The American Psychiatric Association defines the focus of gender-affirming therapy as a stance which prioritizes affirming a patient’s gender identity and does not aim to change it. According to the APA, mental healthcare providers and healthcare professionals who practice gender therapy utilize concepts such as gender affirmation, processing and understanding in a safe zone, reflection and empathy, allowing diversity, and additionally, providing a network of social, legal, and medical support.
Clients who seek gender therapy need space and support to explore their available therapeutic and medical interventions thoroughly without societal judgment. An official position statement regarding the care of transgender and gender-diverse populations by the American Psychiatric Association states that the APA:
- Supports access to affirming and supportive treatment, including appropriate mental health services, which may include puberty suppression and medical transition support when indicated.
- Opposes legislative and governmental attempts to limit access, sanction, or criminalize these service providers.
What is Gender Therapy?
Gender therapy is for clients who want to explore their gender identity, process their life experiences with topics like gender incongruence, and receive letters of support for medical transition. Gender therapists often earn undergraduate degrees with a heavy background in gender-diverse studies, feminist theory, and diversity educational programs.
- Sex refers to an individual’s biological characteristics that one is born with (i.e., assigned at birth).
- Gender refers to the attitudes, feelings, and behaviors linked to an individual’s biological sex.
- Transgender individuals do not identify with their assigned sex at birth and transition their physical or behavioral characteristics to align with their gender identity.
- Cisgender individuals do identify with their assigned sex at birth and identify with the gender associated with their assigned sex.
- Non-binary individuals acknowledge the conventional notion of gender and reject associations with either gender identity.
- Gender fluidity refers to individuals who acknowledge gender as a spectrum and feel flexible in the way they identify their gender, so they may identify as more masculine or more feminine depending on personal context.
Gender is often seen as the social performance of an individual’s biological sex, and these conceptual constructions of gender hold commonplace in societal structures. A deep understanding of the conceptualization of gender and sexuality is necessary for healthcare providers who aim to provide accurate and responsible treatment for transgender and gender-diverse populations.
Gender identity and sexual identity as traditional concepts often only contain limited choices: man or woman, heterosexual or homosexual. Gender therapists allow their clients to explore their gender identity in addition to their sexual identity freely on a spectrum. Identifying on a spectrum enables individuals to reflect on the distinctions between sex, gender, and sexuality.
Dr. Zo Amaro Jimenez, in partnership with Gender Spectrum and CONCEPT, offers on-demand professional training on the Foundations of Gender and Gender Inclusive Counseling to clarify common misinformation surrounding transgender and nonbinary youth with an emphasis on best practices.
Transgender, nonbinary, and gender-diverse populations do not identify with the gender they are associated with because of their assigned sex at birth and experience gender incongruence. Gender incongruence encompasses physical incongruence and social incongruence.
- Physical incongruence is when an individual’s gender identity does not align with their primary and secondary sexual characteristics.
- Social incongruence refers to when an individual does not receive societal acceptance or validation for the gender they identify with but rather the gender associated with the sex they were assigned at birth.
Letters of Support & Surgical Referral Letters
Gender therapists are integral pillars in gender-affirming surgery as they are the individuals who write letters of support and surgical referral letters.
To insure medical services and surgical treatments, clients who are at the decision stage regarding gender-affirming surgery or hormone replacement therapy require letters of support for insurance companies and surgeons to approve the medical interventions.
According to the UCSF Transgender Care Department, a surgery referral assessment requires a qualified medical or mental health provider with at least a master’s degree or additional educational requirements to supply a letter for insurance. UCSF identifies two critical areas for assessment for all individuals undergoing major surgery:
- Ensuring realistic expectations of what surgery can and can not do. Being emotionally prepared for the realities of potential complications and less-than-satisfactory outcomes.
- Ensuring adequate support during the pre- and post-surgery period.
Mental healthcare professionals who offer letters of support need to set clear guidelines on whether they include these services as part of their hourly fee or include additional service fees. Gender therapists should create treatment plans with their clients to make certain they organize emotional and physical care to meet the demands of surgical transition.
Themes in Gender Therapy
Topics that may arise in a gender therapy session include but are not limited to mistreatment and violence, psychological distress and trauma, hormone replacement therapy, and gender-affirming surgery.
Mistreatment and Violence
Transgender and gender non-conforming individuals are likely to experience violence not only at the hands of strangers on the street but also from their own families and intimate partners. According to the 2015 U.S. Transgender Survey, 10% of respondents who were out reported violence against them from a family member, and 8% were kicked out of the family home.
Respondents who self-identified as out or perceived as transgender while in school (K-12) reported:
- Physical Attacks (24%)
- Verbal Harassment (54%)
- Sexual Assault (13%)
The U.S. Government Accountability Office reports the three leading causes of bullying in school (K-12) consist of race (42%), national origin (29%), and gender (28%) for the 2014-2015 school year.
