4Psychological Services for Transgender Youth: A Push towards Better Language and Understanding of Gender Issues

Sybil Geldart

My Background and Interest in Gender Issues

Everyone has a gender identity—an internal sense of maleness or femaleness that forms during socialization in the early years of life (e.g., Diamond, 2002). Many of us do not ponder our gender identity or give it conscious attention. But for some persons, the biological sex to which they were assigned at birth does not correspond with their experienced gender, nor does it fit with how they visibly express themselves. Such persons are referred to as transgender or gender diverse (American Psychological Association, 2011; Gay and Lesbian Alliance Against Defamation [GLAAD], 2007).

Let me introduce this chapter with some general information about me and my professional interests, as well as my rationale for writing about psychological services for transgender youth. It is my intention that, by the end of this chapter, I will have connected Principle I (Respect for the Dignity of Persons and Peoples) of the Canadian Code of Ethics for Psychologists (Canadian Psychological Association [CPA], 2017) to current issues facing transgender youth. The Canadian Code comprises a broad set of ethical principles, with several ethical values and standards subsumed within each principle. It has the goal of guiding psychologists in their conduct and attitudes, and in the resolution of ethical dilemmas. Principle I of the Code speaks to the importance of advancing moral rights to privacy, confidentiality, self-determination, liberty, and social justice for all persons with whom psychologists interact, including primary clients, clients’ familial systems, research participants, students, and supervisees.

I am a research psychologist employed in an academic setting full time, with research interests broadly based in developmental and health psychology. I have published papers ranging from bullying in the workplace to facial attractiveness and its effect on teen attitudes and self-perceptions. My responsibilities also involve teaching, and I typically instruct undergraduate courses in perception, abnormal psychology, clinical psychology, and exceptionalities during childhood and adolescence. I am also a clinical and counselling psychologist, with a part-time practice in Brantford, Ontario. I became registered with the College of Psychologists of Ontario in 2014 (one might say, at mid-career!), having been trained in school psychology (Thames Valley District School Board, London), child-clinical psychology (Madame Vanier Children’s Services, London), and cognitive behavioural therapy (Halton Centre for Cognitive Therapy, Oakville). My clinic work is rewarding for two reasons. For one, I am honoured to help individuals resolve mental health problems and self-actualize—individuals who reside in the small city of Brantford and its surrounding rural communities. It allows me to support a vibrant community that, despite having rapid growth and positive change over the past decade, continues to lag behind larger cities in health services and special education. Second, by virtue of being a trained therapist, I like to think that I listen to concerns and validate problems facing the persons I meet in my work. In my practice, my utmost intention is to offer a respectful, welcoming environment and to give clients and their families the space they need to voice concerns. A related goal is to provide warmth, sensitivity, and advice for persons in my care.

Both in teaching and practice, it is my job to equip persons with a toolbox of life skills to cope with the stressors they face in occupational, educational, and other settings. What has prompted me to compose this work in respect of transgender youth was not so much about showcasing a set of cognitive behavioural therapy skills that could be relevant for this population. Rather, I was inclined to write about experiences in my clinic after having noticed over time an increase in the number of adolescent clients who publicly identified as transgender. These are teenagers who report that they were assigned a sex at birth—based on the reproductive system, sex hormones, and sex chromosomes, that does not match up with how they view their gender (American Psychological Association, 2011; also see Rosenthal, 2016 for a comprehensive review).¹I found that teenagers describing themselves as transgender often seek help to navigate social relationships better, repair family relations, overcome stigma and bullying behaviours and, in some cases, share traumatic experiences of harassment and discrimination. By exploring these issues, the intention of this chapter is to highlight some of the important needs of transgender youth. I believe that this information is important and timely when we consider the fact that transgender individuals—at least those willing to self-identify (i.e., identify to others that they are transgender)—make up 0.5% of the adult population (Conron et al., 2012).

