Counselling Skills for Working with Gender Diversity and Identity

Michael Beattie, Penny Lenihan

• Publisher: Jessica Kingsley Publishers
• Year: 2018
• Print ISBN: 9781785927416
• eBook ISBN: 9781784504816
• Topic: Social Sciences
• Subtopic: Human Sexuality in Psychology
• Index: Social Sciences

For any student or practitioner needing to gain a sound understanding of the complex fields of gender variance, gender identity and gender dysphoria, this book provides the ideal starting point for the knowledge and skills that you need.

Emphasising the need for affirmative practice in gender care, it provides an overview of the subject areas and process issues which most commonly arise in counselling, combining theoretical with practical perspectives. It explores the diverse range of identities including masculinity, femininity, non-binary, gender dysphoria, trans and cisgender. It also addresses challenges which many clients experience in their daily lives - in the workplace, when coming out, when transitioning and in intimate relationships.

The authors highlight the importance of education and reflection to enable good practice. They feature case studies, vignettes and reflective exercises throughout the text, making it a useful tool for professional development as well as suitable as a text for students.

1

INTRODUCTION

Every part of our lives, whether we’re aware of it or not, is touched by gender identity and the cultural and contextual meanings made of it. However, perhaps because of the very pervasive nature of gendered experience, issues of gender dysphoria or even reflexivity around one’s own gender identity are rarely covered in much depth in professional trainings. Instead, gender is either taken for granted or otherwise felt to be the preserve of ‘experts’ and that, outside specialist gender clinics, general practitioners in the mental health field cannot or should not attempt to work with this population.

This book is about recognising that anxiety and providing practitioners with the skills and insights necessary to work effectively. It does not seek to make the reader a ‘specialist’. Instead, it is positioned as part of a drive towards affirmative practice in gender care, focusing on reflexivity and education. It gives an overview of the subject areas and process issues most likely to come up in counselling, and aims to balance the theoretical with the practical and to point to more detailed literature, should the reader want to explore a particular area in more depth.

As the series editor, Christiane Sanderson, suggested when first discussing the idea of writing a book for the Essential Skills for Counselling series: ‘What would you have wanted to know about and be aware of on your first day working at Charing Cross GIC (Gender Identity Clinic)?’ Inspired by that question, we have approached the text with the assumption that, although our readership will be qualified and experienced practitioners, they may have had relatively little experience in reflecting on and working with issues of gender identity and gender variance in their clinical work.

WHY THE BOOK AND WHY NOW?

Discussions around transgender and gender non-conforming (TGNC) identities have become more frequent and salient in many Western societies in recent years, as reflected in the media, legislation, and social debates affecting people across the life span, in part because of several, high-profile celebrities coming out. Although often controversial, these celebrities have pushed questions of gender and gender identity into the forefront of mainstream media.

In addition, the gay rights movement has been largely successful in the West in promoting an agenda of equality. In the UK, for example, we have gone from the world of Section 28 (part of the Local Government Act that prohibited teachers to speak of homosexuality in the classroom as a ‘pretended family relationship’ from 1988 until its full repeal in 2003; see Nixon and Givens, 2007), to full marriage equality with the Marriage (Same Sex Couples) Act 2013, a mere ten years later. Alongside the success in sexual politics, trans and other civil rights activists have been actively campaigning for gender equality. Although there has been some success at a legislative level, one only has to explore the heated debate around bathroom access in the USA over the last couple of years to see that trans people’s experiences in public spaces remain controversial and the fight for recognition and equality continues.

As the understanding of gender variance has evolved over time from a psychiatric disorder to a phenomenon of normal variance, a debate, currently live in the UK’s National Health Service, over the future of gender services has arisen. As the question has shifted from disorder to dysphoria, there are questions around the roles of medical doctors, psychiatrists, psychologists, and the broader psychotherapeutic community in gender care. This debate exists in the context of a drive towards informed consent models inevitably limited by professional responsibilities and accountability.

Greater attention given to issues of gender, both in the public and professional spheres, means that gender identity is now more widely and more often part of public discourse. From a Foucauldian perspective, the production of differing gender discourses is part of the process by which the person accesses ‘those forms of understanding that the subject creates about himself’ (Foucault, 2000a, p.177). Literally, differing forms of gender identity are spoken into being as the discourse widens and language is created to reflect the rich diversity of gendered experience.

