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GuidelinesforPsychologicalPracticeWith
TransgenderandGenderNonconformingPeople
AmericanPsychologicalAssociation
Transgenderandgendernonconforming(TGNC)people
are those who o have e a gender r identity y that is s not fully
alignedwiththeirsexassignedatbirth. Theexistenceof
TGNCpeoplehasbeendocumentedinarangeofhistorical
cultures (Coleman, Colgan, , & & Gooren, 1992Feinberg,
1996Miller& Nichols, 2012Schmidt, 2003). Current
population estimates s ofTGNCpeoplehaverangedfrom
0.17to1,333per100,000(Meier&Labuski,2013).The
MassachusettsBehavioralRiskFactorSurveillanceSurvey
found 0.5% ofthe adultpopulationaged18to64years
identified as TGNC C between 2009 9 and 2011 (Conron,
Scott, Stowell, , & & Landers, , 2012). However, population
estimates likely underreport t the true number of TGNC
people,givendifficultiesincollectingcomprehensivede-
mographicinformationaboutthisgroup(Meier&Labuski,
2013).Withinthelasttwodecades,therehasbeenasig-
nificant increase in research h about t TGNC C people. . This
increaseinknowledge,informedbytheTGNCcommunity,
has resulted d in the development of progressively more
trans-affirmativepracticeacrossthemultiplehealthdisci-
plines involved d in the care ofTGNC people (Bockting,
Knudson, &Goldberg,2006;Colemanetal., 2012). Re-
searchhasdocumentedtheextensiveexperiencesofstigma
anddiscriminationreportedbyTGNCpeople(Grantetal.,
2011)andthementalhealthconsequencesoftheseexpe-
riencesacrossthelifespan(Bockting,Miner,Swinburne
Romine,Hamilton,&Coleman,2013),includingincreased
ratesofdepression(Fredriksen-Goldsenetal., 2014)and
suicidality(Clements-Nolle,Marx,&Katz,2006).TGNC
people’s lack of access to o trans-affirmative mental and
physicalhealthcareisacommonbarrier(Fredriksen-Gold-
senetal.,2014;Garofalo,Deleon,Osmer,Doll,&Harper,
2006;Grossman&D’Augelli, 2006),withTGNCpeople
sometimesbeingdeniedcarebecauseoftheirgenderiden-
tity(Xavieretal.,2012).
In 2009, , the American n Psychological Association
(APA)TaskForceonGenderIdentityandGenderVariance
(TFGIGV)surveyfoundthatlessthan30%ofpsychologist
andgraduatestudentparticipantsreportedfamiliaritywith
issues that TGNC C people experience e (APA TFGIGV,
2009).Psychologistsandothermentalhealthprofessionals
whohavelimitedtrainingandexperienceinTGNC-affir-
mativecaremaycauseharmtoTGNCpeople(Mikalson,
Pardo,&Green,2012;Xavieretal.,2012).Thesignificant
level of f societal l stigma and d discrimination n that TGNC
people face, , the associated mental health consequences,
andpsychologists’lackoffamiliaritywithtrans-affirmative
careledtheAPATaskForcetorecommendthatpsycho-
logicalpracticeguidelinesbedevelopedtohelppsycholo-
gists maximize the effectiveness s of services s offered d and
avoidharm whenworking withTGNC C peopleand their
families.
Purpose
The purpose of theGuidelinesforPsychologicalPractice
with Transgender and Gender Nonconforming People
(hereafterGuidelines) is toassistpsychologists in the pro-
vision of culturally competent, developmentally appropri-
ate, and trans-affirmative psychological practice with
TGNC people. Trans-affirmative practice is the provision
The American Psychological Association’s (APA’s) Task Force on
GuidelinesforPsychologicalPracticewithTransgender andGenderNon-
conforming Peopledeveloped theseguidelines.lorem.dickey,Louisiana
Tech University, and Anneliese A. Singh, The University of Georgia,
served as chairs of the Task Force. The members of the Task Force
included Walter O. Bockting, Columbia University; Sand Chang,Inde-
pendent Practice; Kelly Ducheny, Howard Brown Health Center; Laura
Edwards-Leeper,PacificUniversity;RandallD.Ehrbar,WhitmanWalker
HealthCenter;MaxFuentesFuhrmann,IndependentPractice;MichaelL.
Hendricks,WashingtonPsychologicalCenter,P.C.;andEllenMagalhaes,
Center for Psychological Studies at Nova Southeastern University and
California School of Professional Psychology at Alliant International
University.
TheTaskForceisgratefultoBT,RobinBuhrke,JennBurleton,Theo
Burnes,LoreeCook-Daniels,Ed Delgado-Romero,MaddieDeutsch,Mi-
chelleEmerick,Terry S.Gock, Kristin Hancock,RaziaKosi,Kimberly
Lux, Shawn MacDonald, Pat Magee, Tracee McDaniel, Edgardo Men-
vielle, Parrish Paul, Jamie Roberts, Louise Silverstein, Mary Alice Sil-
verman, Holiday Simmons, Michael C. Smith, Cullen Sprague, David
Whitcomb, and Milo Wilson for their assistance in providing important
input and feedback on drafts of theguidelines. The Task Force is espe-
ciallygratefultoClintonAnderson,Director,andRonSchlittler,Program
Coordinator,of APA’s Officeon LGBT Concerns, who adeptly assisted
andprovidedcounseltotheTaskForcethroughoutthisproject.TheTask
Force would also like to thank liaisons from the APA Committee on
ProfessionalPracticeandStandards(COPPS),AprilHarris-BrittandScott
Hunter,andtheirstaffsupport,MaryHardiman.Additionally,membersof
theTaskForcewouldliketothankthestaffatthePhillipRushCenter and
Agnes ScottCollegeCounseling Center inAtlanta,Georgia,who served
ashosts for face-to-facemeetings.
This document will expireas APApolicy in 2022. After this date,
users should contact the APA Public Interest Directorate to determine
whether theguidelinesin this documentremainin effect as APApolicy.
Correspondence concerning this article should be addressed to the
Public Interest Directorate, American Psychological Association, 750
FirstStreet,NE, Washington,DC 20002.
1Forthepurposesoftheseguidelines,weusethetermtransgender
and gender nonconforming (TGNC). Weintend d forthe e term m to beas
broadly inclusiveaspossible, andrecognizethat someTGNCpeopledo
notascribetotheseterms.ReadersarereferredtoAppendixAforalisting
of terms thatincludevarious TGNC identity labels.
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832
December 2015
American Psychologist
©2015AmericanPsychologicalAssociation0003-066X/15/$12.00
Vol.70,No.9,832–864
http://dx.doi.org/10.1037/a0039906
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of care that is respectful, aware, and supportive of the
identities and life experiences of TGNC people (Korell&
Lorah, 2007).TheGuidelinesareanintroductoryresource
for psychologistswhowillencounter TGNCpeopleintheir
practice, but can also be useful for psychologists with
expertiseinthisareaofpracticetoimprovethecarealready
offered to TGNC people. TheGuidelinesinclude a set of
definitions for readers who may be less familiar with lan-
guage used when discussing gender identity and TGNC
populations (see AppendixA). Distinct from TGNC, the
term “cisgender” is used to refer to people whose sex
assignedatbirthisalignedwiththeir genderidentity (E. R.