Format of Chapter and Topics

In three separate sections, this chapter delves into pertinent issues facing transgender youth in the context of psychological services, namely: (i) the need for privacy, confidentiality, and informed consent; (ii) the need for adoption of gender-nonconforming language that conveys general respect; and (iii) the need for promotion of trans-equality and advocating against discrimination. In an effort to make the material educational and meaningful, each section contains a discussion box with exercises and reflective questions. I ask the reader to think about transgender issues in reference to the Code’s ethical principles, values, and standards, and to apply such thinking to one’s own practice, as relevant. The chapter ends with concluding remarks and four profession-related questions for you to mull over based on the contents of this chapter.

In keeping with the Principle I values of “Informed consent,” “Privacy,” and “Confidentiality,” all the clients mentioned in this work willingly (and happily) gave their consent to share non-identifiable information about themselves. No client information is described in such a way that a given person can be named or otherwise identified. Any first names that appear in this paper were invented by me for ease of illustration and cannot be linked with any actual person or real-life setting. As some clients come from rural communities in southwestern Ontario, I deliberately have chosen scenarios and examples to discuss in general terms in order to help preserve anonymity, and at times have incorporated samples from the academic literature and public health websites to elucidate broader themes and topics.

The Need for Privacy, Confidentiality, and Informed Consent

Before probing the processes in psychological services, it is useful to ask what prompts persons to seek the help of a psychologist. It is important to highlight that persons who identify as transgender seek professional help for issues that are no different from the general population, including anxiety, depression, substance abuse, and relationship problems (Shipherd et al., 2010). Persons who are transgender increasingly have been willing to identify themselves openly. By doing so, transgender individuals help to mobilize their community and government agencies to pay attention to the dimensions of gender and to accept a broader range of individual differences and diversity in humankind. Once they self-identify, however, the unfortunate reality is that transgender persons can develop anxiety, depression, and self-harm behaviours as a result of being marginalized (American Psychological Association, 2015). This is what prompts many to seek counselling. I recall that some of my adolescent clients were ambivalent about coming out (i.e., self-identifying) for fear of being judged by classmates and friends; their decision to seek professional help stemmed from fears of being bullied, ostracized and socially isolated. Some clients who attend therapy are given a diagnosis of gender dysphoria—a mental disorder that involves ongoing, significant distress and/or impairment in day-to-day functioning caused by the knowledge that one’s gender identity does not align with one’s biological sex (from the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. [DSM-5]; American Psychiatric Association, 2013). In this case, such persons seek out advice about how to resolve the mismatch between their assigned sex and experienced gender—usually by asking a psychologist for emotional support, and possibly a medical referral to enable (or at least consider the possibility of) transition from one gender to another.

Regardless of the reason for seeking psychological services (and in line with the Code’s Principle I), psychologists are obligated to ensure that personal information disclosed by their client remains private and confidential. For each client, the psychologist keeps a private and confidential record containing billing information, appointment dates, signed consent forms, and session notes (among other items). In addition to the values of “Privacy” and “Confidentiality,” another value subsumed under Principle I of the Canadian Code of Ethics for Psychologists is “Informed consent”—the notion that psychologists seek full participation from clients in decisions that affect them, including the decision to partake in counselling. This may sound like an obvious detail, but it is possible for clients to be pressured or ordered to see a psychologist because someone has deemed that treatment is in their best interests. For adolescent minors brought to my clinic reluctantly, customarily it is their parent(s) who enticed, convinced, or forced the visit because they believed that their child was in distress, not functioning well, or not behaving as they should be behaving. The latter point is illustrated by an adolescent client who self-identified as lesbian. Although sexual orientation is not equivalent to transgender, I assume that the following example can be applied to any client who does not fit stereotyped social roles.

After Carrie revealed to her family that she had romantic interests in women, Carrie’s mother booked an appointment at my clinic. Carrie attended the initial session on her own and was vocal that she did not want to be in attendance. By her own admission, Carrie was bitter about being portrayed as melodramatic and attention seeking, and for being told that her sexual preference was wrong. That being the case, Carrie was relieved and more inclined to talk after realizing that she herself has the authority to act on behalf of her own needs and cannot be forced to participate in counselling sessions with me. It was easy to establish rapport with Carrie because she ultimately understood that I respected her ideas and decision. It is interesting to note that Carrie voluntarily agreed to continue counselling for help with social relationships at school and to lessen daughter-mother tensions at home.

