Transgender Peoples’ Experiences of Mental Health Care
Research into transgender individuals’ experience of physical and mental health care services is an important developing field. Transgender people, both in Australia and worldwide, experience systemic discrimination in healthcare settings and documented poorer physical and mental health outcomes. To ensure the delivery of appropriate and effective psychology services to this cohort, it is vital that we consult with and research this diverse group in the discovery of positive ways of working together. A recent qualitative study by Laura Halliday and Nerina Caltabiano (2020) of James Cook University (Cairns) helps illuminate what is important in how we do what we do via their exploration of the helpful and unhelpful therapy experiences of six transgender Australians.
Two over-arching themes emerged from analysis of these interviews: use of language and knowledge of transgender issues.
The following are taken directly from the Australian Human Rights Commission (available at humanrights.gov.au/our-work/lgbti/terminology), who acknowledge both the importance of the use of inclusive terminology as well as the variability and evolution in terminology use over time and the individualised nature of use preferences.
Brotherboy: A culturally specific term to describe Aboriginal and Torres Strait Islander transgender men.
Cisgender: Refers to people who identify their gender in the same way as was legally assigned to them at birth.
Endosex: Refers to people whose sex characteristics meet medical and social norms for typically ‘male’ or ‘female’ bodies.
Gender: Refers to the way in which a person identifies or expresses their masculine or feminine characteristics. A person’s gender identity or gender expression is not always exclusively male or female and may change over time.
Gender expression: Refers to the way in which a person externally expresses their gender or how they are perceived by others.
Gender identity: Refers to a person’s deeply held internal and individual feeling of gender.
Intersex: Refers to people who are born with genetic, hormonal or physical sex characteristics that do not conform to medical norms for ‘male’ or ‘female’ bodies. Intersex people have a diversity of bodies and identities.
LGBTI: An abbreviation which is used to describe lesbian, gay, bisexual, trans and intersex people collectively. Many sub-groups form part of the broader LGBTI movement.
Sex characteristics: Refers to a person’s primary and secondary sex characteristics, for example an individual’s sex chromosomes, hormones, reproductive organs, genitals, and breast and hair development.
Sexual orientation: Refers to a person’s romantic or sexual attraction to another person, including, amongst others, the following: heterosexual, gay, lesbian, bisexual, pansexual, asexual or same-sex attracted.
Sistergirl: A culturally specific term to describe Aboriginal and Torres Strait Islander transgender women.
SOGIESC: An abbreviation used to describe sexual orientation, gender identity and expression, and sex characteristics collectively for the purposes of law and policy, most often in human rights and anti-discrimination law. The Commission previously used SOGII (sexual orientation, gender identity, intersex).
SOGIESC rights: Ensuring the equal application of human rights to everyone regardless of an individual’s sexual orientation, gender identity and expression and sex characteristics.
Transgender: The term ‘transgender’ or ‘trans and gender diverse’ is an umbrella term for people whose gender identity is different to that which was legally assigned to them at birth. Trans and gender diverse people may take steps to live in their nominated sex with or without medical treatment. Throughout different cultural contexts transgender identities have specific terms. For example, in some Aboriginal and Torres Strait Islander communities some Sistergirls and Brotherboys are also trans people.
Transition: Transition may involve social, medical and/or legal processes to affirm a person’s gender identity.
Heteronormative: Heteronormativity is the belief that heterosexuality is the preferred or normal mode of sexual orientation. It assumes the gender binary and that sexual and marital relations are most fitting between people of opposite sex. (This definition was found on Wikipedia, accessed 2021).
Why is language important?
The language used by therapists (words and phrases) was identified as a crucial decider in terms of whether these transgender individuals found a therapy session to be helpful or unhelpful. The use of appropriate language impacted on the degree of rapport built between the individual and the therapist. This included using gender-neutral terms and avoiding heteronormative assumptions about the gender of individuals’ partners. The recording and use of preferred names and pronouns by clinic/reception staff was also noted as important, as this was illuminated as a particularly anxiety-provoking situation due to the frequent possibility of being misgendered at reception areas.