Green, 2006; Serano, 2006).
Given the added complexity of working with TGNC
and gender-questioning youth
2
and the limitations of the
available research, theGuidelinesfocus primarily, though
not exclusively, on TGNC adults. Future revisions of the
Guidelines will deepen n a focus s on n TGNC and d gender-
questioning children and adolescents. TheGuidelinesad-
dress the strengths of TGNC people, the challenges they
face, ethical and legal issues, life span considerations,
research, education, training, and health care. Because is-
sues of gender identity are often conflated with issues of
gender expression or sexual orientation, psychological
practice with the TGNC population warrants the acquisi-
tionofspecificknowledgeaboutconcernsuniquetoTGNC
people that are not addressed by other practice guidelines
(APA,2012). It is important to note that theseGuidelines
are not intended to address some of the conflicts that
cisgender people may experience due to societal expecta-
tions regarding gender roles (Butler, 1990), nor are they
intended toaddress intersexpeople (Dreger,1999;Preves,
2003).
Documentation of Need
In 2005, the APA Council of Representatives authorized
the creation of the Task Force on Gender Identity and
Gender Variance (TFGIGV), charging the Task Force to
review APA policies relatedto TGNC people and to offer
recommendationsforAPA tobestmeettheneeds of TGNC
people (APATFGIGV,2009). In 2009, the APA Council
of RepresentativesadoptedtheResolutiononTransgender,
Gender Identity, & Gender Expression Non-Discrimina-
tion, which calls upon psychologists in their professional
roles to provide appropriate, nondiscriminatory treatment;
encouragespsychologiststotake aleadershiproleinwork-
ing against discrimination; supports the provision of ade-
quate and necessary mental and medical health care; rec-
ognizes the efficacy, benefit, and medical necessity of
gender transition; supports access to appropriate treatment
in institutional settings; and supports the creation of edu-
cational resources for all psychologists (Anton,2009). In
2009, in an extensive reportonthe currentstateof psycho-
logical practice with TGNC people, the TFGIGV deter-
minedthat there wassufficient knowledge andexpertise in
the field towarrant the development of practice guidelines
for TGNC populations (APATFGIGV,2009). The report
identifiedthat TGNC people constituted a populationwith
unique needs and that the creation of practice guidelines
wouldbe avaluable resource for the field (APATFGIGV,
2009). Psychologists’ relative lack k of knowledge about
TGNC people and trans-affirmative care, the level of soci-
etalstigma and discriminationthatTGNC people face, and
thesignificantmentalhealthconsequences thatTGNCpeo-
ple experience as a result offer a compelling need for
psychological practice guidelines for this population.
Users
The intended audience for theseGuidelinesincludes psy-
chologists who provide clinical care, conduct research, or
provide education or training. Given that gender identity
issuescan ariseat any stage in aTGNCperson’s life (Lev,
2004),clinicianscanencounteraTGNCpersoninpractice
or have a client’s presenting problem evolve into an issue
relatedtogender identityandgender expression. Research-
ers, educators, and trainers will benefit from use of these
Guidelinestoinformtheirwork,evenwhennotspecifically
focusedonTGNCpopulations. Psychologistswhofocuson
TGNC populations in their clinical practice, research, or
educationalandtrainingactivitieswillalsobenefitfrom the
use of theseGuidelines.
Distinction Between Standards
and Guidelines
When using these Guidelines, psychologists should be
awarethatAPA hasmadeanimportantdistinctionbetween
standardsand guidelines(Reed,McLaughlin,&Newman,
2002).Standardsaremandatestowhichallpsychologists
must adhere (e.g., theEthicalPrinciplesofPsychologists
and Codeof Conduct;APA,2010),whereasguidelinesare
aspirational. Psychologists are encouraged to use these
Guidelinesintandemwiththe Ethical Principles of Psy-
chologists and Code ofConduct,andshouldbeawarethat
stateandfederallawsmayoverridetheseGuidelines(APA,
2010).
In addition, these Guidelines refer to psychological
practice (e.g., clinical work, consultation, education, re-
search, and training) rather than treatment. Practice guide-
lines are practitioner-focused and provide guidance for
professionals regarding “conduct and the issues to be con-
sideredinparticular areas of clinicalpractice” (Reedetal.,
2002,p.1044).Treatmentguidelinesareclient-focusedand
address intervention-specific recommendations for a clini-
calpopulationor condition(Reedetal.,2002). Thecurrent
Guidelines are intended to complement treatment guide-
lines for TGNC people seeking mental health services,
such as those set forth by the World Professional Associ-
ation for Transgender Health Standards of Care (Coleman
et al., 2012)andtheEndocrineSociety(Hembree et al.,
2009).
2Forthepurposesoftheseguidelines,“youth”referstobothchildren
and adolescents under theageof 18.
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833
December 2015
American Psychologist
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Compatibility
These Guidelines are consistent with the APA Ethical
Principles of Psychologists and Code of Conduct (APA,
2010), theStandards ofAccreditationforHealthService
Psychology(APA,2015),theAPATFGIGV(2009)report,
and the APA Council of Representatives Resolution on
Transgender, Gender Identity, & Gender Expression Non-
Discrimination (Anton,2009).
Practice Guidelines Development
Process
To address one of the recommendations of theAPATF-
GIGV (2009),theAPACommitteeonSexualOrientation
and Gender Diversity (CSOGD; then the Committee on
Lesbian, Gay, Bisexual, and Transgender Concerns) and
Division 44 (the Society for the Psychological Study of
Lesbian, Gay, Bisexual and Transgender Issues) initiateda
jointTaskForceonPsychologicalPracticeGuidelineswith
Transgender and Gender Nonconforming People in 2011.
Task Force members were selectedthrough an application
andreview processconductedbytheleadershipof CSOGD
and Division 44. The Task Force included 10 members
who had substantial psychological practice expertise with
TGNC people. Of the 10 task force members, five individ-
uals identified as TGNC with a range of gender identities
andfive identified as cisgender. In terms of race/ethnicity,
six of the taskforce members identified as White and four
identified as people of color (one Indian American, one
Chinese American, one Latina American, and one mixed
race).
The TaskForce conductedacomprehensivereview of
the extant scholarship, identified content most pertinent to
the practice of psychology with TGNC people, and evalu-
atedthe levelof evidence tosupportguidancewithin each
guideline. To ensure the accuracy and comprehensiveness
of theseGuidelines, TaskForcemembers metwith TGNC
community members and groups and consulted with sub-
jectmatterexpertswithinandoutsideofpsychology.When
theTaskForcediscoveredalackofprofessionalconsensus,
everyeffort was made toinclude divergent opinions in the
field relevant to that issue. When this occurred, the Task
Force describedthevarious approaches documentedin the
literature. Additionally, theseGuidelineswereinformedby
comments received at multiple presentations held at pro-
fessionalconferences and comments obtained through two
cycles of openpubliccommentonearlierGuidelinedrafts.
This documentcontains16guidelines for TGNC psy-
chological practice. Each guideline includes a Rationale
section, which reviews relevant scholarship supporting the
need for the guideline, and an Application section, which
describes how the particular guideline may be applied in
psychological practice. TheGuidelinesare organized into
five clusters: (a) foundational knowledge and awareness;
(b) stigma, discrimination,andbarrierstocare;(c) lifespan
development; (d) assessment, therapy, and intervention;
and (e) research, education, and training.