Even before providing services, psychologists are required to explain the purpose of obtaining informed and voluntary consent from each client and must discuss limits to confidentiality. As far as breaches to confidentiality are concerned, the client is informed at the outset that, rare as it is, it may be necessary to disclose confidential information under such conditions as: (a) the client poses a danger to themself or threatens to harm someone else; (b) it comes to the attention of the psychologist that a minor is in need of protection by Child and Family Services (with the reporting of potential child abuse being mandated by law); (c) there is reason to suspect client abuse by a regulated health professional, which necessitates an investigation by their respective College; and, (d) the psychologist has been ordered by the court to release professional records, in accordance with a legal case involving the client. As a side note, in none of my cases thus far involving transgender individuals have I had to breach confidentiality for any of the aforementioned reasons.

How I determine whether a substitute decision-maker is required to provide informed consent on behalf of an adolescent client depends on my judgement as to whether the young person is capable of understanding the nature of counselling and can foresee the risks and benefits. I practice in the province of Ontario and, in my jurisdiction, the Substitute Decisions Act (1992) maintains that a person 16 years of age or older is presumed to have the cognitive capacity to appreciate the nature of treatment unless the psychologist suspects otherwise. In Ontario, individuals who are 16 years of age and older must be asked explicitly whether they give voluntary and informed consent to counselling before they partake in this service. However, even a person younger than 16 can understand the purpose of counselling and therefore need not get permission from a guardian to participate. In my clinic, I ask the custodial parent(s) of children under the age of 12 to give informed consent on their child’s behalf. In cases where parents share custodial rights to their child, I ensure that consent is obtained from both parents. For adolescents between the ages of 12 and 15 who I think are capable of understanding the nature of counselling and its risks and benefits, I give them the option of consenting to participate in counselling themselves rather than having the parent do so on their behalf. Any adolescent client who provides their own consent is assured that their personal information will not be shared, not even with the parents, unless they provide written and verbal consent to release the information. (Let me add here that I use consent forms to supplement the informed consent process and consider it legitimate for a client to sign the consent form using their preferred name rather than their legal name given at birth.) At the same time, I ask those who have legal custody of the child to agree that their child is consenting for treatment on behalf of themselves and that parents understand and agree with the parameters for sharing information. In essence, my goal is to ensure that clients and their parents are aware of how personal information about my clients is collected, used, and disclosed.

When I ask parents to agree, my intent is to be respectful of the legal rights of parents to safeguard their child’s interests, while at the same time encouraging families to be respectful of the rights of their child regarding treatment. The latter point relates to the ethical value “Extended responsibility” in Principle I of the Canadian Code of Ethics for Psychologists. Extended responsibility implies that the psychologist should do what it takes to encourage those involved in the lives of the client to respect their dignity as a person. That being the case, caregivers, who many times happen to be the motivating force behind seeking out therapeutic services for their child, often have a strong desire to be privy to information discussed in one-to-one sessions between their child and the psychologist. During my telephone intake (before any counselling sessions begin), I note that it is often the parent who has screened their child for possible mental health issues and identified a problem. It is the parent who often expresses concern for their child, enquires about fees and payment, schedules the appointment, and arranges transportation to my clinic. Therefore, in light of parents’ vested interest in their child’s progress, I usually ask adolescent clients—those who have consented to participate in counselling on their own behalf—for verbal permission to provide brief summaries of sessions to parents on an as-needed basis. I do so primarily as a way of offering strategies and helpful tips for supporting their child at home. Because some clients are known to have persistent difficulties with their family’s adjustment to their gender and sexual orientation, I find they generally welcome the opportunity for family members to join the end of some of their sessions for education and feedback.

Review and Discussion Question:

Informed consent, privacy, and confidentiality are ethical values subsumed under Principle I of the Canadian Code of Ethics for Psychologists, and each has the purpose of respecting the dignity of persons.

Suppose your 14-year-old client, John, shares with you that they are unsure about their own gender identity. Maybe they are trying to figure it out and say they would like to keep their gender identity private from their parents for the time being. How would you handle this scenario? Is it ethical to disclose John’s personal information, or the personal information of any adolescent client for that matter?

