How Therapists Can Support Transgender Clients By Centering Trans Experiences

Transgender clients in the process of transitioning may find themselves wondering whether family or friends will accept them, what physical changes they will experience, and how various aspects of their lives will change—in the short and long-term. 

Systemic oppression introduces other, more structurally violent forms of uncertainty. Depending on where a trans client lives, their identity could also impact their personal safety, employment, housing, and healthcare. 

Daily headlines announcing potential bans in gender affirming care confront trans folks with public debate over their own rights to medical support. 

These looming uncertainties distract from the radical joy and beauty that is inherent to embracing trans identity. 

As a nonbinary therapist specializing in trans-affirming care, I watch these threatening realities shift the collective focus away from the client’s resilience, self-knowledge, power, and even delight that comes with transition. 

Media coverage conditions us to associate trans identity with trauma and controversy, instead of dignity, joy, and pleasure.

To effectively work with and support trans clients, I believe it is crucial to partner with the client in facing the tension and uncertainty—while continually centering the client’s experience of radical joy and resilience. 

Clinical Consequences of Deep Uncertainty

As with any counseling work involving massive personal change or upheaval, it is important to observe, with curiosity, how the client is responding to their uncertainty. 

Their responses may reach clinical or diagnostic significance, or they may simply form a constellation of coping mechanisms—some adaptive, some less so. 

Developing the client’s awareness of how uncertainty shapes these responses empowers the client to own which responses they want to keep and which they want to change. 

Let’s say your client, a trans woman, has been extensively researching the potential changes she can expect from starting feminizing hormone replacement therapy. 

She may pore over the transition timelines associated with different estrogen dosages and closely follows the transitions of women on social media.

She may read and reread scientific articles about testosterone blockers.

You may choose to ask your client about the feelings that arise when she does her research: 

Is she excited? 

Is she nervous? 

What is her experience of these emotions? 

In addition to this processing, you may also interpret the presence of reassurance seeking: 

Is she craving answers to particular questions about her future? 

What does she wish she could be more sure of? 

What does she hope for?

Identifying clinically significant responses to uncertainty, like reassurance seeking in the example above, must not become another form of pathologizing trans folks’ responses to transition. 

Our field’s history of diagnosing and approaching LGBTQIA+ identities as mental illness has created reasonable mistrust and suspicion within queer and trans communities. 

Instead, we can deliver more collaborative psychoeducation, equipping the client to deepen their awareness of their responses to stress. 

Aligning with the client and acknowledging the systemic realities that shape this stress can strengthen the therapeutic bond, creating an environment of safety and trust. 

In the example above, you may wish to acknowledge the reality that requires trans folks to extensively research their own medical care, often educating and informing their doctors on how to best support them.

What to Say When Control Is Stripped Away

At its core, uncertainty is a loss of control. 

When we think about this clinically, it may look a lot like fear. And it may look a lot like grief. 

Maybe your client responds by creating certainty in other areas of their life, maybe they seek reassurance, and maybe they practice avoidance. 

We have a clinical responsibility to respect the client’s efforts to regain control. We can work with them to ensure that their efforts are sustainable or healthy, but within this work, it’s equally important that we affirm trans clients—validating that what they are feeling and how they are responding makes sense.

After a client tells me that they have realized they are trans, I empathize with and acknowledge the uncertainty they may face, then empower them to explore their own personal journey in transitioning. 

Feel free to use a version of the statements I’ve found useful in my practice of affirmative care:   

An Example Statement of Empathy and Acknowledgement of Uncertainty: 

A lot of times, when we realize we’re not the gender we were assigned, it can feel like we are hit with this big eureka moment, and then a big, scary carpet rolls out in front of us—THUD. 

And while we’re going through this process of realization and discovery, suddenly we have to walk down this carpet, and we even try to predict everything that happens along it: 

How are we going to come out, and to whom? 

Are we going to medically transition? Legally transition? 

Will we need to move? 

Will our partners stay with us? 

An Example Statement of Empowerment and Exploration:

Your transition is yours. It doesn’t have to be linear, you don’t have to predict what is going to happen, and in many ways, we both know that you can’t. 

And just because our current narrative slaps this long, narrow carpet in front of you, doesn’t mean your realization is any less unique, powerful, or rich with possibility. 

Questions to Center Trans Joy

As clinicians and advocates, we have the privilege of witnessing our clients’ power up close. 

Transition is, in many ways, an act of powerful self-knowledge and self-trust. 

In our interventions, we can emphasize these forces so that the client feels equipped to face uncertainty in their life. 

This can look like asking about gender euphoria, as well as gender dysphoria. 

When we’ve spent time in a session processing the distress and discomfort that can occur when someone’s gender identity does not align with their sex assigned at birth, we can also spend intentional time talking about what does feel comfortable or good. 

Was there an item of clothing that felt affirming to wear this week? 

Did someone see the client as they love to be seen? 

Is there a way of speaking or singing or moving that has started to feel exciting?

We can also prioritize interventions like mindfulness to connect the client with pleasure. This can have the added benefit of helping the client learn what they like, and maybe even learn how it feels to let themself enjoy these things. 

Are there smells that they enjoy in their environment? 

Are there textures that feel comforting? 

Connection With Community Is Crucial

When our clients leave our offices, the layered uncertainty around them may feel isolating or overwhelming. We can remind them that this work is not solitary. We can connect them with community resources, support groups, other affirming providers, and inclusive media. In and outside of our own practice, we can advocate for trans folks’ rights to safety, self-determination, and flourishing. 

Our clinical work is incomplete without these efforts. 

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