Nevertheless, despite the context of the current sociopolitical discourse around gender, the American Psychological Association Task Force on Gender Identity and Gender Variance survey in 2009 found that ‘less than 30% of psychologist and graduate student participants reported familiarity with issues that TGNC people experience’ (2015, p.832). We therefore believe that it is more urgent and important than ever that practitioners ‘knowledge up’ and become fluent in the field in order to work more effectively and compassionately with issues of gender identity and diversity wherever they encounter them.

WESTERN CULTURAL FRAMEWORK AND UNDERSTANDINGS

This book, and much of the research and clinical practice that supports it, is situated in a modern, Western understanding of gender, and the authors are mindful that it will not necessarily speak to readers from cultures where gender is understood and performed differently. Our Western cultural framework is suffused with the binary complementarity of female and male that underpins heteronormativity as well as the feminist and postmodern critiques of binary that trouble it.

Heteronormativity describes the belief that people fall into distinct and complementary genders (male and female) with natural roles in life. It assumes that heterosexuality is the only sexual orientation or only norm, and states that sexual and marital relations are most (or only) fitting between people of opposite sexes. Yet, despite winning greater freedoms and civil rights in many Western countries over the last 50 years, sexual and gender minority people still need to explain and justify themselves to the cisgender, heterosexual majority through a process of ‘coming out’ and ‘acceptance’ (explored in greater depth in Chapter 12).

This reciprocal relationship between gender, sex, and desire creates what Butler (2006, p.23) terms ‘intelligible persons’. She argues that the gender binary is tightly bound to the notion of heterosexuality, where ‘normality’ is demonstrated by desire for a complementary opposite. Drawing on the work of Wittig (1980), Butler questions the link between the discursive production of biological sex as the natural basis for heterosexual desire, suggesting that, in fact, binary gender and sex and compulsory heterosexuality are mutually productive. To accept the ‘truth’ of the binary nature of gender is also to accept the ‘truth’ of the naturalness of heterosexuality. She suggests that we are so embedded in these discursive structures that to deny them can seem nonsensical.

This book aims to focus on and unpack many of our taken-for-granted assumptions about gender and its relationship to sex and sexuality, and to encourage greater flexibility and reflexivity in our thinking and practice as mental health professionals. Nevertheless, this is the cultural framework in which both ourselves and our clients are situated, and we recognise the difficulty of maintaining this questioning and critical stance as we struggle to navigate between the binary polarities to which we are always being drawn and directed.

EPISTEMOLOGICAL UNDERPINNINGS IN AFFIRMATIVE PRACTICE

There is considerable literature (a lot of it US-based) exploring the negative impact on the mental and physical health of trans people when they cannot access affirmative care (Frederik-Goldsen et al., 2014; Garofalo et al., 2006; Grossman and D’Augelli, 2006) and when access to care is denied on the grounds of gender identity (Xavier et al., 2012). Moreover, the literature supports the positive influence of an accepting and affirmative social and family environment on outcomes and the psychosocial well-being of trans youth (Ryan et al., 2010; Travers et al., 2012).

Both of the authors of this book are Chartered Counselling Psychologists and, as such, we see our work as ‘a field embedded within a post-modern philosophy’ (Rizq, 2006, p.614), which ‘attempts to bridge the gap between research and practice and conceptualises human activity and meaning relationally’ (Manafi, 2010, p.21). We are engaged in an endeavour to arrive at a ‘holistic conceptualisation of human beings’ (Manafi, 2010, p.22), not simply as an academic pursuit, part of a project in the human sciences that attempts to arrive at a definition of the human being, but because the field is an inherently practical one. We explore human subjectivity and relatedness because, in our roles as counselling psychologists, we work with people who come to us seeking help with their problems in living.

Our work in the field of gender care, and our approach to writing this book, are both informed by a model of affirmative practice. There is an extensive literature that describes and explores the models and benefits of affirmative practice (see Austin and Craig, 2015; Chang and Singh, 2016; dickey and Singh, 2016; Edwards-Leeper, Leibowitz, and Sang-ganjanavanich, 2016; Singh and dickey, 2016), but, at its base, affirmative practice is about practitioner reflexivity.