Adopting Language About Gender That Conveys General Respect

As a backdrop to how we can be more sensitive to labels and develop better language for transgender youth, let’s consider some definitions and basic assumptions held by the lesbian, gay, bisexual, transgender, queer (LGBTQ) community. It is important to distinguish between sexual orientation (i.e., one’s preferred gender in terms of sexual attraction or love) and gender identity (i.e., the internal concept of being masculine or feminine) (Diamond, 2002; Israel, 2005). To be precise, gender is not a binary construct; rather, it constitutes a range of gender identities. Because gender identity appears on a continuum, it may or may not differ from the sex assigned at birth. The basic tenet is that individuals’ experience of gender is what matters and, consequently, persons have the right to decide their gender identity without any reference to the category of sex. In actuality, the gender chosen—man versus woman versus other—need not be a permanent entity for individuals who classify themselves as gender diverse or gender queer. Rather, they consider their identity as being fluid over their lifetime. Therefore, psychologists who work with transgender and gender-diverse individuals must be cognizant of the terminology used by the LGBTQ community and guard against pathologizing gender that is non-traditional and nonconforming. Instead, in line with Principle I of the Canadian Code of Ethics for Psychologists (Canadian Psychological Association, 2017) and with the Guidelines for Psychological Practice with Transgender and Gender Nonconforming People (American Psychological Association, 2015), it is expected that practitioners will offer safe spaces and respect for persons to explore how they wish to express their gender.

When transgender individuals are in “transition,” this marks a change in gender expression that parallels their experienced gender identity. The ways in which transition can be achieved include:

• coming out to persons involved in their lives, including parents, friends, teachers, and employers;
• altering their first name and/or sex on legal documents;
• changing pronouns used to describe themselves (e.g., he/him, she/her, they/them);
• initiating hormone therapy, either because they wish to produce desired secondary sexual characteristics or because they hope to decelerate or eliminate the development of secondary sexual characteristics that otherwise would occur during the pubertal period; and
• undergoing surgery to make physical appearance match up with gender identity.

Each transgender person must make a personal choice about how to express their gender. Although fewer than 25 percent of transgender individuals take the step of undergoing permanent changes to the body (Scheim & Bauer, 2015), one can appreciate that for some, surgical removal of breast tissue (from female-to-male, called transgender male) or the reduction of the testicles (from male-to-female, called transgender female) might go a long way in attaining self-acceptance and individuality. Strictly speaking, however, gender transition is primarily a psychosocial process. What this means is that, more frequently than not, transgender individuals articulate their gender publicly by verbal labels and how they choose to dress (Bockting, 2008; Bockting & Coleman, 2007).

Changing one’s given name is a big personal decision for transgender individuals, and it can be a challenge to enforce because it relies on other persons to fulfill one’s wishes about being understood and accepted. Principle I of the Canadian Code outlines ethical values of “General respect” and “Extended responsibility,” implying that psychologists must not only adopt language that conveys respect for the dignity of persons and peoples themselves, but should encourage others to do the same. I have seen that transgender youth often express frustration, anger, and despair when confronted by persons who refuse to call them by their chosen name or preferred pronoun. Below are some examples:

1. Siobhan (transgender male) expressed mixed emotions in describing his relationship with his parents. On the one hand, Siobhan felt empathy because, as older parents, they lacked present-day knowledge about gendered pronouns, and understandably had trouble switching from the formerly used pronoun “she” to using Siobhan’s preferred pronoun “he.” On the other hand, Siobhan felt undermined because his parents, Dale and Norma, seemed glib in conversations with him, which was uncharacteristic of his view of them as cultured and otherwise caring persons. For example, during one exchange between Siobhan, Dale and Norma, Siobhan corrected Norma:
   Norma:“Dale, listen to her . . .
   Sibohan: Him.
   Norma: . . . I mean him. You never seem to listen when she . . . oops, your kid . . . tries to tell you how he’s feeling.”
2. Jamie (who never actually adopted the label “gender queer,” yet appeared to identify with this gender identity), requested that friends use the pronoun “they” because this term captured Jamie’s identity as a person better than did pronouns like “she” or “he.” However, Jamie was hurt and resentful when friends did not take the request seriously enough to change their wording.

