Tailoring Therapy for Gender and Sexual Minority Clients

Clients with minority identities related to their sexual orientation or gender seek therapy for a variety of concerns, and many therapists use the evidence-based approaches they are most comfortable with to respond to the presenting symptoms. The impact of possessing a stigmatized identity, encountering discrimination, or witnessing political debates regarding one’s belonging in society lead to vulnerabilities and challenges that set these clients apart. Some of the most researched difficulties experienced by gender and sexual minorities that traditional treatment packages may not respond to are internalized stigma, rejection sensitivity, and shame.

When Our Worst Thoughts are About Ourselves

Internalized stigma (i.e., internalized homophobia, biphobia, or transphobia) refers to those attitudes or stereotypes about a minority group present in our culture that might be internalized and believed by an individual. These sorts of thoughts can be painful, from assertions that attraction to the same sex is a result of sexual abuse as a child (a theory that might be repeatedly asserted by family or religious leaders), to ideas about what the future holds (“I’ll never be respected in my field”, “Real relationships don’t exist for people like me”, or “My parents will never love me again”).

Tips for addressing internalized homophobia:

Don’t argue with the fears – a client can get caught in a cycle of attempting to convince ourselves of which fears are true or not. Mindfulness techniques can help the therapist and client to observe when those thoughts arise, how they affect the client, and to notice those moments when the client might decide to engage with the world differently.
Defusion exercises can be helpful – fusion refers to the way that our thoughts, in that echo chamber between our ears, can seem completely true. Those same thoughts might feel lighter in the course of a day when a client is able to notice how the believability rises and falls, or old habits of responding to those thoughts.

Armor Up: Avoiding Rejection and Intimacy

Growing up, many GSM individuals have experienced rejection – and not just rejection, but rejection from parents, siblings, and those who knew them and had appeared to love them most! Learning to be less guarded emotionally, to engage vulnerably and authentically in relationships after such experiences of rejection, is one of the most difficult tasks for GSM clients to overcome, in my clinical experience – particularly if one’s parents do not allow for reestablishing a relationship after adjusting to a child coming out.

Tips for building client capacity for vulnerability and intimacy:

Drawing attention to the relationship in the room – for many clients, it is easy to discount a therapist’s warmth as part of their job, or service in response to payment. Slow down, be mindful, and guide a client to notice the feel in the room with therapist.
A warm relationship including disclosure – while associated with better therapeutic relationships for all clients, a relationship that emphasizes the client’s genuine care for the client and authentic responses to events in the client’s life are particularly important.
Encouraging risks outside of therapy – tracking and sharing experiences of behaving in a more vulnerable or authentic way, particularly when the risk of rejection feels possible, can both build confidence and reduce fear of being fully seen by others.

When You Can’t Seem to Love Yourself

Shame is a complicated emotion, and tends to involve barriers to notice or let in warmth from others, a harsh and judgmental attitude toward yourself, and a feeling of isolating difference from other people. According to some experts, like Paul Gilbert, this is an emotion with evolutionary roots tied to being a social animal. We want to feel safe in our group, as it’s a dangerous world to go alone. Shame also may have different origins for GSM people. One recent study of cisgender men’s experiences found that while heterosexual men have a variety of people, places, and situations that come up when reporting early shame memories, gay men overwhelmingly report experiences of feeling shamed by their fathers. In this study, caregiver shame was more associated with depressive symptoms.

Use compassion training skills to address shame:

Compassion for others – at times the most accessible way to notice how a lack of safety or of shaming environments affects a GSM client is to encourage exploring how those around them are affected. Caring for others warms the heart to care for ourselves.
Compassion from others – as described above, guardedness to the emotional responses of others can become habit for many GSM people. In CFT, practicing guided visualization exercises that involve receiving warmth from a loving, ideal figure is sometimes required as a precursor to feeling safe receiving it from the therapist or others in the client’s life.
Compassion toward ourselves – in the face of bias, relationship challenges, or navigating politically charged environments, GSM clients benefit from the reminder to slow down and notice those parts in need of care. To work effectively, one must be able to both generate and receive compassion, so this is often the most difficult step for clients (or clinicians).

If you are a therapist wanting to learn more about responding to these common processes in psychotherapy, you can read more about these approaches here, or attend an upcoming workshop on this topic at Portland Psychotherapy.

Matthew D. Skinta, Ph.D., ABPP, is a board-certified clinical psychologist and a trainer of acceptance & commitment therapy and functional analytic psychotherapy. He directs Palo Alto University’s Sexual & Gender Identities Clinic, and is passionate about increasing the application of evidence-based care to work with GSM clients.