Singh and dickey suggest that affirmative practice is about developing ‘empathy for how gender-role training and socialization affects all people – transgender and cisgender people alike’ (2016, p.196). They see affirmative practice as being based on two pillars: reflexivity and education.

1. Reflexivity: Developing an awareness for how we are all situated within a gendered world and how we all have an experience of gender identity and gender diversity – that the problems in living are ‘in here’ in relationship and not ‘out there’ in the bounded person of the client.

As Chang and Singh (2016) suggest, ‘cisgender psychologists…can work to bring awareness to their cisgender privilege or the unquestioned ways in which they have been able to move through society without experiencing anti-TGNC prejudice or discrimination’ (p.141). In doing so, they are invited to ‘bring a spirit of curiosity and openness’ (p.141), an openness to the exploration of identity without the need to be fixed or to fix identity within normative frameworks.

2. Education: An ethical duty to inform ourselves about the field where our clients are experiencing distress and not leaving it to the client to educate their counsellor or therapist.

Part of that process of informing ourselves about the field in question is to look to the variety of relevant professional practice guidelines that exist and that are discussed below.

World Professional Association for Transgender Health (WPATH) Standards of Care (SOC)

The World Professional Association for Transgender Health (WPATH) was formerly the Harry Benjamin International Gender Dysphoria Association (HBIGDA), a professional organisation devoted to the understanding and treatment of gender dysphoria and named after Harry Benjamin, one of the earliest practitioners in the field. WPATH first published the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People in 1979 and Version 7 was published in 2011. The Standards of Care (SOC) are available to read free online in PDF format from WPATH’s website and are based on a number of core principles that assert that affirmative practice is rooted in demonstrating respect for diversity (WPATH, 2011).

British Psychological Society (BPS) Guidelines (2012)

As counselling psychologists, one of whom was an author of these, we affirm the British Psychological Society (BPS) Guidelines and Literature Review for Psychologists Working Therapeutically with Sexual and Gender Minority Clients (2012). As with the WPATH (SOC), the BPS Guidelines have been written ‘to engender better understanding of clients who may have suffered social exclusion and stigmatization in order to reduce the possibility of this in the clinical arena’ (BPS, 2012, p.3). Once again, the focus is on both practitioner reflexivity and education, including continuing professional development (CPD), in the field as part of an ethical and affirmative approach to practice. There are 17 guideline statements in total, and these can be found online at: www.bps.org.uk/sites/default/files/images/rep_92.pdf.

American Psychological Association Guidelines (2015)

In December 2015, the American Psychological Association published its Guidelines for Psychological Practice with Transgender and Gender Nonconforming People. The purpose of the guidelines ‘is to assist psychologists in the provision of culturally competent, developmentally appropriate, and trans-affirmative psychological practice with TGNC people’ (p.832). The document distinguishes between ‘standards’, which it argues are ‘mandates to which all psychologists must adhere’, and ‘guidelines’, which it describes as ‘aspirational’ (p.833).

The American Psychological Association has issued 16 guidelines for working affirmatively, and these can be found online at www.apa.org/practice/guidelines/transgender.pdf. Although we recognise that these are American guidelines (and that both authors practise in the UK), and moreover that not all readers of this book will be psychologists, we, nevertheless, take them into consideration in our practice. In fact, with the exception of guidelines specifically focused on working with youth and children, this book explores all the issues raised in the WPATH (SOC), BPS, and American Psychological Association Guidelines.

In the Psychology of Sexual Orientation and Gender Diversity journal’s special issue, ‘Trans Affirming Psychological Practice’, Singh and dickey (2016) reflect on the responsibilities that these guidelines give to practitioners. They advocate for a change in which gender variance is taught on professional training courses, arguing that, ‘if trainees learn about TGNC people, it is likely that the topic will be covered in a psychopathology course’, and suggesting that this unnecessarily categorises and pathologises TGNC people from the outset (Singh and dickey, 2016, p.197).

In the same way, this book aims to be part o...

Table of contents

• Cover
• Title Page
• Contents
• Series Editor’s Foreword by Christiane Sanderson
• 1. Introduction
• Part I: Gender Identities
• Part II: Working with Gender Dysphoria
• Part III: Practitioner Self-Care
• Glossary
• References
• Subject Index
• Author Index
• Join Our Mailing List
• Copyright
• Of Related Interest