One way that I have supported gender transition is to offer family-based sessions involving the client and significant others. A family-based session can be useful to caregivers because it permits support and encouragement towards change. Likewise, a counselling session with family members gives clients an opportunity to learn about obstacles from another perspective and can reveal that family members have a genuine desire to help the development and growth of their child (See Brill & Pepper, 2008 and Torres Bernal & Coolhart, 2012 for the value of family therapy in fostering acceptance and understanding of transgender children). As much as possible, I provide education to clients and families about each person’s moral right to be addressed by their chosen name and preferred pronouns.²And, when needed, I address what is often a complicated term for most persons, i.e., gender fluidity—namely, that individuals who identify as gender diverse or queer often resist traditional pronouns such as he and she because these labels thwart the expression of a nonbinary identity. So, while he/him/his and she/her/hers are masculine and feminine pronouns, respectively, some persons prefer to use more than one set of pronouns and opt for gender-neutral pronouns instead. The most common gender-neutral pronouns are they/them/theirs—used in this context to describe a single person who does not want to be gendered. Newer gender-neutral pronouns being recognized today include: ze/hir/hirs (pronounced zee/here/heres) or ey/em/eir (pronounced ay/em/air). These new pronouns can be used by anyone and can be used interchangeably, although they are most often used by gender-nonconforming persons. The central point is that transgender individuals should be treated with respect—which in this case means the rest of us using the name and pronouns individuals have decided to use on themselves.

A related issue has to do with the recording of names and pronouns in the psychologist’s client files. As mentioned previously, files are required for every client, and each contains records of sessions as well as contact and other information. My recommendation is that psychologists document somewhere in their files the chosen name and preferred pronoun of their transgender client(s)—to increase the probability that the language is accurate and used consistently. At the same time, one must address the ethical question of whether it is in the best interests of our clients to record demographic information such as gender on a form, particularly when gender was never disclosed. (Let me emphasize here that most of us do assume gender merely by taking a glance at someone’s physical appearance or hearing a given name.) Also, I believe it is disrespectful to ask a client to divulge a legal name when they explicitly have requested the use of a preferred name (unless, for some reason, the legal name is pertinent for sharing information from the case file with a legal guardian or the courts).

Review and Discussion Question:

LGBTQ is considered an umbrella acronym for homosexual, bisexual, transgender, and gender-nonconforming individuals. It is important to understand that sexual orientation (gay, lesbian, bisexual, asexual, heterosexual) and gender are not synonymous terms. Nor are they binary constructs (e.g., boy vs girl). Think of some disadvantages to the therapy process when a clinician inaccurately applies the binary model of gender in their work with transgender clients. In what way(s) might a practitioner’s biases and stereotypes regarding gender affect the quality of care provided to clients?

Promoting Trans-Equality and Advocating Against Discrimination

Discrimination can be based on a number of characteristics (e.g., age, gender, weight, ethnicity, religion, among others), and is the outcome of prejudice—a preconceived judgement or negative attitude about individuals or groups. People who are prejudiced against individuals or groups view themselves as being superior, which then can lead to acts of disrespect, mistreatment, and even violence. Transgender adults have been known to face discrimination from all types of individuals in the community—co-workers and supervisors at their place of employment, fellow patients and medical personnel at health clinics, and even doctors and police officers (e.g., Clements-Nolle et al., 2001).³Systemic discrimination against LGBTQ individuals has been known to occur in religious organizations, including faith-based schools (Liboro et al., 2015; MacDougall & Short, 2010), where administrators blatantly have opposed LGBTQ issues and neglected the Canadian Charter of Rights and Freedoms. Transgender youth face discrimination at different levels—by their classmates, their teachers, and even by members of their family. In fact, transgender teens have been assaulted physically by schoolmates because of their gender identity (e.g., Greytak et al., 2009). I have seen first-hand clients who are saddened, depressed, and anxious after having faced rejection by their peers, derogatory remarks by caregivers, and physical altercations by classmates, as these examples demonstrate:

