By Titus Shuangquan Tan
Comparing to the near past, counselling services are becoming increasingly more inclusive of trans* people. Today, many trans* people who rejected counselling services before may start seeking them again (Austin and Goodman 30). To achieve this somewhat more positive reputation of counselling services among trans* population is not easy: a number of factors have simultaneously been reserving trans* people from seeking counselling services. These factors include (but is not limited to) the high costs, previous bad experiences with healthcare, fear of horrendous treatments, gender stigmatisation, gender discrimination, lack of gender knowledge and insensitivity to gender needs (Shepherd et al. 94 and 96), gender bias, (structural) oppression towards trans* people (Austin and Goodman 18) among counsellors, difficulty to find suitable counsellors (McCann 79) and even outright refusal of care (Mizock and Lundquist 148).
A number of proposals have been put forward for counsellors to address these issues, including in-service trainings (Singh and Burnes 250), peer consultations/mentorship (Singh and Burnes 131) and supervisions (McCann 80) and collaborations with LGBTQA communities. Notably, a new trans-friendly method of counselling, namely affirmative care, is proposed in an attempt to replace the current system: “…a [feminist, multicultural and social justice-related, (Singh and Burnes 126-127)] non-pathologising and non-judgemental (Mizock and Lundquist 153) approach [and settings (Austin and Goodman 29), based on client resilience and conceptualisation (Singh and Burnes 126) of their genders, whose practitioners possess requisite gender knowledge]…that accepts, validates, and supports the full spectrum of gender expressions, experiences [and healthcare or other needs]” (Austin and Goodman 18 and 30).
Although these strategies have brought some valuable changes, two intrinsic shortcomings are identified: first, they highly depend on the personal wills of the counsellors: counsellors who are originally prone to trans* activism are likely to engage in these efforts; second, the availability of these strategies rules out counsellors in underdeveloped (in other researches, “rural”) areas since there are simply very few in-service trainings or accredited peers to consult with. Thus seen, the discrepancies between activist and/or city-based counsellors and other and/or country-based counsellors may be further polarised without adopting a more overreaching strategy. To universalise affirmative care with trans* clients, I argue that this overreaching strategy could be to incorporate Trans* Studies in counselling educations.
The misconceived preconceptions of clients’ genders are prevalent among counsellors. These preconception include (but not limited to) the irrelevance between mental health issues and gender (Shepherd et al. 95), ahistorical perspectives (i.e. “gender is a new or fashionable thing with no history”) (Singh and Burnes 251), generalisations from gender-binary conceptualisations (i.e. “trans* clients are exclusively either MtFs or FtMs”) (Austin and Goodman 18), assumption of a universal narrative in gender experiences, gender pathologisation (i.e. perceiving minority genders as diseases to be cured through medical interventions), gender inflation (i.e. attributing all trans* clients’ mental health difficulties solely to gender) (Mizock and Lundquist 151), gender narrowing (i.e., counsellors have a set of limited conceptualisations of gender and are not willing to accept clients’ conceptualisations), (Mizock and Lundquist 151-152), misconceived universal desire for SRS surgeries (Austin and Goodman 19).
Through the compilation of misconceived preconceptions, three roots are identified that may contribute to them. First, these counsellors are unaware of the tremendous diversity among trans* clients (i.e. “… the heterogeneity of identities, experiences…[medical and/or emotional] needs…gender identities [and expressions], sexual orientations, and degree of “outness” to others [among trans* clients]” (Austin and Goodman 26-27 and 29)). Second, these counsellors are unaware that gender knowledge constantly updates itself. Correspondingly, Anneliese A. Singh & Theodore R. Burnes suggest that “[counsellors] must acknowledge the [many new voices and perspectives]…” (131). Third, these counsellors are unaware that since each trans* client has unique conceptualisations and experiences of their genders, they have the duty to listen to what trans* clients have to say about themselves.
