This piece is the first in a series of three monthly articles for CT Online. It is the result of the work of ACA President S. Kent Butler’s Gender Equity Task Force. The task force is taking a close look at how society influences gender and the oppression that many people experience because of it. Find the second article in this series here and the third here.

The article series will view gender from three different identity perspectives: transgender and gender expansive (TGE) people, girls and women, and boys and men. We do this with the aim of breaking the binary — deconstructing gender socialization in society and the ways our clients and others (perhaps including ourselves) have been caged by it.

Throughout the three articles, we will offer suggestions for counselor practitioners to refresh their understanding of gender identity and to support clients in considering their own relationships to gender socialization and their continual identity development processes. We acknowledge the hierarchical attention that gender in society often receives; therefore, we have placed the articles in an intentional order, and we begin with our elevation of information about TGE people.

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In this first piece, our focus centers on the large and diverse ways that individuals may identify their gender. Here, we aim to break the binary by highlighting the expansive landscape of gender identity and how TGE people challenge the historical stratification of the traditional sex and gender labels.

It is important to distinguish between gender (social construct) and sex (unique blend of chromosomes and hormones) that each of us embody. These two concepts are different, and both are different still from one’s sexual identity or sexual orientation, a major discussion of which is beyond the scope of our work on the task force.

Historically, one’s biological sex was considered to mean either female or male, and the social construct of gender came to mean either woman or man. In the early days of our understanding of transgender identities, even these were seen on the binary system: people assigned to female at birth (AFAB) or people assigned to male at birth (AMAB). If they desired to transition, they transitioned to the “opposite” gender.

With significant research efforts conducted over the past half-century and accelerated much more recently, we understand that the binary structure is false and far too limiting/constraining for both the concepts of biological sex and socially constructed gender. Gender can be conceptualized on a spectrum or as a spider web or as a vast gray area, but it is no longer simply two seemingly opposing labels.

The following sections help illuminate what it is about counseling TGE people that counselors need to know, why we need to know it and what we can do with this knowledge. 

Historical contexts

The term “transgender” has been around for approximately 57 years, yet how we understand the identities of TGE people is still being constructed. Many terms may be new, but evidence of transgender people dates back centuries. Two examples include Thomas or Thomasine Hall, a servant in Virginia in the 1620s who lived as both a man and a woman, and Deborah Sampson, who enlisted in the Revolutionary War as a man.

In the mid-19th century, the Industrial Revolution brought masses of people to cities, and the arts and cultural nuance followed. This migration provided new ideas and experiences, but this age of social change also experienced backlash. For example, cities formalized ordinances and restrictions for a dress code in which people were not to dress in attire that did not “belong to his or her sex,” and medical literature of the late 19th and early 20th centuries consistently pathologized TGE experiences and identities.

In response to mounting medical and social oppressions, transgender liberation increased through the 20th century, with important inciting events at Cooper Do-Nuts in 1959, Dewey’s in Philadelphia in 1965 and Compton’s Cafeteria in 1966, all spur-of-the-moment resistance movements against police harassment. In the late 1980s and early 1990s, at the height of the AIDS epidemic, transgender people were hit especially hard because of a lack of social and political recognition and access to resources. Poor health care due to poverty, isolation, discrimination and stigma only served to compound the problem.

Despite the passage of time and growing social acceptance, health, financial, social and psychological barriers still present significant challenges to the TGE communities today. According to the National Center for Transgender Equality, violence against transgender people has increased over the past several years, particularly for trans women of color.

 Exploring contemporary TGE identities

Over the past several decades of gender research, we have come to understand gender as a dynamic, rather than fixed, layer of our individual identities, especially when taking an intersectional approach. Through this lens, we consider that each of us embodies a unique set of identities (i.e., sexual/affectional orientation, religion/spirituality, ability status, citizenship, ethnicity, etc.). How these identities interact in the various contexts in which we find ourselves will shape our experiences of freedom and constraint to be who we are, making ourselves smaller or bigger based on where we are and who we are with.

The level of acceptance and affirmation we feel for ourselves and which we receive from others will differ based on each unique role we hold and the context we are in (e.g., home and family, school, church, work, social, sports,). Some of us might find it easy to discover ourselves, express ourselves and enjoy the support of those around us, whereas others will have mixed experiences and distinct pockets of support in being our authentic selves. Some of us may struggle to gain support altogether. This is important to understand because we know that feelings of isolation and a lack of family and social support will often negatively impact our emotional and psychological well-being.