• Kevin (transgender female) felt betrayed by her mother who denied her gender identity. Reportedly, Kevin’s mother refused to come to terms with the fact that wearing skirts and blouses, letting her hair grow long, and wearing nail polish and necklaces comprised a constellation of features that enabled Kevin to express a female gender. Kevin decided to keep their birth name after having been ridiculed by younger siblings when she asked them to start calling her “Kara.” What hurt Kevin the most was that her mother did not back her up in the presence of family members and did not support her gender expression.
• Fae (transgender male) reported that cousins gossiped and called Fae a homosexual after he cut his hair short, started wearing boys’ clothes, and dated a female student. Fae always had thought that he had a close relationship with extended family, but that all changed after having self-identified. Relatives did not comprehend the difference between homosexuality and transgender, nor did they accept diversity in gender. It was common for family members to make disparaging remarks about persons who chose same-sex partners—insinuating that their cousin was stupid and deviant. Fae’s relatives were especially prejudiced against men who wore women’s apparel, saying that they were “weak and unmanly.” These attitudes about gender identity left Fae feeling hopeless and depressed.
• Justin (gay), from a rural community, complained to the high school principal when former friends repeatedly bullied him after he had opened up about being gay. Justin was the victim of harassment and violence over many months, with fellow students waiting until after classes each day to gang up on him with insults and physical fights. In Justin’s mind, his teachers, administrators, and the school counsellor all had failed to support him. Consequently, Justin felt terrified to attend classes and had regrets about remaining a high school student. He tried to avoid physical assaults by skipping classes, but then was the one who was reprimanded for recurrent school absences.

In the case of Justin (above), one could argue that it was the lack of support from the school counsellor and the lack of change in attitude by his teachers and fellow students that made him begin to feel hopeless, depressed, and panicky in social situations. In research conducted within Canadian schools, it has been shown that almost 75 percent of transgender youth report verbal harassment by their peers and just under 40 percent have experienced physical violence (Taylor et al., 2011). Almost identical statistics have been found in the U.S. for verbal and physical abuse by the caregivers of transgender youth (Grossman & D’Augelli, 2007).

A remarkable and disheartening finding is that transgender individuals also have reported negative experiences with their therapists in the course of psychotherapy. In a qualitative study (i.e., using one-to-one interviews) with 45 transgender adult clients (Mizock & Lundquist, 2016), it was reported that psychotherapists overemphasized gender in therapy sessions by treating it as a pathological condition and as the cause of the client’s anxiety. In addition, psychotherapists were described as uneducated in gender issues, and were criticized for avoiding or denying gender altogether, perhaps because of their lack of expertise and/or low comfort level with the topic.

Taken together, all these examples bring to light the ethical standards in Principle I that pertain to maintaining general respect and ensuring non-discriminatory practices and attitudes. The House of Commons Bill C-16, otherwise known as the Gender Identity Bill, was created to support the inclusion of gender-diverse persons and provide protections against alienation, discrimination, and violence. The bill amends the Criminal Code of Canada by listing transgender and other gender-diverse persons as an identified group that should be protected from hate propaganda. According to the Criminal Code, any degrading comments, harassment, and violent acts centred around gender identity or gender expression is considered a hate crime and a prohibited ground for discrimination in the Canadian Human Rights Act.⁴In essence, the introduction of Bill C-16 in 2011, which subsequently was passed and approved in 2014, is intended to provide members of the transgender community better protections of their moral rights.

Let me add that even in my own clinic, I recognize that I inadvertently have made mistakes in my role as therapist when working with gender-diverse clients. This is an important issue to me as it speaks to the ethical value “Fair treatment/due process” in Principle I of the Canadian Code of Ethics for Psychologists. This is exemplified by a therapy session I had with an adolescent client, which turned into an assessment session.