These unawareness could be tackled in class settings with the instructors constantly emphasising trans* diversity, gender knowledge updating and varied individual gender conceptualisations and experiences. Plus, by digging into transgender history (such as the one written by Susan Stryker), these key features would be made even clearer. However, if counsellors were to learn these from their clinical experiences, they may well be confused, and generate new misconceived preconceptions of their own. Thus seen, rather than fixing the so-called gender knowledge into counsellors’ heads, the ultimate goal of the incorporated Gender Studies courses is to allow counsellors to validate and trust their trans* clients while effacing trans* clients’ burden to educate their counsellors from absolute scratch. Sing and Burnes describe the ideal outcome of such incorporation:
“…[E]very trans[*] client who walks into a counse[l]lor’s office finds not only an environment where the client does not have to educate the counse[l]lor, but also an environment that mirrors their strengths and supports their future wellness.” (133)
The incorporated Trans* Studies courses could be the start-points to push forward the process of depathologisation, in which the legitimacy of Gender Dysphoria diagnosis could be questioned. Unfortunately, Gender Dysphoria (or its earlier version, Gender Identity Disorder) has not yet been ridded from DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) (Austin and Goodman 18) (one of its author, Doctor Kenneth Zucker, is trans-hostile outright (Plett)), which compels many trans* people to be diagnosed as such in order to pursue Gender Affirmation Surgeries (Mizock and Lundquist 148). This pathologisation has been questioned for a long time, but medical professionals hesitate to completely disengage with it. Some argue that such diagnosis allow trans* people to be “visible”: Singh and Burnes summarises:
“…[H]aving a diagnosis of [Gender Identity Disorder] can facilitate issues of accessing health care and supporting transgender youth and adults in family, school, community, and employment settings among providing other access to important resources for transgender people.” (127)
McCann adds that without such “visibility”, insuring trans* medical services would by all means put off the table. Plus, McCann also points that Gender Dysphoria may still be applicable to those who experience “…psychological distress…in the incongruence between one’s gender identity and birth sex” (153). In effect, these arguments are highly problematic in that trans* people should not be pathologised to be seen, and McCann’s application of “distress” (153) should not be to such extent that it has to be pathologised.
However, insofar as APA (American Psychology Association) does not repeal Gender Dysphoria from DSM, counsellors are practically still “gatekeepers”. Lauren Mizock and Chrstine Lundquist find that many counsellors are not well prepared for this role: they either overfocus on controlling access to gender affirmation surgery so much so that trans* clients feel compelled to reserve their true feelings to and deceive counsellors, or perform in permissive and/or perfunctory manners that letters are prescribed as unattended routines (152). The incorporated Trans* Studies courses could be good platforms for counsellors to negotiate their gatekeeper roles in the context that all participants are well informed of the role’s historical and current implications such as power structures. A possible positive outcome is demonstrated in Sand C. Chang’s enactment:
“From the start, I make it clear that I have a dual role: first and foremost, as a [counsellor] who can provide emotional support and psychoeducation with a consideration of the client’s [needs], and second as a evaluator of the request for [gender affirmation surgeries]…what I can include in the letter [depends] on a detailed conversation about information and expectations concerning the requested medical intervention. I talk about the power imbalance…[I am willing to] document Gender Dysphoria…when it helps the client achieve their goals…” (48)
This enactment could be a model because it clearly shows support to trans* clients’ needs (as required by affirmative care) while explicitly articulating on the workings of the current unfortunate system. In sum, transparency is the key.
Another controversy is whether trans* people’s mental health issues are in all manners related to their genders. Many counsellors believe that since researches have shown that trans* people’s mental health issues are similar to others’, counsellors could treat these issues in isolation to or in total disregard of trans* clients’ genders (Shipherd et al. 95). However, affirmative care, which should be acquired through the incorporated Trans* Studies courses, requires counsellors to trust their trans* clients’ perceptions (that is, if the trans* client thinks they are relatable, they are, and vice versa).
In Mizock and Lundquist’s research, trans* participants reported that they felt obliged to educate their counsellors about basic gender knowledge (153). It may take sessions before counsellors who are completely innocent of such knowledge could superficially apprehend the basics (Mizock and Lundquist 151), let alone those who blatantly reject them. Educating counsellors may be burdensome to some trans* clients since the time of sessions always costs money. Also, when they perceive the counsellors incapable of providing the assistance they need, they are likely to cancel further sessions. In this respect, having each counsellor to acquire some fundamentals of gender knowledge is absolutely necessary.
By educating counsellors with gender knowledge, McCann notes, “[c]ounselling can help people [explore] gender…” (80). Many may seek counselling services because in a yet-still cisnormative world, they feel confounded by gender and the lack of its knowledge thereof, which may further cause (mild) self-doubt and/or depression. This is particularly common in areas where gender awareness is nearly absent, as famous Japanese novelist Keigo Higashino describes in his novel One-sided Love:
“…‘[A]ccepting you interviews, meanwhile overcoming various worries. What you can eventually hear comes nowhere but from those who already have overcome multiple barriers. Recently, several non-fictions have been published about this [in Japan], all of which describe strong-minded protagonists, [it seems like trans* population] is full of strong-minded people. In fact, it is relatively not so, [much more [trans*] people cannot even overcome the first barrier].’” (220)
Noteworthy is that “helping people [explore] gender” (McCann 80) is not tantamount to (nor are counsellors ever entitled to) didactically teaching clients about their genders. Affirmative care requires counsellors on one hand to be affirmative about what they are confounded of themselves, on the other to stop such exploration as soon as their trans* clients show even the subtlest sign of irritation and/or rejection.