New resource: a dictionary of terms commonly used in transgender and gender nonconforming communities

New resource: a dictionary of terms commonly used in transgender and gender nonconforming communities

APA has a new set of guidelines for psychologists working with transgender and gender nonconforming people (TGNC). In an appendix to those guidelines, APA included a very useful index defining many of the terms used within the TGNC community. Terminology of this sort is rapidly evolving and it can be difficult to stay abreast of it all. The index APA included in its guidelines is a helpful resource as psychologists strive towards treating others in a respectful and culturally competent way. For example, the term “transgender” has rapidly become part of American lexicon, especially since Caitlyn Jenner told her story in Vanity Fair magazine earlier this summer. However, although I’m familiar with the term, I’ve never heard the term “cisgender” used in the popular media. The APA terminology index defines “cisgender” as “An adjective used to describe a person whose gender identity and gender expression align with sex assigned at birth; a person who is not TGNC.” Only using a term to describe one experience/group implies that those in that group are “not the norm”; you’re either transgender or you’re “normal.” By knowing and using terms like cisgender to describe people whose experience isn’t that of those in the TGNC community, we make a small but important statement affirming the equality of all experiences of gender identity. If you’re interested in updating your knowledge of terms commonly used in the TGNC community, go to the appendix of the APA document.

Jenna LeJeune, Ph.D

Author: Jenna LeJeune, Ph.D

Jenna is a clinical psychologist who specializes in working with people who struggle with relationship and intimacy difficulties and with those who have a trauma history. Her research focuses on developing compassion-based interventions targeting stigma, shame, and chronic self-criticism.

APA’s new guidelines for psychological practice with transgender and gender nonconforming people: A brief summary

APA’s new guidelines for psychological practice with transgender and gender nonconforming people: A brief summary

There is great news coming out of APA this week. (Finally, some good news coming out of APA!) The APA Council of Representatives has finally approved a set of guidelines for psychologists working with transgender and gender nonconforming people (TGNC).  You can read the entire 55 page document here and it is certainly on my “to read” list as well. However, given how important this is and given the fact that my “to read” list is dauntingly long at this point, I wanted to make sure I was familiar with at least the main guidelines until I can have time to read the entire document. And so, I created this cheat sheet of the 16 guidelines outlined in the document.  So if your “to read” list is like mine, here is a summary of the APA guidelines on working with TGNC people.

APA Guidelines for Psychological Practice with Transgender and

Gender Nonconforming People

Guideline 1. Psychologists understand that gender is a non-binary construct that allows for a range of gender identities and that a person’s gender identity may not align with sex assigned at birth.

Guideline 2. Psychologists understand that gender identity and sexual orientation are distinct but interrelated constructs.

Guideline 3. Psychologists seek to understand how gender identity intersects with the other cultural identities of TGNC people.

Guideline 4. Psychologists are aware of how their attitudes about and knowledge of gender identity and gender expression may affect the quality of care they provide to TGNC people and their families.

Guideline 5. Psychologists recognize how stigma, prejudice, discrimination, and violence affect the health and well-being of TGNC people.

Guideline 6. Psychologists strive to recognize  the influence  of  institutional  barriers  on  the  lives of TGNC people  and  to assist in  developing TGNC-affirmative  environments.

Guideline 7. Psychologists understand the need to promote social change that reduces the negative effects of stigma on the health and well-being of TGNC people.

Guideline 8. Psychologists working with gender questioning and TGNC youth understand the different developmental needs of children and adolescents and that not all youth will persist in a TGNC identity into adulthood.

Guideline 9. Psychologists strive to understand both the particular challenges that TGNC elders experience and the resilience they can develop.

Guideline 10. Psychologists strive to understand how mental health concerns may or may not be related to a TGNC person’s gender identity and the psychological effects of minority stress.

Guideline 11. Psychologists recognize that TGNC people are more likely to experience positive life outcomes when they receive social support or trans-affirmative care.

Guideline 12. Psychologists strive to understand the effects that changes in gender identity and gender expression have on the romantic and sexual relationships of TGNC people.

Guideline 13. Psychologists seek to understand how parenting and family formation among TGNC people take a variety of forms.

Guideline 14. Psychologists recognize the potential benefits of an interdisciplinary approach when providing care to TGNC people and strive to work collaboratively with other providers.

Guideline 15. Psychologists respect the welfare and rights of TGNC participants in research and strive to represent results accurately and avoid misuse or misrepresentation of findings.

Guideline 16. Psychologists seek to prepare trainees in psychology to work competently with TGNC people.

American Psychological Association. (2015). Guidelines for Psychological Practice with Transgender and Gender Nonconforming People. Retrieved from http://www.apa.org/practice/guidelines/transgender.pdf.

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