I had been working with a 14-year-old female client, named Madeline, over nine weeks to resolve persistent motor tics and social anxiety disorder. Then, at our 10th session, my client self-identified as a transgender male and asked to no longer be called Madeline. Instead, he wanted to be called Kai (pronounced |Kye|). Because the client, as Madeline, had previously disclosed being a lesbian, I was surprised to hear the disclosure of transgender. In fact, you could say that I had some doubts about my client’s understanding of concepts like transgender and homosexuality. As such, I began taking on the role of “assessor” (not therapist or advocate) and queried whether Kai met DSM-5 diagnostic criteria for gender dysphoria. I questioned whether Kai was, in fact, experiencing a change in gender given that it had never been mentioned until now. I asked Kai to give retrospective reports from childhood about whether he had expressed a desire to wear apparel typical of the other gender (e.g., jeans, sweatshirts, ball caps), and to recount the times he had preferred to play with toys typical of the other gender (e.g., trucks and action figures instead of dolls). I can see now that using this type of assessment—whether intentional or not—I attempted to confirm gender identity rather than simply accept at face value Kai’s gender experience.

It has been noted that assessing clients in this way takes away from providing support to clients in need and emphasizes a diagnosis of a psychological disorder (www.transhealth.ucsf.edu/guidelines). As an alternative, it has been suggested that a transgender affirmative approach in counselling is more appropriate and involves the following affirmative actions: (i) permitting the client to articulate the gender experience, and then reflecting that experience back; (ii) developing rapport by asking the client to talk about experiences growing up and how this was handled by their caregivers; (iii) determining the needs of the client regarding self-acceptance and well-being; and, (iv) establishing a good support system for the client (e.g., parents, extended family, friends, teachers, and counsellors). (For details of transgender affirmative therapy, refer to the American Psychological Association’s (2015) Guidelines for Psychological Practice with Transgender and Gender Nonconforming People, or see Mizock and Lundquist (2016).)

Review and Discussion Questions:

1. Legislative changes that promote trans-equality are a good start in informing the public that it is unacceptable and illegal to target people with verbal and physical assaults because of how they choose to identify or express their gender. Even so, there can be repercussions when one decides to self-identify as transgender or gender diverse. Imagine what it would be like to be told that you must be a particular gender (e.g., the one you were assigned at birth), when you feel that you are not that gender. How might it make you feel if people in your life—your parents, your siblings, your long-time friends insisted that you change your ways and conform to their opinions instead?
2. Imagine you are employed as a school psychologist for the local school board, providing support and guidance to students and consultation to school staff for student development and learning. A student approaches you and says that she wishes to change her gender, via physical appearance and given name.
   • Of teachers, principals, and the student body, who might you expect to be more or less supportive of this transgender youth?
   • How might you deal with potential harassment and bullying?
   • In what way(s) can (fellow) students and school staff persevere in the fight for equal rights and treatment?

In rare circumstances, you may need to deal with suicidal ideation, suicidal thoughts, and/or self-harm—which has been known to follow from discrimination and bullying. What might be some ways to intervene, and thereby promote the health of your client?

Concluding Remarks

A basic need of transgender youth, as is true for all human beings, is to find and use language that conveys respect for their dignity—one that is not dependent on culture, race, religion, sex, gender, or sexual orientation. This chapter described scenarios involving transgender youth (and, in some cases, homosexual adolescents) that point toward lack of respect, as well as discrimination, harassment, and violence. The intent of these clinical presentations was to draw attention to current ethical issues in working with a vulnerable population. I am hopeful that the chapter content, including the exercises and discussion questions, is helpful for those working with gender-nonconforming persons, and of some help for those working with other vulnerable, and often marginalized, groups. For clinicians and students of clinical and counselling psychology, I hope the information in this chapter leads you to assess your level of understanding of transgender issues, to consider your level of competence in working with transgender youth at this moment in time, and to ponder the extent of empathy and interest you have towards the subject matter. For some of you, specific training and professional development in the area of psychological services for transgender youth may seem challenging, but also worth exploring.

I took the opportunity to explore gender issues within the context of my own experience as a provider of psychological services, and I believe that it goes without saying that the next step for us as scholars and practitioners is to develop better ethical practices. In my opinion, to do so effectively means that continuously referring to the Canadian Code of Ethics for Psychologists is very helpful whenever ethical questions arise. Psychologists must be vigilant in evaluating our own conduct in the same way that we—sometimes vehemently—challenge the stereotypical behaviours and attitudes of others. My hope is that one day we will develop ideal solutions for clients who utilize psychological services, while simultaneously eradicating discrimination and harassment, and putting an end to ignorance from others.

