Diversity Lecture 4

Why do we need to knwo about gender diversity?

• You will be a mental health professional for all types of clients

• You will meet transgender people even if you do not work in a gender clinic

• Transgender and gender diverse population is vulnerable for mental health challenges

Positionality

• The social and political context that creates your identity

• How your identity influences and biases your perception of and outlook on the world

Terminology: Gender

Socially-constructed roles, behaviors, expressions and identities of girls, women, boys, men and gender diverse people 

Terminology: Sex

Biological attributes of humans and animals, including physical features, chromosomes, gene expression, hormones, and anatomy 

Terminology: Cisgender vs transgender

• Cisgender: Your assigned sex at birth alines with your gender

• Transgender: Your assigned sex at birth does not aline with your gender

The Gender Unicorn: Differences in:

• Gender identity

• Gender expression

• Sex assigned at birth

• Physically attracted to

• Emotionally attracted to

How do we explain this increase of Numbers in NL Gender Care?

• More awareness and social acceptance

• Increased availability of information and representation

• Increased accessibility and higher quality of care

• Publication of DSM-5 (2013), diagnosis of gender dysphoria now more sensitive for NBGQ gender experience

• Change of 'Transgender Law' in 2014

Dutch Gender Care

• Mandatory health insurance for every resident of the Netherlands.

• Government mandates insurance coverage for necessary gender-affirming treatments

• Dedicated, multidisciplinary gender clinics available (e.g., at Amsterdam University Medical Center)

DSM-V Gender Dysphoria

• A-criterium

• A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six months duration, as manifested by [at least 2 of 6]

• 1. Incongruence between experienced gender and sex characteristics

• 2. Desire to be rid of one’s sex characteristics

• 3. Desire for the sex characteristics of the other/or alternative gender

• 4. Desire to be of the other gender/or alternative

• 5. Desire to be treated as the other/or alternative gender

• 6. Conviction that one has the typical feelings and reactions of the other/alternative gender

• B-criterium: The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Types of Dysphoria

• Social: Discomfort with presenting socially as your birth-gender

• Body: Discomfort with your body being of a different gender

• Mind: Discomfort with your mind and emotions not lining up with your gender identity

Steps in Dutch Gender Care

• Psychologist: Diagnostic phase

• Endocrinologist: Hormone treatment (like second puberity for other sex)

• Surgeon: Gender affirming surgery

Effects of Gender-Affirming Hormone Therapy: Physical Changes

• Transmen (Testosterone therapy):

  • Menstruation stops

  • Voice deepens

  • Facial and body hair growth

  • Body fat redistributed

  • Muscle mass and strength increase

• Transwomen (Estrogen + anti-androgens):

  • Breast development

  • Fewer erections, decreased ejaculation

  • Less facial/body hair growth

  • Slower scalp hair loss

  • More body fat, reduced muscle mass

Effects of Gender-Affirming Hormone Therapy: Mental Health Changes 

• Feminizing therapy:

  • ↓ Psychological distress and depressive symptoms

  • ↑ Quality of life, emotional balance, expressiveness (weaker evidence)

• Masculinizing therapy:

  • ↓ Psychological distress and depressive symptoms

  • ↓ Anxiety and social anxiety symptoms (weaker evidence)

  • ↑ Quality of life, affective dampening, anger expression (weaker evidence)

Psychologist’s Role Before Referring for Medical Treatment

Confirm that:

• There is evidence of gender incongruence;

• The transgender individual's resilience and support system are sufficient;

• The proposed treatment is appropriate and well-suited to the individual;

• There are no medical or psychiatric contra-indications;

• All additional criteria for treatment are met

Gender Diversity and Mental Health Prevalence

• Psychiatric Diagnoses: x 2 Trans individuals have a two fold higher risk of receiving a psychiatric diagnoses as compared to their cisgender counterparts.

• Mood Disorders: x 1.5 Transgender individuals are 1.5 more often diagnosed with mood disorders than cisgender individuals.

• Anxiety Disorders: x 3.9 Trans individuals are 3.9 times more often diagnosed with anxiety disorders than cisgender individuals

• Suicidality: x 13 The prevalence of suicidality is 13 times higher in the transgender population compared to the cisgender population.

Integrated Framework of TNB (Trans and Non-Binary) Mental Health Disparities

• Socioecological Context

  • Structural/Systemic level: Policies, healthcare access, education, documentation laws.

  • Interpersonal level: Family, community, and social relationships.

• TNB Minority Stressors

  • External stressors:

    • Barriers in healthcare, education, housing

    • Anti-trans legislation and discrimination

    • Violence, harassment, and social rejection

  • Internal stressors:

    • Internalized transnegativity

    • Anticipated stigma

    • Identity non-disclosure

• Psychological Mediation Processes

  • Rumination, hopelessness, shame

  • Cognitive and emotional factors at the individual level

• Outcomes: Leads to mental and behavioral health disparities

External Stressors

• Discrimination

• Rejection

• Victimization

• Non-affirmation

• In 2022, we saw a sharp increase in the number of reported incidents of discrimination against transgender individuals in NL. There have never been so many reports before.

Internal Stressors

• Internalized transphobia

• Negative expectations

• Concealment

Trans Affirmative CBT - Assessment 

You could ask:

• What are the client's experiences with gender minority stress?

