin their own personal research into TGNC issues, while others may be tempted to rely on their patients to educate them. Given the ways in which TGNC people have often had to parent themselves—a side effect of hiding a part of oneself that others do not have access to, as well as a potential lack of appropriate parental presence—it is important for therapists to show interest in and care for their TGNC patients by seeking education and understanding of TGNC issues outside of the therapeutic relationship.
Ultimately, working with TGNC patients creates complex challenges for any clinician. How do we work with such a socially and psychologically vulnerable population in a manner that supports individuation, identity-development, and healing from complex trauma?
As a TGNC identified therapist myself, it might seem that I was naturally suited to work with TGNC individuals; however, this was not my area of focus right out of graduate school. In fact, my first TGNC patient sought me out. He saw me at his college counseling center (in a markedly patriarchal and religious institution) and decided that I looked “queer enough” that I might be able to help him.
As a result of this young man seeking me out, I decided to receive supervision from a psychologist who has led the way in working with TGNC patients. Through that supervision, I gained many of the skills necessary to work ethically and competently with TGNC folks. Since then, I have worked with dozens of TGNC individuals in various stages of social and physical transition; with those seeking long-term psychotherapy, and providing surgical support letters after a short period of evaluation. I have also provided supervision and education on TGNC related psychotherapy to pre-doctoral and licensed mental health providers and offer consultation and psychoeducational seminars to individuals and organizations who are seeking to provide more competent healthcare to TGNC folks.
Working with TGNC individuals quickly shed light on my own limitations in understanding and working with complex trauma. As my involvement with ISSTD has grown, I find myself with more and more questions regarding how to best support my deeply traumatized, TGNC patients.
With the opportunity ISSTD offers through their support of SIGs, I hope to create a space for therapists to learn about TGNC identities, a space to ask hard questions about the intersections of trauma, dissociation and identity, and to foster an environment of mutual edification and support for the both challenging and rewarding work that comes with sitting together with TGNC people. If you are interested in being a part of this new SIG, please email me directly at firstname.lastname@example.org.
- TGNC is a term that indicates various forms of transgender experience across a broad spectrum, including both binary and non-binary identities, those who seek physical transition, and those who do not.
Fraser, L. (2009). Depth psychotherapy with transgender people. Sexual and Relationship Therapy, 24:2: 126-142. http://dx.doi.org/10.1080/14681990903003878
McBee, C. (2013). Towards a more affirming perspective: Contemporary psychodynamic practice with trans and gender non-conforming individuals. Advocates’ Forum, The University of Chicago. https://www.ssa.uchicago.edu/sites/default/files/uploads/AdcovatesForum_2013_TowardsAMoreAffirmingPerspective.pdf