Lastly, although this chapter explicitly addresses current issues facing transgender youth within the context of Principle I (Respect for the Dignity of Persons and Peoples) of the Code (CPA, 2017), I would be remiss if I did not acknowledge that some of these same issues could easily benefit from application of many of the values subsumed under Principle II (Responsible Caring) and Principle IV (Responsibility to Society). It is impossible to ignore the sizable number of transgender youth in our country and abroad who suffer from emotional problems and psychiatric disorders (e.g., Becerra-Culqui et al., 2018; Clark et al., 2014; Grossman & D’Augelli, 2007; Veale et al., 2017).⁵Using large-scale population surveys, Veale and colleagues reported that only 25 percent of Canadian adolescents identifying as transgender actually reported having good or excellent mental health. On the contrary, transgender youth in Canada have a higher risk of reporting psychological distress, self-harm, major depressive episode, and suicide attempts compared to the general population. As emerging adults (19 to 25 years of age), transgender individuals were found to have eight times the risk of suicidal thoughts and 16 times the risk of a suicide attempt compared to the general population. As such, Veale et al. concluded that there is inadequacy in existing mental health services in Canada. The authors articulate this problem movingly by suggesting that mental health training of practitioners must progress from being transgender friendly to becoming transgender competent. In a similar vein, Becerra-Culqui et al. (2018) contend that clinicians ought to be responsive to current statistics of mental health problems facing gender-nonconforming youth and be able to provide social and educational support to those who are exploring their gender identity. I give credit to these experts for recognizing the need for enhanced training, education, and support. As I work more and more with transgender youth, it is important that I evaluate my competence, that I seek professional development, and that I remain open to understanding gender variance. It also is important that I serve willingly and competently what often is deemed an underserved and misunderstood segment of the population.

Questions for Reflection

1. After receiving a request for support for a transgender youth, you think it best to refer the youth to another therapist. How do you select the therapist to ensure a positive match?
2. In the faith-based school in which you work as a school counsellor, there is an internal policy stating that the principal must be made aware of students who do not identify with their assigned sex. In light of Principle I, what do you do?
3. What are your strengths and biases with regard to working with gender-diverse clients?
4. What competencies do you think you need to be able to work confidently with gender-diverse clients?

notes

1. 1 For comparison, cisgender is a term used to describe individuals who identify with the gender assigned to them at birth.

2. 2 The issue of respecting what individuals prefer to be called and being sensitive to offensive labels is not limited to gender. The Publication manual of the American Psychological Association aims to help scholars write scientifically and objectively in describing persons and groups using a set of “General Guidelines for Reducing Bias” (see Chapter 5, American Psychological Association, 2020, p. 131). According to the manual, some examples of avoiding biased language include: describing people without objectifying them (e.g., expressing “the child with a disability” or “the man with schizophrenia” rather than saying “the disabled child” or “the schizophrenic”), keeping descriptors specific and avoiding vague terminology (e.g., describing ”Chinese Canadians” rather than referring them to as a “minority group”); and keeping abreast of up-to-date labels (e.g., using “lesbian, gay, bisexual, LGBQ,” etc. rather than “homosexual”).

3. 3 It is interesting to note, however, that the Canadian Department of Public Services and Procurement recently developed a new workplace guide for both workers and managers, with the intent of supporting transgender employees. For a look at the guide online, visit https://www.tpsgc-pwgsc.gc.ca/apropos-about/guide-et-te-eng.html.

4. 4 For details, refer to: Department of Justice, Government of Canada (2017), Protecting against discrimination, hate propaganda, hate crime on the grounds of gender identity and gender expression. https://www.justice.gc.ca/eng/csj-sjc/pl/identity-identite/techpaper-papiertech.html

5. 5 For interested readers, there is a wealth of data emerging on the prevalence of psychiatric disorders among transgender and nonbinary adults. For example, Beckwith et al., 2019 and Hanna et al., 2019 discuss the prevalence of psychiatric (including Substance Use) disorders among transgender adult patients in the United States. See Chen et al., 2019 for a look at the first national study on suicidal ideation and attempted suicide rates (comorbid with mental illness) amongst Chinese transgender adults.

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