For an in-depth look at how gender impacts violence rates, Dr. Caroline Logan explores the prevalence rates of various forms of violence perpetrated by individuals with differing sexualities, gender expressions, and gender identities in her program, Diversity Issues in Violence Risk Assessments: Gender and Sexuality.
Psychological Distress and Trauma
Out of the respondents with supportive families, 27% experienced homelessness, 37% attempted suicide, and 31% were currently experiencing serious psychological distress, according to the National Center for Transgender Equality. For transgender individuals with unsupportive family members, these numbers drastically increase to 45% experiencing homelessness, 54% attempting suicide, and 50% experiencing serious distress.
In the 2022 Annual Homeless Assessment Report to Congress (AHAR), the U.S. Department of Housing and Urban Development revealed the most significant subgroups of those living unsheltered are transgender (56%), not singularly male or female (66%), or gender-questioning (78%) individuals while the overall population of those living unsheltered averages at 40%. Additionally, national rates of suicide hover around 13.5-14.2%, demonstrating transgender individuals attempt suicide at a statistically higher rate than the general population, according to the Centers for Disease Control and Prevention.
Hormone Replacement Therapy
Dr. Maddie Deutsch is the medical director for the University of California, San Francisco Transgender Care, who offers information on Estrogen Hormone Therapy (feminizing) and Testosterone Hormone Therapy (masculinizing). She outlines physical, sexual, emotional, and reproductive system changes expected for individuals receiving hormone replacement therapy, which also outlines risks dependent on evidence-based research. These may include low-risk side effects such as acne or higher-risk and rarer cases of blood thickening due to elevated testosterone. With the appropriate care team, routine testing is able to manage side effects and risks.
To provide an understanding experience for clients, gender therapists should familiarize themselves with which common surgical treatments comprise gender-affirming surgery. Gender-affirming surgeries include:
- Facial Feminization Surgery
- Feminizing Mammoplasty (Breast Augmentation)
- Masculinizing Chest Reconstruction (Mastectomy)
- Hysterectomy/Oophorectomy (Uterus and/or Ovary Removal)
- Orchiectomy (Testicle Removal)
- Vaginoplasty, Vulvoplasty, Metaoidioplasty, and Scrotoplasty
When writing letters of support to surgeons and insurance, the therapy provider does not need to identify the patient as transgender but rather determine the capacity of the individual to undergo surgery. A letter of support contains a brief mental health history, the surgical procedure being performed, and a statement if the individual is ready for the surgery.
What are the Benefits of Gender Therapy?
The benefits of gender therapy include greater self-expression, management of mental diagnoses, and reduction of self-harm or suicidality. Gender affirmation therapy is a concept in opposition to the former harmful and ineffective Gender Identity Change Efforts, also known as conversion therapy, which is still widely in practice in certain geographical locations.
In the February 2021 American Psychological Association resolution on Gender Identity Change Efforts (GICE), the APA divulges that those experiencing change efforts were more than twice as likely to report attempting suicide. Additionally, GICE does not alleviate or resolve gender dysphoria and can reduce one’s willingness to pursue future mental health treatment.
Conversion therapy harmfully attempts to coerce or manipulate transgender and gender-diverse individuals to align with the gender identity assigned to them at birth through physically or psychologically violent tactics. The American Psychological Association shares that legislatures in 23 states drafted literature to ban healthcare professionals from providing gender-affirming care to minors.
How to Find a Gender Therapist
The World Professional Association for Transgender Health provides a downloadable version of the Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 (SOC-8).
The subsequent points are Statements of Recommendations for healthcare providers who aim to offer care for transgender and gender-diverse populations:
- Use culturally relevant language.
- Use language that upholds dignity, safety, and respect.
- Discuss with your transgender and gender-diverse clients what language they prefer.
To ensure the most up-to-date gender therapy providers, inquire whether your mental health professional is familiar with the Standards of Care, which states to:
- Provide medically necessary gender-affirming care.
- Provide culturally sensitive care and recognize the realities of the country they practice in.
- Understand the social attitudes, law, economic circumstances, and health systems on lived experiences.
- Utilize an accurate translation of the SOC-8 with cross-cultural, conceptual, and literal equivalence.
- Apply the SOC-8 core principles to ensure respect for human rights and access to appropriate and competent healthcare.
To find a provider using online resources, look into “Gender Therapists” on psychology directories such as PsychologyToday or Gaylesta. If you prefer someone who practices locally, research local hospitals that provide gender-affirming surgery care and reach out to the unit asking for resources to local mental healthcare providers with an established connection and history as a provider of gender-affirming therapy.