Many counsellors may perceive that counselling trans* clients is mostly individual-based. In effect, McCann notes, “family [and/or partners] were deeply affected[, especially] by the transitioning process. There [is] a lack of support [from] family members [and/or partners]” (79). Therefore, counselling trans* clients are very likely to involve familial and/or group counselling to address mainly three concerns, namely successfully “coming out” to (or sometimes hiding from) familial members and/or partners (Austin and Goodman 27), differentiated future expectations (e.g. “As much as she knew I was trans, she certainly didn’t think I would go the whole way with it”), preconceptions of family members and/or partners (like those of counsellors) (McCann 78). Thus seen, the incorporated Trans* Studies courses may also be good platforms on which counsellors’ familial and/or group counselling competencies could be reinforced by engaging in the practical topic of bridging the gaps between trans* clients and their family members and/or partners.
Negative experiences with counselling services almost without exception occur negative reputation. Tremendous effort has been taken before counselling services is somewhat re-gaining its reputation among trans* people, therefore crucial to preserve it. To counter the misconceived preconceptions and the lacuna of gender knowledge that together have been driving trans* clients away, affirmative care is expected to be acquired by counsellors through incorporated Trans* Studies courses in their counselling educations which not only incessantly underscore trans* diversity, gender knowledge updating and varied individual gender conceptualisations and experiences, but also actively engage in topics of depathologisation, negotiation of gatekeeper role and familial and/or group counsellings in class settings. Although this paper specifies the positive side of such incorporating, it does not mention the practicalities of its implementation (such as financing these courses). Besides, I identify a vacancy of scholarship about the relationships between trans* people’s medical treatments and their mental health statuses (for instance, how hormone therapy affects trans* people’s emotions), which, if studied, could also shed significant light on counselling services for upcoming trans* clients.
Works Cited
Austin, Ashley and Goodman, Revital. “Perceptions of Transition-related Health and Mental Health Services Among Transgender Adults”. Journal of Gay & Lesbian Social Services, Volume 30, Issue 1, 2018, pp. 17-32.
Chang, Sand C.. “Confession of a Gender Specialist”. The Remedy: Queer and Trans Voices On Health and Health Care, edited by Zena Sharman, Arsenal Pulp Press, 2016, pp. 45-52.
Higashino, Keigo. One-sided Love (Kataomoi, 片想い), Translated By the Author From Chinese Version, Kindle E-book, Second Edition, Hainan Publication Corporation, 1 October, 2016.
McCann, E.. “People Who Are Transgender: Mental Health Concerns”. Journal of Psychiatric and Mental Health Nursing, Volume 22, Issue 1, 2014, pp. 76-81.
Mizock, Lauren and Lundquist, Christine. “Missteps In Psychotherapy With Transgender Clients: Promoting Gender Sensitivity In Counseling and Psychological Practice”. Psychology of Sexual Orientation and Gender Diversity, American Psychological Association, Volume 3, Issue 2, pp. 148–155.
Plett, Casey. “Zucker’s ‘Therapy’ Mourned Almost Exclusively By Cis People.” Harlot, 11 April, 2016.
Shipherd, Jillian C. et al.. “Transgender Clients: Identifying and Minimizing Barriers to Mental Health Treatment”. Journal of Gay & Lesbian Mental Health, Volume 14 Issue 2, 2010, pp. 94-108.
Singh, Anneliese A. and Burnes, Theodore R.. “Introduction to the Special Issue: Translating the Competencies for Counseling with Transgender Clients into Counseling Practice, Research and Advocacy”. Journal of LGBT Issues in Counseling, Volume 4, Issue 3-4, 2010, pp. 126-134.
Singh, Anneliese A. and Burnes, Theodore R.. “Shifting the Counselor Role From Gatekeeping To Advocacy: Ten Strategies For Using the Competencies For Counseling With Transgender Clients For Individual and Social Change”. Journal of LGBT Issues in Counseling, Volume 4, Issue 3-4, 2010, pp. 241-255.
Stryker, Susan. Transgender History: The Roots of Today’s Revolutions, Second Edition, Published By Seal Press, New York, 2017, pp. 1-44.