Clinic forms without diverse name, gender and sexuality response options were identified as unhelpful, as were forms with an overwhelmingly large amount of diverse options. The individuals noted that they might be on a journey with their gender identity at particular times and that having to fit themselves in to tick boxes may be distressing. One respondent experienced an assessment of their transgender ‘status’ and found this pathologizing very unhelpful.
Knowledge of Transgender Issues
While participants of this study did demonstrate a preference for therapists with previous experience with transgender clients or the wider LQBTIQ+ community, this was explained as due to how the therapist integrated that information into the session. A therapist with relevant experience was observed as less likely to use inappropriate language, ask offensive questions or attribute all psychological distress to gender-related issues. A therapist with knowledge of Gender Dysphoria assessment, diagnosis and intervention was highlighted by some as particularly helpful. It was noted that even a therapist with no prior relevant knowledge could still create an open, honest space for therapy, and that a willingness to understand was paramount.
Ignorance of transgender issues, leading to offensive behaviour by the therapist, was identified as particularly unhelpful, as was a therapist having a rigid understand of transgender people and requiring individuals to fit in to their own pre-determined concepts. Transgender people can find it difficult to find well-informed therapists and experience long waitlists for appropriate clinicians.
How much impact does this really have?
Current research indicates that the distress experienced by transgender individuals is related to conflict between the individual and society, typically in the form of discrimination, rather than anything inherent to the individual’s mental health (Bartlett, Vasey, & Bukowski, 2000). Even when compared to cisgender populations within the LGB community, transgender populations report higher levels of suicidal behaviour, poorer mental health outcomes and increased experience of discrimination, harassment, and violence (Leonard et al., 2012).
The needs of transgender individuals are also unique when compared to other such populations, particularly in terms of the potential legal and medical role that clinicians may play in their lives (Israel, Gorcheva, Burnes, & Walther, 2008). In terms of their experience of health care in Australia, transgender people have been shown to commonly experience gender-related victimisation (Leonard, 2012) and this can result in transgender individuals delaying seeking treatment (Heck, Sell, & Gorin, 2006; Mayer et al., 2008).
What can we do?
All respondents in this study called for more training for therapists in the issues faced by transgender individuals and communities. They also acknowledged that a therapist without a lot of relevant knowledge may still be able provide effective therapy, provided they were flexible and open-minded and understood that every individual’s story is unique. The use of inclusive and appropriate language was also identified as key to supporting helpful therapeutic experience for transgender people.
Bartlett, N. H., Vasey, P. L., & Bukowski, W. M. (2000). Is Gender Identity Disorder in Children a Mental Disorder? Sex Roles, 43, 753-785. https://doi.org/10.1023/A:1011004431889
Halliday, L. M., & Caltabiano, N. J. (2020). Transgender Experience of Mental Healthcare in Australia. Psychology, 11, 157-172. https://doi.org/10.4236/psych.2020.111011
Heck, J. E., Sell, R. L., & Gorin, S. S. (2006). Healthcare Access among Individuals Involved in Same-Sex Relationships. American Journal of Public Health, 96, 1111-1118. https://doi.org/10.2105/AJPH.2005.062661
Israel, T., Gorcheva, R., Burnes, T. R., & Walther, W. A. (2008). Helpful and Unhelpful Therapy Experiences of LGBT Clients. Psychotherapy Research, 18, 294-305. https://doi.org/10.1080/10503300701506920
Leonard, W. (2012). Private Lives 2: The Second National Survey on the Health and Wellbeing of Gay, Lesbian, Bisexual and Transgender (GLBT) Australians.
Leonard, W., Pitts, M., Mitchell, A., Lyons, A., Smith, A., Patel, S., & Barrett, A. (2012). Private Lives 2: The Second National Survey of the Health and Wellbeing of GLBT Australians. Melbourne: Australian Research Centre in Sex, Health and Society, La Trobe University.