Having distinguished sex (a unique collection of chromosomes and hormones) from gender (a social construct of roles and norms) earlier in this article, we will begin here with perhaps more unfamiliar terms.

Cisgender describes a felt match between the sex one is assigned at birth and their gender as expressed in society. For example, a baby who is declared female at birth is socialized as a girl and eventually a woman, continues to strongly identify this way and does not waver to a great degree throughout her life.

Transgender is a term used to describe someone who does not identify internally or express in society the same way they were assigned at birth. Some transgender individuals choose confirming medical interventions (hormones, surgery, etc.) to help their outsides better match their insides, and some do not.

Intersex is a term used to describe people with various physical, chromosomal, or hormonal variations outside of binary sex characteristics that may or may not be visible. Some intersex people may have ambiguous external genitalia when they are born and have historically been subjected to non-consensual surgical procedures to alter genitalia and/or reproductive processes to reflect their eventual socialization as male or female. Other intersex people may have phenotypically expected genitalia with variations in chromosomes or reproductive organs (e.g., individuals assigned female at birth with androgen insensitivity and XY chromosomes, Turner syndrome, Klinefelter’s syndrome).

Nonbinary/enby/N.B. is a term used to describe someone whose behavior and expression is other than that of a traditionally socialized man or woman. Nonbinary people do not necessarily identify as transgender, but some do. They may seek surgical or hormonal treatments, or may not.

There is a vast array of further identities, and the Society for Sexual, Affectional, Intersex and Gender Expansive Identities (SAIGE; a division of the American Counseling Association formerly known as ALGBTIC) has provided an index of terminology that readers may find useful (saigecounseling.org/public-resources). There is great mutability in this list, and it may change and grow as new understandings emerge. Additionally, these are contemporary and prevalent terms in the United States and may vary greatly over the world depending on the restrictions of freedom TGE people have in their respective societies or the lived experience they bring with them to the U.S. It is always best to follow your client’s lead as they discover and define their own identities in the way that makes sense for them.

Ethics and competencies

The 2014 ACA Code of Ethics requires that when working with “clients, students, employees, supervisees, and research participants,” we do not “condone” or “engage in” discrimination based on any number of identities, including gender and gender identity (Standard C.5.). Counselors must use care in selecting, administering and interpreting assessments, with consideration given to how norm groups differ from the individuals or groups counselors are assessing (Standard E.8.).

Furthermore, professional competencies available through SAIGE exist to specifically guide practitioners in their work with gender diverse clients, including transgender clients, and the Multicultural and Social Justice Counseling Competencies (MSJCC). These documents encompass an intersectional approach while also exploring privilege within the counselor and client roles. The MSJCC further explore how these roles interact within domains of self-awareness, client worldview, the counseling relationship, and counseling and advocacy interventions. These ethics codes and competencies lay the groundwork for best practice and are a practitioner’s ever-present guides.

One of the fundamental elements of a professional counselor’s work is to build cultural competency and be aware of and informed about their client’s cultural background. For TGE clients, this will include their experiences with discrimination, oppression, violence and rejection due to their gender identity.

Clients may present to counseling unconcerned with their gender identification, or they may be struggling with some aspect of their gender identity development and need assistance in processing who they are in the world or navigating difficult relationships with family and friends who do not understand who the client is. Clients may also present to counseling with an unresolved trauma history related or unrelated to their gender, or they may have worked through past traumas and could be attending counseling for entirely other reasons. As culturally competent counselors, we do not want to assume that the client has any gender trouble or that their gender is a problem that needs resolution, but neither do we want to avoid asking about how their gender journey has influenced them.

Counselors need to be aware of the many constraints society still places on TGE people, including discriminatory state and federal legislation related to employment, bathroom use, athletics and military service. Almost half of trans youth report feeling unsafe in schools. They often have higher absence rates and lower GPAs and are less likely to pursue higher education. According to the most recent National School Climate Survey, over 28% of trans youth were denied the use of the restrooms or locker rooms that aligned with their gender identity, and almost 23% were prevented from using their names and pronouns. Most recently, anti-transgender legislation has targeted high school, collegiate and professional athletics, threatening to keep trans youth and adults from competing on teams that align with their gender identity.