Funding for this project was providedby Division 44
(Societyfor the Psychological Studyof LGBT Issues); the
APA Office on Lesbian, Gay, Bisexual, and Transgender
(LGBT) Concerns; a grant from the Committee on Divi-
sion/APA Relations (CODAPAR); and donations from
Randall Ehrbar and Pamela St. Amand. Some members of
the Task Force have received compensation through pre-
sentations (e.g., honoraria) or royalties (e.g., book con-
tracts) based in part on information contained in these
Guidelines.
Selection of Evidence
Although the number of publications on the topic of
TGNC-affirmative practice has beenincreasing, this is still
anemergingareaofscholarlyliteratureandresearch.When
possible, the Task Force relied on peer-reviewed publica-
tions, but books, chapters, andreports that do nottypically
receive a high level of peer review have also been cited
when appropriate. These sources are from a diverse range
of fields addressing mental health, including psychology,
counseling, social work, and psychiatry. Some studies of
TGNC people utilize small sample sizes, which limits the
generalizability of results. Few studies of TGNC people
utilize probability samples or randomized control groups
(e.g.,Conronetal.,2012;Dhejneetal.,2011). Asa result,
the Task Force relied primarily on studies using conve-
nience samples, whichlimits thegeneralizabilityof results
to the population as a whole, but can be adequate for
describing issues and situations that arise within the pop-
ulation.
Foundational Knowledge and
Awareness
Guideline 1. Psychologists understand that
gender is a nonbinary construct that allows
for a range of gender identities and that a
person’s gender identity may not align with
sex assigned at birth.
Rationale.
Gender identity is defined as a per-
son’s deeplyfelt, inherentsense of being agirl, woman, or
female; a boy, a man, or male;a blend of male or female;
or an alternative gender (Bethea&McCollum,2013;In-
stitute of Medicine [IOM], 2011). Inmany y cultures s and
religious traditions, gender has been perceived as a binary
construct, with mutually exclusive categories of male or
female, boy or girl, man or woman (Benjamin, 1966;
Mollenkott, 2001; Tanis, 2003).Thesemutuallyexclusive
categories include an assumption that gender identity is
always in alignment with sex assigned at birth (Bethea&
McCollum, 2013).ForTGNCpeople,genderidentitydif-
fersfrom sexassignedatbirthtovaryingdegrees,andmay
beexperienced and expressedoutside of the gender binary
(Harrison,Grant,&Herman,2012;Kuper,Nussbaum, &
Mustanski, 2012).
Gender as a nonbinary construct has been described
and studied for decades (Benjamin, 1966Herdt, 1994;
Kulick, 1998).Thereishistoricalevidenceofrecognition,
societal acceptance, and sometimes reverence of diversity
in gender identity and gender expression in several differ-
ent cultures (Colemanetal.,1992;Feinberg,1996;Miller
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834
December 2015
American Psychologist
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&Nichols, 2012; Schmidt, 2003).Manyculturesinwhich
gender nonconforming persons and groups were visible
were diminished by westernization, colonialism, and sys-
temic inequity (Nanda,1999). In the 20th century, TGNC
expression became medicalized (Hirschfeld, 1910/1991),
and medical interventions to treat discordance between a
person’s sex assigned at birth, secondary sex characteris-
tics, and gender identity became available (Meyerowitz,
2002).
As early as the 1950s, research found variability in
how an individual described their3 gender, withsome par-
ticipants reporting a gender identity different from the
culturally defined, mutuallyexclusive categories of “man”
or “woman” (Benjamin, 1966). In several recent large
onlinestudiesoftheTGNCpopulationintheUnitedStates,
30% to 40% of participants identified their gender identity
as other than man or woman (Harrisonetal.,2012;Kuper
et al., 2012). Although some e studies have cultivated a
broader understandingof gender (Conron,Scout,&Austin,
2008),themajorityofresearchhasrequiredaforcedchoice
betweenmanandwoman,thusfailingtorepresentordepict
those with different gender identities (IOM, 2011). Re-
search over the last two decades has demonstrated the
existenceof awidespectrum of gender identityandgender
expression(Bockting,2008;Harrisonetal.,2012;Kuperet
al., 2012), which h includes s people whoidentify y as s either
man or woman, neither man nor woman, a blend of man
and woman, or a unique gender identity. A person’s iden-
tificationasTGNCcanbehealthyandself-affirming,andis
not inherently pathological (Colemanetal.,2012). How-
ever, people may experience distress associated with dis-
cordance between their gender identity and their body or
sex assigned at birth, as well as societal stigma and dis-
crimination (Colemanetal.,2012).
Between the late 1960s and the early 1990s, health
care to alleviate gender dysphoria largely reinforced a
binary conceptualization of gender (APATFGIGV,2009;
Bolin, 1994; Hastings, 1974).Atthattime,itwasconsid-
ered an ideal outcome for TGNC people to conform to an
identity that alignedwith either sexassignedat birthor, if
not possible, with the“opposite”sex, witha heavyempha-
sis on blending into the cisgender population or “passing”
(APATFGIGV,2009;Bolin,1994;Hastings,1974). Vari-
ancefromtheseoptions couldraiseconcern for healthcare
providers about a TGNC person’s abilityto transition suc-
cessfully. Theseconcernscouldactasabarrier toaccessing
surgery or hormone therapy because medical and mental
health care provider endorsement was requiredbefore sur-
gery or hormones could be accessed (Bergeretal.,1979).
Largelybecauseof self-advocacyofTGNCindividualsand
communities in the 1990s, combined with advances in
research and models of trans-affirmative care, there is
greater recognition and acknowledgment of a spectrum of
gender diversityand correspondingindividualized,TGNC-
specific health care (Bocktingetal.,2006;Colemanetal.,
2012).
Application.
Anonbinary understanding of gen-
der is fundamental to the provision of affirmative care for
TGNC people. Psychologists are encouraged to adapt or
modifytheirunderstandingof gender,broadeningtherange
of variation viewed as healthy and normative. By under-
standing the spectrum of gender identities and gender ex-
pressions thatexist,andthataperson’sgenderidentitymay
not be in full alignment with sex assigned at birth, psy-
chologists can increase their capacity toassist TGNCpeo-
ple, their families, and their communities (Lev, 2004).
Respecting and supporting TGNC people in authentically
articulating their gender identity and gender expression, as
wellastheir livedexperience,canimproveTGNCpeople’s
health, well-being, and quality of life (Witten,2003).
Some TGNC people may have limited access to vis-
ible, positive TGNC role models. As aresult, many TGNC
peopleareisolatedandmustcopewiththestigmaof gender
nonconformitywithoutguidance or support, worsening the
negative effect of stigma on mental health (Fredriksen-
Goldsen etal., 2014;Singh, Hays, & Watson, 2011).Psy-
chologists mayassist TGNC people inchallenging gender
norms and stereotypes, and in exploring their unique gen-
deridentityandgenderexpression. TGNCpeople, partners,
families, friends, and communities can benefit from edu-
cation about the healthy variation of gender identity and
gender expression, and the incorrect assumption that gen-
der identityautomaticallyalignswith sexassignedat birth.
