Real World Clinical Blog: The Mental Health of Trans People

by Dr. Danna Bodenheimer, LCSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way 

(Editor's Note: This is a follow-up to last week's post on The Health of Trans People.)

     While there is no one way to ever practice with a specific population, there are typically themes that are worth making note of as we engage in clinical work. For example, no two eating disorder clients are the same. But the fact that treatment typically takes eight years when working with anorexia certainly does inform one’s thinking. The same is true when working with the trans population. There is huge diversity within the trans population, and the term trans is merely an umbrella term. Nonetheless, there are certain clinical themes and concepts that are worthy of our engagement when cultivating a set of best practices.

     First, it is essential to note that the idea of transitioning occurs on a continuum. While some people are migrating from the gender that they were assigned at birth to becoming male or female identified, others are not on a journey with a clear beginning, middle, and end. There are many trans people who identify with the gender that they were assigned at birth while performing other gender identities only some of the time. There are others who are gender queer or non-binary who are not identifying with either traditional gender, male or female. We have been left with a social construct, largely perpetuated by people like Caitlin Jenner and Chaz Bono, that suggests that transitioning is a one-way process. This, in fact, is not always the case. The process of transitioning cannot be reduced as a linear movement from point A to point B. 

     For many trans individuals, the wish to use hormone replacement therapy (HRT) is a central piece of their transition. This triangulates social workers, leaving us in the role of agents of social control. In order to use health insurance to cover the HRT, a mental health professional must become involved to give an assessment. This has created tense and problematic relationships, many times, between the trans community and the mental health community. This tension is completely legitimate and ought to be recognized by the clinician. To be placed in the role of gatekeeper of someone’s gender transition process almost inevitably places the client in a "down" position within a complex power structure. It is also worth noting that because of the need for health insurance, there is a socioeconomic dimension added to this power structure. Clients with more privilege, and less of a need to use health insurance, are less likely to be embroiled in mental health treatment as permission giver. Certainly, this threatens the possibility of creating a safe space to do clinical work, and extra care must be taken to assure this safety. 

     Of course, not all people who transition use HRT. Some opt for surgery and others opt out of any medical intervention at all. It has been found that medical intervention often lessens the distress of feeling wrongly gendered, providing individuals with the relief of creating a body that feels more like home. While there are mental health issues that are associated with being trans, often medical intervention alleviates these issues alone. Having “top surgery” or removing one’s Adam’s apple can provide more psychological relief than any social work ever could. We must maintain a dual eye on the work we can do and the limits of our field in working to relieve feelings of gender inauthenticity. 

     For some, the wish to transition has been a long-standing wish - something that they have been aware of since early childhood. For others, the notion of transitioning came at them in a fast and furious manner. Neither internal experience is more or less valid than the other. There is a faulty, and largely shared, assumption that the longer one has suffered in the “closet,” the more legitimate their experience of gender dysphoria is. In fact, all we know about those who have suffered longer than others is that some have seen others transition and are aware of the possibility, while others may have never even been exposed to the option. The other interpretation that is worth considering is that different experiences with the closet reveal different internal defensive structures and correlating levels of consciousness.

     When working with someone who has a trans identity, it probably is most important to remain aware of the extent to which they walk through the world and that this world is typically a very hostile environment. In 1999, Leslie Feinberg wrote about this experience in the book Trans Liberation: Beyond Pink or Blue. Feinberg stated, “We live under the constant threat of horrifying violence. We have to worry about what bathroom to use when our bladders are aching. We are forced to consider whether we’ll be dragged out of a bathroom and arrested or face a fist fight while our bladders are still aching. It’s an everyday reality for us. Human beings must use toilets.... If I go into the women’s bathroom, am I prepared for the shouting and shaming? Will someone call security or the cops? If I use the men’s room, am I willing to fight my way out? Am I really ready for the violence that could ensue?” (p. 68-69)

     This is a striking quote, given that 17 years later, a lot has changed and a lot certainly has not. Clinically, it can be seductive to enter the fantasy that trans people are living in an increasingly more supportive and open world. This is a dangerous fantasy that might disavow that truth of the trans struggle. Not every trans person struggles equally, and some are more in danger than others. For example, the more that someone “passes,” the safer they are. Or, being a white trans person often lends a layer of safety that trans people of color do not have. In fact, the National Coalition of Anti-Violence Programs found that 40 percent of the fatal attacks against the lesbian, gay, bisexual, and transgender (LGBT) community in 2011 specifically targeted trans women, particularly trans women of color. 

     Successful work with trans people requires a deft awareness of several issues. We must remain aware of our power, which can be exploitive, when working with the trans population. We must also remain aware of the idiosyncratic nature of each client’s transition process. We must be aware of the intrapsychic reverberations of a national debate about bathrooms, which is really a debate about human dignity and human rights. And lastly, and perhaps most importantly, we must sustain a rich awareness of the ways in which intersecting identities increase vulnerability and invisibility in nearly equal measure. 

Danna R. Bodenheimer, LCSW, is in private practice at Walnut Psychotherapy Center in Philadelphia, PA, and teaches at Bryn Mawr College Graduate School of Social Work and Social Research. She provides more of her clinical perspective and tips for developing clinicians in her book, Real World Clinical Social Work: Find Your Voice and Find Your Way.