According to the National Transgender Discrimination Survey, TGE individuals reported facing serious acts of discrimination, including:

• Violence
• Employer discrimination and difficulties finding employment
• Struggles in coming out and family issues
• Lack of gender affirmative and inclusive health care (including mental health care)
• Lack of access to housing (sometimes resulting in homelessness)
• Roadblocks in obtaining proper identity documents (which impacts voting rights and travel)
• Barriers to immigration
• Unique issues related to military service and navigating the Department of Veterans Affairs
• Discrimination by police internal or external to jails and prisons
• Racial and economic injustice
• Life span issues concerning aging/older adults

In fact, 39% of participants reported experiencing serious psychological distress in the month prior to taking the survey. The same survey went on to paint a portrait of concern for TGE individuals: 40% of respondents reported attempting suicide, 29% lived in poverty, and 48% reported being denied equal treatment or being the target of verbal harassment or physical attack in the past year due to being transgender.

Despite these troubling statistics, we know that this group is resilient and resourceful and that there is growing acceptance of TGE identities in society. They are finding ways, just as they always have, to support one another and build safety, coalition and agency through connection. Furthermore, supportive allies outside the community are instrumental in creating space for and advocating alongside members of this community. The growth of online communities from Tumblr to YouTube to TikTok have created platforms of connection where gender expansive individuals can build spaces for themselves. This is especially important when physical and local community is scarce (e.g., in rural areas, in nonsupportive environments) and where influencers in the community bring gender expansive identities and issues to the mainstream culture. Additionally, recent television shows such as Queer Eye, Pose, Euphoria, Shrill, Sex Education, Sort Of, Big Sky and Madagascar: A Little Wild have brought gender diverse characters to mainstream audiences across the life span.

The counseling space, whether school-based, rehabilitation or community agency, is one of exploration and insight. Many individuals first explore their gender identity in the safe confines of the counseling session. They may first use affirming names and pronouns with their counselor, and they may also work on unresolved and co-occurring concerns. These concerns include crisis/acute care related to suicide, mental health diagnoses (anxiety, depression, posttraumatic stress disorder), relational issues, past violence and trauma, and coming out processes and life changes.

Counseling interventions and approaches

As noted earlier, the MSJCC provide an important structure for counselors to demonstrate their cultural competency through knowing themselves, knowing their clients, building skills and engaging in advocacy. Many counselors do not know how to implement this framework and feel unprepared to support TGE clients. Here are some concrete steps counselors can take to begin or continue this development.

The first step in supporting TGE clients is to better understand our own attitudes and beliefs regarding gender identity. I (Mickey White) often ask my students to reflect on the following questions:

• What is your gender identity, and how do you describe it? How did you develop your gender identity?
• When did you first become aware of people with different gender identities than your own?
• What are your thoughts regarding people who identify as transgender, gender expansive, nonbinary or any other noncisgender identities?
• What messages about transgender, gender expansive, nonbinary or other noncisgender identities have you heard? Where did you hear them?

Everyone has various degrees of exposure to TGE people, and these questions may help facilitate exploration of the internalized messages regarding gender identity and provide a basis for further awareness and knowledge development.

There exists a rich global history of gender diversity and expansiveness. Gaining more knowledge regarding the history of diverse identities and experiences is incredibly valuable to fostering resilience and liberation for TGE clients.

Where to begin? Fortunately, there is a panoply of resources counselors can access. An excellent starting place are documentaries, particularly those led by transgender individuals. Laverne Cox’s documentary Disclosure explores the impact of Hollywood on the United States’ understanding of and sentiments toward the transgender community. Trans in Trumpland is a four-part documentary chronicling the experiences of four transgender individuals in the rural South and showcasing the unique intersectional experiences of transgender people in the South. Finally, Frontline PBS’s Growing Up Trans highlights the experiences of transgender children and their families.

There are also many written works by transgender authors that provide both scholarly and personal insights into the experiences of TGE individuals, available for both children and adults. For adults, Transgender History by Susan Stryker, Redefining Realness by Janet Mock and the collected stories in Nonbinary: Memoirs of Gender and Identity edited by Micah Rajunov and Scott Duane are just a few recommendations. For children and teens, there are numerous nonfiction and fiction stories with gender diverse characters, including Being Jazz by transgender activist Jazz Jennings and Stacey’s Not a Girl by Colt Keo-Meier, which specifically explores nonbinary and gender expansive identities. Later this year, the Gender Equity Task Force will release a toolkit containing additional sources for counselors to continue developing their knowledge.

There are a few skills that are important toward effective work with TGE clients. The first is a commitment to ensuring an affirmative and responsive space for gender diverse clients. Commonly, this means always using a client’s correct name and pronouns. This is often a new skill for counselors not commonly engaged with transgender clients. It is important to practice a person’s pronouns and name as necessary to refer to them/zir/her/him correctly. Expanding our own views of gender and no longer assigning pronouns and identity based on appearance (e.g., not assuming a person with a masculine gender expression uses he/him pronouns) often makes this process easier.