Psychologists may model an acceptance of ambiguity
as TGNC people develop and explore aspects of their
gender, especially in childhood and adolescence. A non-
judgmental stance toward gender nonconformity can help
to counteract the pervasive stigma faced by many TGNC
people and provide a safe environment to explore gender
identityandmakeinformeddecisionsaboutgender expres-
sion.
Guideline 2. Psychologists understand that
gender identity and sexual orientation are
distinct but interrelated constructs.
Rationale.
The constructs of gender identity and
sexual orientation are theoretically and clinically distinct,
eventhough professionals andnonprofessionals frequently
conflate them. Althoughsomeresearchsuggestsapotential
link in the development of gender identity and sexual
orientation, the mechanisms of such a relationship are
unknown (Adelson & American Academy of Child and
Adolescent Psychiatry [AACAP] Committee on Quality
Issues [CQI], 2012; APA TFGIGV, 2009; A. . H. Devor,
2004; Drescher & Byne, 2013).Sexualorientationisde-
fined as a person’s sexual and/or emotional attraction to
another person (Shively & De Cecco, 1977), compared
withgenderidentity, which is defined by a person’s felt,
inherent sense of gender. For most people, gender identity
develops earlier thansexualorientation. Gender identityis
often established in young toddlerhood (Adelson &AA-
CAP CQI, 2012; Kohlberg, 1966),comparedwithaware-
3Thethird person plural pronouns “they,”“them,”and “their” ” in
someinstances function in theseguidelinesas third-person singular pro-
nouns to model acommon technique used to avoid theuseof gendered
pronounswhen speaking to or about TGNC people.
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835
December 2015
American Psychologist
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ness of same-sex attraction, which often emerges in early
adolescence (Adelson&AACAPCQI,2012;D’Augelli&
Hershberger, 1993; Herdt & Boxer, 1993; Ryan, 2009;
Savin-Williams& Diamond,2000).Althoughgenderiden-
tity is usually established in childhood, individuals may
become aware that their gender identity is not in full
alignment with sex assigned at birth in childhood, adoles-
cence, oradulthood.Thedevelopmentalpathwayof gender
identity typically includes a progression through multiple
stages of awareness, exploration, expression, and identity
integration (Bockting & & Coleman, 2007; A. H. Devor,
2004; Vanderburgh, 2007). Similarly, a a person’s s sexual
orientationmayprogressthroughmultiplestagesof aware-
ness, exploration, and identity through adolescence and
into adulthood (Bilodeau & & Renn, 2005). Just as some
peopleexperience their sexual orientationas being fluidor
variable (L. M.Diamond,2013), some people alsoexperi-
ence their gender identity as fluid (Lev,2004).
The experienceof questioningone’sgender cancreate
significant confusion for some TGNC people, especially
for those who are unfamiliar with the range of gender
identities that exist. To explain any discordance they may
experience between their sex assigned at birth, related
societal expectations, patterns of sexual and romantic at-
traction, and/or gender role nonconformity and gender
identity,some TGNCpeoplemayassumethattheymustbe
gay, lesbian,bisexual, orqueer (Bockting,Benner,&Cole-
man, 2009).Focusingsolelyonsexualorientationas the
cause for discordance may obscure awareness of a TGNC
identity. It can be very important to include sexual orien-
tationand gender identity inthe process of identity explo-
ration as well as in the associated decisions about which
options will work best for any particular person. In addi-
tion, many TGNC adults have disguised or rejected their
experienceof gender incongruence in childhood or adoles-
cence to conform to societal expectations and minimize
their fear of difference (Bockting&Coleman,2007;Byne
et al., 2012).
Because gender and patterns of attraction are used to
identify a person’s sexual orientation, the articulation of
sexual orientation is made more complex when sex as-
signed at birth is not aligned with gender identity. A
person’s sexual orientation identity cannot be determined
bysimply examiningexternalappearance or behavior, but
must incorporate a person’s identity and self-identification
(Broido,2000).
Application.
Psychologists may assist people in
differentiating gender identity and sexual orientation. As
clients become aware of previously hidden or constrained
aspects of their gender identity or sexuality, psychologists
may provide acceptance, support, andunderstanding with-
out making assumptions or imposing a specific sexual
orientation or gender identity outcome (APA TFGIGV,
2009).Becauseoftheirrolesinassessment,treatment,and
prevention, psychologists are in a unique position to help
TGNC people better understand and integrate the various
aspects of their identities. Psychologists may assist TGNC
people by introducing and normalizing differences ingen-
der identity and expression. As a TGNC person finds a
comfortable way to actualize and express their gender
identity, psychologists may notice that previously incon-
gruentaspects of theirsexualorientationmaybecomemore
salient, better integrated, or increasingly egosyntonic
(Bocktingetal.,2009; H. Devor, 1993;Schleifer, 2006).
This process may allow TGNC people the comfort and
opportunitytoexploreattractionsor aspectsof their sexual
orientation that previously had been repressed, hidden, or
in conflict with their identity. TGNC people may experi-
ence a renewed exploration of their sexual orientation, a
widened spectrum of attraction, or a shift in how they
identify their sexual orientation in the context of a devel-
oping TGNC identity (Coleman, Bockting, & & Gooren,
1993; Meier, Pardo, Labuski, & Babcock, 2013; Samons,
2008).
PsychologistsmayneedtoprovideTGNCpeoplewith
information about TGNC identities, offering language to
describethe discordanceandconfusionTGNCpeoplemay
be experiencing. To facilitate TGNC people’s learning,
psychologists mayintroducesomeof thenarrativeswritten
by TGNC people that reflect a range of outcomes and
developmentalprocessesinexploringandaffirminggender
identity (e.g.,Bornstein&Bergman,2010;Boylan,2013;
J. Green, 2004Krieger, 2011Lawrence, 2014). These
resources maypotentiallyaidTGNCpeopleindistinguish-
ingbetweenissuesofsexualorientationandgenderidentity
and in locating themselves on the gender spectrum. Psy-
chologists mayalso educate families and broader commu-
nity systems (e.g., schools, medical systems) to better un-
derstand how gender identity and sexual orientation are
different but related; this may be particularly useful when
working with youth (Singh & Burnes, 2009Whitman,
2013).Becausegenderidentityandsexualorientationare
often conflated, even by professionals, psychologists are
encouraged to carefully examine resources that claim to
provide affirmative services for lesbian, gay, bisexual,
transgender, and queer (LGBTQ) people, and to confirm
which are knowledgeableabout andinclusive of the needs
of TGNC people before offeringreferrals or recommenda-
tions to TGNC people and their families.
Guideline 3. Psychologists seek to
understand how gender identity intersects
with the other cultural identities of TGNC
people.
Rationale.
Gender identityandgender expression
may have profound intersections with other aspects of
identity (Collins,2000;Warner,2008). These aspects may
include, but are not limited to, race/ethnicity, age, educa-
tion,socioeconomic status, immigrationstatus,occupation,
disability status, HIV status, sexual orientation, relational
status, and religion and/or spiritual affiliation. Whereas
some of these aspects of identity may afford privilege,
others maycreatestigmaandhinderempowerment(Burnes
&Chen, 2012;K.M.de Vries, 2015).Inaddition,TGNC
people who transition may not be prepared for changes in
privilege or societaltreatmentbasedongender identityand
gender expression.Toillustrate,anAfricanAmericantrans
man may gain male privilege, but may face racism and
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836
December 2015
American Psychologist
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societal stigma particular to African American men. An
Asian American/Pacific Islander trans womanmayexperi-
encethe benefit of being perceivedas a cisgender woman,
but may also experience sexism, misogyny, and objectifi-
cation particular to Asian American/Pacific Islander cis-
gender women.