In the case that you do misgender or incorrectly name someone, the most important things to do in the moment are to apologize, correct yourself and move on. Later, spend some time practicing the person’s name/pronouns in a way that protects confidentiality, like talking to a pet, plant or stuffed animal. It may seem silly, but practice makes perfect, and your clients will be positively impacted.

Another skill is broaching. Broaching is an integral part of the counseling process in which counselors consistently invite the client to explore issues of diversity by creating a therapeutic environment where the client feels safe to discuss issues of difference. Acknowledging both the client’s and your own impacting identities is crucial to creating that therapeutic environment. For cisgender counselors, this may involve asking a question such as “What are your thoughts and feelings about working with a cisgender counselor?” near the start of the relationship. Transgender or gender expansive counselors also should broach gender to avoid possible transference and countertransference.

It is important to check in with clients periodically regarding the relationship. In addition to an absence of microaggressions, Annalisa Anzani and colleagues found that acknowledging and disrupting cisnormativity was a key element of positive therapeutic relationships for transgender clients. Counselors can acknowledge and disrupt cisnormativity by discussing the impact of gender norm expectations with TGE clients, encouraging clients to explore and create their own meaning of gender identity, and providing resources that are vetted as affirming for TGE communities.

Finally, counselors can intentionally create practices that are trans-affirming. A content analysis conducted by Shannon Skaistis and colleagues found that often our intake paperwork is not trans-inclusive. Providing clients with a space to express their gender and pronouns on intake paperwork, rather than providing only limited checkbox options, is one way to create a welcoming space before even meeting the client. Including your pronouns on your online bio, in marketing materials and when introducing yourself also demonstrates competence and an openness to disclose noncisgender identities.

In addition, consider hanging or displaying pride flags representing diverse gender identities or including gender-inclusive decorations in your office space. If possible, restrooms should be accessible for people of all gender identities. Placing a generic “restroom” sign rather than a “male” or “female” sign on single-stall facilities or labeling the types of facilities (i.e., urinals and toilets, toilets) can remove some of the discomfort many TGE individuals experience in public daily.

Identifying attitudes and beliefs, acquiring knowledge and developing skills in the ways provided constitute the action component of the MSJCC. It is our duty as counselors to be consistently learning and assessing competence. There are many opportunities to learn about TGE communities, and part of the mission of the Gender Equity Task Force is to provide counselors with useful tools and resources. This article, the first of three, has provided information and tools to assist counselors in becoming more familiar with and providing better services for TGE populations. In future articles, considerations for working with girls and women and boys and men will be discussed.

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Find out more about ACA’s Gender Equity Task Force at acagenderequity.weebly.com

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Mickey White is a national certified counselor (NCC), board-certified telemental health provider, and assistant professor in the Department of Counseling and Human Services at East Tennessee State University. He is the chair of the Transgender and Gender Expansive subgroup of the ACA Gender Equity Task Force, co-chair of the Southern Association for Counselor Education and Supervision (SACES) Webinar Committee and immediate past co-chair of the SACES Social Justice and Human Rights Interest Network. Contact him at whiteme@etsu.edu.

Tracy Peed is a licensed professional school counselor in Illinois and Minnesota, an assistant professor and doctoral coordinator in the Department of Counseling and Student Personnel at Minnesota State University, Mankato, and a member of the ACA Gender Equity Task Force, where she serves as chair of the Girls and Women subgroup and as a member of the Transgender and Gender Expansive subgroup. Contact her at tracy.peed@mnsu.edu.

Jane Rheineck has been a counselor and counselor educator for 22 years and has sustained membership with ACA, ACES, SAIGE and the Association for Adult Development and Aging since 1999. She is a licensed professional counselor (LPC) in Wisconsin, an NCC and an approved clinical supervisor. She currently serves on the ACA Governing Council, representing SAIGE and serving on the council’s Executive Committee and the Gender Equity Task Force. Contact her at rheinecj@mtmary.edu.

Suzy Wise is an LPC in Illinois, an NCC, and an assistant professor and core faculty in the clinical mental health counseling program at Valparaiso University, also serving as faculty adviser for the university’s chapter of Counselors for Social Justice. Suzy’s participation on the Gender Equity Task Force includes chairing the Boys and Men subgroup and being a member of the Transgender and Gender Expansive subgroup. Contact Suzy at Suzy.Wise@valpo.edu.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.