The intersection of multiple identities within TGNC
people’s lives is complex and may obstruct or facilitate
access tonecessarysupport(A.Daley,Solomon,Newman,
&Mishna, 2008).TGNCpeoplewithlessprivilegeand/or
multipleoppressedidentities mayexperience greater stress
and restricted access to resources. They may also develop
resilience and strength in coping with disadvantages, or
may locate community-based resources available to spe-
cific groups (e.g., for people living with HIV;Singhetal.,
2011).Genderidentityaffirmationmayconflictwithreli-
gious beliefs or traditions (Bockting &Cesaretti, 2001).
Finding an affirmative expression of their religious and
spiritual beliefs and traditions, including positive relation-
ships with religious leaders, can be an important resource
for TGNC people (Glaser, 2008Porter, Ronneberg, , &
Witten, 2013; Xavier, 2000).
Application.
In practice, psychologists strive to
recognize the salient multiple and intersectingidentities of
TGNC people that influence coping, discrimination, and
resilience (Burnes &Chen,2012). Improved rapport and
therapeutic alliance are likely to develop when psycholo-
gists avoid overemphasizing gender identity and gender
expression when not directly relevant to TGNC people’s
needs andconcerns.Evenwhen gender identityis themain
focus of care, psychologists are encouraged to understand
that a TGNC person’s experience of gender may also be
shaped by other important aspects of identity (e.g., age,
race/ethnicity, sexual orientation), and that the salience of
different aspects of identity may evolve as the person
continues psychosocial development across the life span,
regardless of whether they complete a social or medical
transition.
At times, a TGNC person’s intersection of identities
may result in conflict, such as a person’s struggle to inte-
grate gender identity with religious and/or spiritual up-
bringing and beliefs (Kidd&Witten,2008;Levy&Lo,
2013; Rodriguez & Follins, 2012).Psychologistsmayaid
TGNC people in understanding and integrating identities
that maybe differentlyprivilegedwithinsystems of power
and systemic inequity (Burnes &Chen,2012). Psycholo-
gists mayalsohighlightandstrengthenthe developmentof
TGNC people’s competencies and resilience as they learn
tomanagethe intersectionof stigmatized identities (Singh,
2012).
Guideline 4. Psychologists are aware of how
their attitudes about and knowledge of
gender identity and gender expression may
affect the quality of care they provide to
TGNC people and their families.
Rationale.
Psychologists, like other members of
society, come to their personal understanding and accep-
tance of different aspects of human diversity through a
process of socialization. Psychologists’ cultural biases, as
well as the cultural differences between psychologists and
their clients, have a clinical impact (Israel, Gorcheva,
Burnes, & Walther, 2008; Vasquez, 2007). The assump-
tions, biases, and attitudes psychologists hold regarding
TGNCpeopleandgenderidentityand/or genderexpression
canaffectthequalityof services psychologists provide and
their ability to develop an effective therapeutic alliance
(Bess&Stabb,2009;Rachlin,2002). Inaddition, alackof
knowledge or training in providing affirmative care to
TGNC people can limit a psychologist’s effectiveness and
perpetuate barriers to care (Bess&Stabb,2009;Rachlin,
2002).Psychologistsexperiencedwithlesbian,gay,orbi-
sexual (LGB) people may not be familiar with the unique
needs of TGNCpeople(Israel,2005;Israeletal.,2008). In
community surveys, TGNC people have reported that
many mental health care providers lack basic knowledge
and skills relevant to care of TGNC people (Bradford,
Xavier, Hendricks, Rives, & Honnold, 2007; Xavier, Bob-
bin, Singer, & Budd, 2005)and receive little training to
prepare them towork with TGNC people (APATFGIGV,
2009;Lurie, 2005).TheNationalTransgenderDiscrimina-
tionSurvey(Grantetal.,2011)reportedthat50%of TGNC
respondents shared that they had to educate their health
care providers about TGNC care, 28% postponed seeking
medical care due to antitrans bias, and 19% were refused
care due to discrimination.
The APA ethics code (APA,2010)specifies that psy-
chologists practice in areas only within the boundaries of
their competence (Standard 2.01), participate in proactive
andconsistentwaystoenhancetheircompetence(Standard
2.03), and base their work upon established scientific and
professional knowledge (Standard 2.04). Competence in
working with TGNC people can be developed through a
range of activities, such as education, training, supervised
experience,consultation,study, orprofessionalexperience.
Application.
Psychologists may engage in prac-
tice with TGNC people in various ways; therefore, the
depthand levelof knowledge and competencerequired by
a psychologist depends on the type and complexity of
service offered to TGNC people. Services that psycholo-
gists provide to TGNC people require a basic understand-
ing of thepopulationand its needs, as wellas the ability to
respectfully interact ina trans-affirmative manner (L.Car-
roll, 2010).
APA emphasizes the use of evidence-based practice
(APAPresidentialTaskForceonEvidence-BasedPractice,
2006).Givenhoweasilyassumptionsorstereotypescould
influence treatment, evidence-basedpractice may be espe-
cially relevant to psychological practice with TGNC peo-
ple. Until evidence-based practices are developed specifi-
cally for TGNC people, psychologists are encouraged to
utilize existing evidence-based practices in the care they
provide.APA alsopromotescollaborationwithclientscon-
cerning clinicaldecisions, includingissuesrelatedtocosts,
potential benefits, and the existing options and resources
related to treatment (APAPresidentialTaskForceonEv-
idence-Based Practice, 2006).TGNCpeoplecouldbenefit
fromsuch collaborationandactive engagement in decision
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837
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American Psychologist
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making, given the historical disenfranchisement and dis-
empowerment of TGNC people in health care.
In an effort to develop competence in working with
TGNC people, psychologists are encouraged to examine
their personal beliefs regarding gender and sexuality, gen-
der stereotypes, and TGNC identities, in addition to iden-
tifying gaps in their own knowledge, understanding, and
acceptance (American Counseling Association [ACA],
2010).Thisexaminationmayincludeexploringone’sown
gender identity and gendered experiences related to privi-
lege, power, or marginalization, as wellas seeking consul-
tation and training with psychologists who have expertise
in working with TGNC people and communities.
Psychologists are further encouraged to develop com-
petence in working with TGNC people and their families
by seeking up-to-date basic knowledge and understanding
of gender identity and expression, and learning how to
interact with TGNC people and their families respectfully
andwithoutjudgment. CompetenceinworkingwithTGNC
people may be achieved and maintained in formal and
informalways, rangingfromexposureinthe curriculum of
training programs for future psychologists and continuing
education at professional conferences, to affirmative in-
volvement as allies in the TGNC community. Beyond
acquiring general competence, psychologists who choose
tospecializeinworkingwithTGNCpeoplepresentingwith
gender-identity-relatedconcernsarestronglyencouragedto
obtain advanced training, consultation, and professional
experience (ACA,2010;Colemanetal.,2012).
Psychologists may gain knowledge about the TGNC
community and become more familiar with the complex
social issues that affect the lives of TGNC people through
first-handexperiences (e.g., attendingcommunitymeetings
andconferences, readingnarratives writtenbyTGNCpeo-
ple). If psychologists have not yet developed competence
inworkingwithTGNCpeople,itisrecommendedthatthey
referTGNCpeopletoother psychologists or providerswho
are knowledgeable and able to provide trans-affirmative
care.
Stigma, Discrimination, and Barriers
to Care
Guideline 5. Psychologists recognize how
stigma, prejudice, discrimination, and
violence affect the health and well-being of
TGNC people.
Rationale.
Many TGNC people experience dis-
crimination, ranging from subtle to severe, whenaccessing
housing, healthcare, employment, education, public assis-
tance, andother socialservices (Bazargan&Galvan,2012;
Bradford, Reisner, Honnold, & Xavier, 2013; Dispenza,
Watson, Chung, & Brack, 2012; Grant et al., 2011).Dis-
crimination can include assuming a person’s assigned sex
at birth is fully aligned with that person’s gender identity,
not using a person’s preferred name or pronoun, asking
TGNC people inappropriate questions about their bodies,
or making the assumption that psychopathology exists
given a specific gender identity or gender expression (Na-
dal, Rivera, & Corpus, 2010; Nadal, Skolnik, & Wong,
2012).Discriminationmayalsoincluderefusingaccessto
housing or employment or extreme acts of violence (e.g.,
sexual assault, murder). TGNC people who hold multiple
marginalized identities are more vulnerable to discrimina-
tion and violence. TGNC women and people of color
disproportionatelyexperiencesevereforms ofviolenceand
discrimination, including police violence, and are less
likely to receive help from law enforcement (Edelman,
2011;NationalCoalitionofAnti-ViolencePrograms, 2011;
Saffin, 2011).
TGNC people are at risk of experiencing antitrans
prejudice and discrimination in educational settings. In a
national representative sample of 7,898 LGBT youth in
K-12settings, 55.2%ofparticipantsreportedverbalharass-
ment, 22.7% reported physical harassment, and 11.4% re-
ported physical assault based on their gender expression
(Kosciw,Greytak,Palmer,&Boesen,2014). In a national
community survey of TGNC adults, 15% reported prema-
turely leavingeducationalsettings rangingfrom kindergar-
tenthrough college as a result of harassment (Grantetal.,
2011). Many y schoolsdonotinclude genderidentityand
gender expression in their school nondiscrimination poli-
cies; this leaves TGNC youth without needed protections
frombullyingandaggressioninschools (Singh&Jackson,
2012). TGNC youthinrural l settings may be even more
vulnerable tobullyingandhostilityintheir schoolenviron-
ments due to antitrans prejudice (Kosciwetal.,2014).
Inequities in educational settings and other forms of
TGNC-related discrimination may contribute to the signif-
icant economic disparities TGNC people have reported.
Grantandcolleagues (2011)foundthatTGNCpeoplewere
four times more likely to have a household income of less
than $10,000compared with cisgender people, andalmost
half of a sample of TGNC older adults reported a house-
hold income at or below 200% of poverty (Fredriksen-
Goldsen et al., 2014).TGNCpeopleoftenfaceworkplace
discriminationbothwhenseekingandmaintainingemploy-
ment (Brewster, Velez, , Mennicke, , &Tebbe, 2014Dis-
penza et al., 2012; Mizock & Mueser, 2014).Inanonrep-
resentative national study of TGNC people, 90% reported
having“directlyexperiencedharassmentor mistreatmentat
work and felt forced to take protective actions that nega-
tively impacted their careers or their well-being, such as
hiding who they were to avoid workplace repercussions”
(Grantetal.,2011, p. 56). In addition, 78% of respondents
reported experiencingsome kind of direct mistreatment or
discrimination at work (Grant et al.,2011). Employment
discrimination may berelated to stigma based on a TGNC
person’s appearance, discrepancies in identity documenta-
tion, or being unable to provide job references linked to
that person’s pretransition name or gender presentation
(Bender-Baird,2011).
Issues of employment discrimination and workplace
harassment are particularly salientfor TGNC military per-
sonnelandveterans. Currently, TGNCpeoplecannotserve
openlyintheU.S.military.Militaryregulationscite“trans-
sexualism” as a medical exclusion from service (Depart-
ment of Defense, 2011; Elders & Steinman, 2014).When
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838
December 2015
American Psychologist
enlisted, TGNC military personnel are faced with very
difficult decisions related to coming out, transition, and
seekingappropriate medical and mental healthcare, which
may significantly impactor end their military careers. Not
surprisingly,researchdocuments veryhighratesof suicidal
ideation and behavior among TGNC military and veteran
populations (Blosnichetal.,2013;Matarazzoetal.,2014).
Being open about their TGNC identity with health care
providerscancarryriskforTGNCmilitarypersonnel(Out-
Serve-Servicemembers LegalDefenseNetwork, n.d.).Bar-
riers to accessing health care noted by TGNC veterans
include viewingtheVA healthcare system as anextension
of the military, perceiving the VA as an unwelcoming
environment, and fearing providers’ negative reactions to
their identity (Sherman, Kauth,Shipherd,&Street,2014;
Shipherd, Mizock, Maguen, & Green, 2012). A A recent
study shows28%of LGBT veterans perceivedtheir VA as
welcomingandone third as unwelcoming(Shermanetal.,
2014). Multiple initiatives are underway y throughout the
VA system to improve the quality and sensitivity of ser-
vices to LGBT veterans.
Given widespreadworkplace discrimination and pos-
sible dismissal following transition, TGNC people may
engage in sex work or survival sex (e.g., trading sex for
food), or selldrugs togenerate income(Grantetal.,2011;
Hwahng&Nuttbrock, 2007;Operario, Soma, & Underhill,
2008; Stanley, 2011).Thisincreasesthepotentialforneg-
ativeinteractions withthelegalsystem, suchasharassment
by the police, bribery, extortion, and arrest (Edelman,
2011;Testaet al.,2012),aswellasincreasedlikelihoodof
mental health symptoms and greater health risks, such as
higher incidenceof sexuallytransmitted infections, includ-
ing HIV (Nemoto,Operario,Keatley,&Villegas,2004).
Incarcerated TGNC people report harassment, isola-
tion, forced sex, and physical assault, both by prison per-
sonnel andother inmates (AmericanCivilLibertiesUnion
National Prison Project, 2005; Brotheim, 2013;C. Daley,
2005).Insex-segregatedfacilities,TGNCpeoplemaybe
subjected to involuntary solitary confinement (also called
“administrative segregation”), which can lead to severe
negativementalandphysicalhealthconsequences andmay
blockaccess to services (Gallagher,2014;NationalCenter
for Transgender Equality, 2012).Anotherareaofconcern
is for TGNC immigrants and refugees. TGNC people in
detention centers may not be granted access to necessary
careandexperiencesignificantratesofassaultandviolence
inthese facilities (Gruberg,2013).TGNCpeoplemayseek
asylum in the United States to escape danger as a direct
resultoflackofprotections intheircountryof origin(APA
Presidential Task Force on Immigration, 2012; Cerezo,
Morales, Quintero, & Rothman, 2014; Morales, 2013).
TGNC people have difficulty accessing necessary
health care (Fredriksen-Goldsenetal.,2014;LambdaLe-
gal, 2012)andoftenfeelunsafesharingtheirgenderiden-
tityor their experiences of antitransprejudice and discrim-
ination due to historical and current discrimination from
health care providers (Grant et al., 2011Lurie, 2005;
Singh & McKleroy, 2011).EvenwhenTGNCpeoplehave
health insurance, plans may explicitly exclude coverage
related to gender transition (e.g., hormone therapy, sur-
gery). TGNC people may also have difficulty accessing
trans-affirmative primary health care if coverage for pro-
ceduresis deniedbased ongender. For example, trans men
may beexcludedfrom necessary gynecological care based
on the assumption that men do not need these services.
Thesebarriersoftenleadtoalackofpreventivehealthcare
for TGNC people (Fredriksen-Goldsen et al., 2014;
LambdaLegal, 2012).Althoughthelandscapeisbeginning
to change with the recent revision of Medicare policy
(National Center r for r Transgender Equality, , 2014) and
changes to state laws (Transgender Law Center, n.d.),
many TGNC people are still likely to have little to no
access to TGNC-related health care as a result of the
exclusions in their insurance.
Application.
Awareness of and sensitivity to the
effects of antitrans prejudice and discrimination can assist
psychologists in assessing, treating, and advocating for
their TGNC clients. When a TGNC person faces discrim-
ination based on gender identity or gender expression,
psychologists may facilitate emotional processingof these
experiences and work with the person to identify support-
ive resourcesandpossible courses ofaction.Specificneeds
of TGNC people might vary from developing self-advo-
cacy strategies, to navigating public spaces, to seeking
legal recourse for harassment and discrimination in social
services and other systems. Additionally, TGNC people
who have been traumatized by physical or emotional vio-
lence may need therapeutic support.
Psychologists may be able to assist TGNC people in
accessing relevant social service systems. For example,
psychologists may be able to assist in identifying health
care providersandhousingresources thatareaffirmingand
affordable, or locating affirming religious and spiritual
communities (Glaser,2008;Porteretal.,2013). Psycholo-
gists mayalsoassistinfurnishingdocumentationorofficial
correspondencethataffirms gender identityfor thepurpose
of accessing appropriate public accommodations, such as
bathroom use or housing (Lev,2009; W. J.Meyer,2009).
Additionally, psychologists may identify appropriate
resources, information, and services to help TGNC people
in addressing workplace discrimination, including strate-
gies during a social and/or medical transition for identity
disclosureatwork. Forthosewhoareseekingemployment,
psychologists may help strategize about how and whether
to share information about gender history. Psychologists
may also work with employers to develop supportive pol-
icies for workplacegender transitionor todevelop training
to help employees adjust to the transition of a coworker.
For TGNC military and veteran populations, psychol-
ogists may help to address the emotional impact of navi-
gatingTGNCidentitydevelopment inthe military system.
Psychologists are encouraged to be aware that issues of
confidentiality may be particularly sensitive with active
duty or reserve status service members, as the conse-
quences of being identified as TGNC may prevent the
client’s disclosure of gender identity in treatment.
In educational settings, psychologists may advocate
for TGNC youth on a number of levels (APA&National
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839
December 2015
American Psychologist
Associationof SchoolPsychologists, 2014;BoulderValley
School District, 2012). Psychologists s may consult t with
administrators, teachers, and school counselors to provide
resources and trainings onantitransprejudice anddevelop-
ingsaferschoolenvironmentsforTGNCstudents(Singh&
Burnes, 2009).PeersupportfromotherTGNCpeoplehas
been shown to buffer the negative effect of stigma on
mental health (Bocktingetal.,2013). As such, psycholo-
gists mayconsider anddeveloppeer-based interventions to
facilitate greater understanding andrespectful treatment of
TGNC youth by cisgender peers (Case& Meier, 2014).
Psychologists may work with TGNC youth and their fam-
ilies to identify relevant resources, such as school policies
thatprotectgender identityandgender expression(APA&
National Association of SchoolPsychologists, 2014; Gon-
zalez & McNulty, 2010), referrals to TGNC-affirmative
organizations, and online resources, which may be espe-
cially helpful for TGNC youth in rural settings.
Guideline 6. Psychologists strive to recognize
the influence of institutional barriers on the
lives of TGNC people and to assist in
developing TGNC-affirmative environments.
Rationale.
Antitrans prejudice andthe adherence
ofmainstream societytothegender binaryadverselyaffect
TGNC people within their families, schools, health care,
legal systems, workplaces, religious traditions, and com-
munities (AmericanCivilLibertiesUnionNationalPrison
Project, 2005;Bradfordet al., 2013; Brewster etal., 2014;
Levy& Lo, 2013; McGuire, Anderson, & Toomey, 2010).
TGNC people face challenges accessing gender-inclusive
restrooms, which may result in discomfort when being
forced to use a men’s or women’s restroom (Transgender
Law Center, 2005).Inadditiontotheemotionaldistressthe
forced binary choice that public restrooms may create for
some, TGNCpeoplearefrequentlyconcernedwithothers’
reactions to their presence in public restrooms, including
potential discrimination, harassment, and violence (Her-
man, 2013).
Many TGNC people may be distrustful of care pro-
viders due to previous experiences of being pathologized
(Benson, 2013). Experiences of discrimination and preju-
dice with health care providers may be complicated by
power differentials within the therapeutic relationship that
may greatly affect or complicate the care that TGNC peo-
ple experience. TGNCpeoplehave routinelybeenasked to
obtain an endorsement letter from a psychologist attesting
to the stability of their gender identity as a prerequisite to
access an endocrinologist, surgeon, or legal institution
(e.g., driver’s license bureau; Lev, 2009). The need for
such required documentation from a psychologist may in-
fluencerapport, resultingin TGNC people fearing prejudi-
cial treatment in which this documentation is withheld or
delayed by the treating provider (Boumanet al., 2014).
Whether aTGNCpersonhas personallyexperiencedinter-
actions with providers as disempowering or has learned
from community members toexpect such a dynamic, psy-
chologistsareencouragedtobe preparedfor TGNCpeople
to be very cautious when entering into a therapeutic rela-
tionship. When TGNC people feel validated and empow-
ered within the environment in whicha psychologist prac-
tices, the therapeutic relationship will benefit and the
person may be more willing to explore their authentic
selves and share uncertainties and ambiguities that are a
common part of TGNC identity development.
Application.
Because many TGNC people expe-
rience antitrans prejudice or discrimination, psychologists
are encouraged to ensure that their work settings are wel-
coming and respectfulof TGNC people, andtobe mindful
of what TGNC people may perceive as unwelcoming. To
do so, psychologists may educate themselves about the
manyways thatcisgender privilege and antitrans prejudice
may be expressed. Psychologists may also have specific
conversations with TGNC people about their experiences
of the mental health system and implement feedback to
foster TGNC-affirmative environments. As a result, when
TGNC people access various treatment settings and public
spaces, they may experience less harm, disempowerment,
or pathologization, and thus will be more likely to avail
themselves of resources and support.
Psychologists are encouraged to be proactive in con-
sidering how overt or subtle cues in their workplaces and
other environments may affect the comfort and safety of
TGNC people. To increase the comfort of TGNC people,
psychologists are encouragedtodisplayTGNC-affirmative
resources in waiting areas and to avoid the display of
items that reflect antitrans attitudes (Lev, 2009). Psy-
chologists are encouraged to examine how their lan-
guage (e.g., use of incorrect pronouns and names) may
reinforce the gender binary in overt or subtle and unin-
tentional ways (Smith,Shin,&Officer,2012). It maybe
helpful for psychologists to provide training for support
staff on how to respectfullyinteract with TGNC people.
Apsychologist may consider making changes to paper-
work, forms, or outreach materials to ensure that these
materials are more inclusive of TGNC people (Spade,
2011b). For example, , demographic questionnaires s can
communicate respect through the use of inclusive lan-
guage and the inclusion of a range of gender identities.
In addition, psychologists may also work within their
institutions to advocate for restrooms that are inclusive
and accessible for people of all gender identities and/or
gender expressions.
WhenworkingwithTGNC people ina varietyof care
and institutional settings (e.g., inpatient medical and psy-
chiatric hospitals, substanceabusetreatmentsettings, nurs-
ing homes, foster care, religiouscommunities, militaryand
VA health care settings, and prisons), psychologists may
become liaisons and advocates for TGNC people’s mental
health needs and for respectful treatment that addresses
their gender identityinanaffirmingmanner.Inplayingthis
role, psychologists may find guidance and best practices
that have been published for particular institutional con-
texts to be helpful (e.g.,DepartmentofVeteransAffairs,
Veterans’ HealthAdministration, 2013;Glezer, McNiel, &
Binder, 2013; Merksamer, 2011).
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Guideline 7: Psychologists understand the
need to promote social change that reduces
the negative effects of stigma on the health
and well-being of TGNC people.
Rationale.
The lack of public policy that ad-
dresses the needsof TGNC people creates significanthard-
ships for them (Taylor, 2007). Although there have been
major advances in legal protections for TGNC people in
recent years (Buzuvis,2013;HarvardLawReviewAsso-
ciation, 2013), manyTGNCpeoplearestillnotafforded
protections from discrimination on the basis of gender
identityorexpression(NationalLGBTQTaskForce,2013;
Taylor, 2007).Forinstance,inmanystates,TGNCpeople
donothaveemploymentorhousingprotectionsandmaybe
fired or lose their housing based on their gender identity.
Many policies that protect the rights of cisgender people,
including LGB people, do not protect the rights of TGNC
people (Currah,&Minter,2000;Spade,2011a).
TGNC people can experience challenges obtaining
gender-affirming identitydocumentation (e.g., birthcertif-
icate, passport, social security card, driver’s license). For
TGNC peopleexperiencing povertyor economic hardship,
requirements for obtainingthis documentation may be im-
possible to meet, in part due to the difficulty of securing
employment without identity documentation that aligns
withtheir genderidentityandgender expression(Sheridan,
2009). Additionally, , systemic barriers related to o binary
gender identification systems prevent some TGNC people
from changing their documents, including those who are
incarcerated, undocumented immigrants, and people who
live in jurisdictions that explicitly forbid such changes
(Spade, 2006). Documentation requirements can also as-
sumea universalTGNCexperiencethatmarginalizes some
TGNC people, especially those who do not undergo a
medicaltransition.ThismayaffectaTGNCperson’ssocial
and psychological well-being and interfere with accessing
employment, education, housing and shelter, health care,
public benefits, andbasic life management resources (e.g.,
opening a bank account).
Application.
Psychologists are encouraged to in-
form public policy to reduce negative systemic impact on
TGNC people and topromote positive socialchange. Psy-
chologists are encouragedtoidentify and improve systems
that permit violence; educational, employment, and hous-
ing discrimination; lack of access to health care; unequal
access to other vital resources; and other instances of
systemic inequity that TGNC people experience (ACA,
2010).ManyTGNCpeopleexperiencestressorsfromcon-
stant barriers, inequitable treatment, and forced release of
sensitive and private information about their bodies and
their lives (Hendricks &Testa, , 2012). To obtain proper
identity documentation, TGNC people may be required to
provide court orders, proof of having had surgery, and
documentationof psychotherapyor apsychiatricdiagnosis.
Psychologists may assist TGNC people by normalizing
their reactions of fatigueandtraumatizationwhile interact-
ing with legal systems and requirements; TGNC people
may alsobenefit from guidance about alternate avenues of
recourse, self-advocacy, or appeal. When TGNC people
feel that it is unsafe to advocate for themselves, psychol-
ogists may work with their clients to access appropriate
resources in the community.
Psychologists are encouraged to be sensitive to the
challenges of attaining gender-affirmingidentitydocumen-
tationandhow thereceiptor denialof suchdocumentation
may affect social and psychological well-being, the per-
son’sabilitytoobtaineducation andemployment,findsafe
housing, access public benefits, obtain student loans, and
access healthinsurance. It may be of significant assistance
for psychologiststounderstandandofferinformationabout
the process of a legal namechange, gender marker change
onidentification, or theprocessfor accessingothergender-
affirming documents. Psychologists may consult the Na-
tional Center for Transgender Equality, the Sylvia Rivera
Law Project, or the Transgender Law Center for additional
information on identity documentation for TGNC people.
Psychologistsmaychoosetobecomeinvolvedwithan
organization that seeks to revise law and public policy to
better protect the rights and dignities of TGNC people.
Psychologists mayparticipate atthelocal, state, or national
level to support TGNC-affirmative health care accessibil-
ity, human rights in sex-segregated facilities, or policy
changeregardinggender-affirmingidentitydocumentation.
Psychologists working in institutional settings may also
expand their roles to work as collaborative advocates for
TGNC people(Gonzalez&McNulty,2010). Psychologists
are encouraged to provide written affirmations supporting
TGNC people and their gender identity so that they may
access necessary services (e.g., hormone therapy).
Life Span Development
Guideline 8. Psychologists working with
gender-questioning
4
and TGNC youth
understand the different developmental
needs of children and adolescents, and that
not all youth will persist in a TGNC identity
into adulthood.
Rationale.
Many children develop stability (con-
stancyacrosstime) intheir gender identitybetweenAges3
to 4 (Kohlberg, 1966), although gender consistency (rec-
ognition that gender remains the same across situations)
oftendoes not occur untilAges 4to7(Siegal&Robinson,
1987).Childrenwhodemonstrategendernonconformityin
preschool and early elementary years may not follow this
trajectory (Zucker & & Bradley, 1995). Existing research
suggests that between 12% and 50% of childrendiagnosed
with gender dysphoria may persist in their identification
with a gender different than sex assigned at birth into late
adolescence and young adulthood (Drummond, Bradley,
4Gender-questioningyoutharedifferentiatedfromTGNCyouthin
thissectionof theguidelines.Gender-questioningyouthmaybequestion-
ingorexploringtheirgenderidentitybuthavenotyetdevelopedaTGNC
identity.As such,they may not beeligiblefor someservices thatwould
be offered to TGNC youth. Gender-questioning youth areincluded here
becausegender questioning may leadto a TGNCidentity.
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