• What were client's early messages about LGBTQ+ people?

• What are early learning experiences about LGBTQ+ individuals and identities that may contribute to the current problems?

• What are the client's underlying beliefs about themselves as LGBTQ+ people?

• Does the client have hope for the future?

• What stressors currently interfere with the client's ability to cope and/or solve problems?

Therapy Plan in TA-CBT model

1. Psychoeducation on CBT model and minority stress

2. Understanding the impact of anti-LGBTQ+ attitudes on behavior and stress

3. Understanding the influence of thoughts on emotions

4. Using thoughts to change emotions

5. Understanding how behavior affects emotions

6. Work with breaking the pattern of maladaptive thinking and negative emotions

7. Understanding the impact of minority stress on social attitudes and behavior, relationship building

8. Developing support networks

Lack of Knowledge on Gender Topic Lead to:

• Unnecessary referrals to specialized clinics

• Clients feel like they must educate their therapist on gender-related topics

• Lack of gender sensitivity, unnuanced approach in language and views

Clinical practice: Gender sensitivity

• How can I help foster gender euphoria in my patients?

• Update the patient’s gender and pronouns in their medical file.

• Make your work environment as inclusive as possible (e.g., by having gender-neutral toilets next to the waiting room).

• Display a rainbow-patterned ornament in your workplace or on yourself (e.g., a sticker at the front desk, wearing a rainbow lanyard, etc.).

• Adopt gender-inclusive language and practices.

• Display your own pronouns on your name badge and in your email signature.

• Register yourself in your local database of queer-friendly care providers.

Clinical practice: Exploring gender identity

• Differentiate between gender identity, biological sex, presentation and sexual orientation (e.g. using the gender unicorn or genderbread person)

  • How would you describe your gender identity/sexual orientation?

• Explore person's gender awareness and gender identity throughout their lifespan

  • When did you first become aware of gender – in yourself or others?

  • Were there key moments, relationships, or experiences that made you reflect deeper on your gender?

• Explore person's ideas about gender stereotypes and gender roles

  • What messages did you learn growing up about boys, girls, or other genders ‘should’ behave?

  • How do you feel about these traditional gender roles today?

• Explore which ideas about gender (roles) they have encountered in their family, culture, school, media etc. And how this has influenced them

  • How did your family respond when you first shared something about your gender identity?

  • To what extend do you feel accepted by your family for who you are right now?

Clinical practice: Differential diagnostics 

Differentiate between:

• Psychological problems that may (partly) result from gender dysphoria

• Psychological problems that may have influenced gender dysphoria

• Psychological problems that make it difficult to assess gender dysphoria

Study on Missteps in Psychotherapy with Transgender clients 

• Explored common mistakes therapists make when working with transgender and gender-nonconforming (TGNC) clients.

• Method:

  • Interviews with 45 TGNC adults about psychotherapy experiences.

  • Used grounded theory to identify themes of therapist errors.

• Main Findings: 8 Common Missteps:

1. Education Burdening: Clients must teach therapists about TGNC issues.

2. Gender Inflation: Therapist focuses too much on gender.

3. Gender Narrowing: Binary or limited view of gender.

4. Gender Avoidance: Avoiding discussion of gender.

5. Gender Generalizing: Treating all TGNC people as the same.

6. Gender Repairing: Trying to “fix” transgender identity.

7. Gender Pathologizing: Seeing TGNC identity as a disorder.

8. Gatekeeping: Controlling access to medical or gender-affirming care.

Study on Missteps in Psychotherapy with Transgender clients: Conclusion

• TGNC clients often face harm from uneducated or biased therapists.

• Missteps can undermine trust, cause distress, and reinforce stigma.

• Clinical Implications:

  • Therapists must develop gender sensitivity and cultural competence.

  • Create a safe, affirming environment for all gender identities.

  • Recognize and challenge personal biases.

  • Balance focus on gender with attention to other life issues.

  • Support clients’ autonomy and gender affirmation without pathologizing.

Study on Barriers to Mental Health Care for Transgender people

• Explored what prevents transgender and gender-nonconforming (TGNC) adults from accessing effective mental health care.

• Systematic literature review of 8 studies
  (6 qualitative, 2 quantitative).

• Focused on TGNC adults’ experiences with mental health professionals.

• Main Findings – 3 Major Barriers:

1. Personal Concerns:

   • Fear of being pathologized or stereotyped.

   • Discomfort with uninformed or biased therapeutic approaches.

2. Incompetent Professionals:

   • Therapists often lack knowledge, nuance, or supportive attitudes toward TGNC clients.

3. Affordability Factors:

   • High costs, lack of insurance, and financial instability reduce access to care.

Study on Barriers to Mental Health Care for Transgender people: Conclusion 

• TGNC adults face serious barriers to quality mental health care.

• Negative experiences often lead to avoidance of treatment or distrust of professionals.

• Clinical Implications:

  • Urgent need for training in TGNC-affirming therapy.

  • Services should be affordable, accessible, and non-pathologizing.

  • Therapists must develop cultural competence, sensitivity, and respect for gender diversity.

  • Promoting affirming environments improves mental health and encourages help-seeking.

Psychological problems that may (party) result from gender dysphoria

• Mood Disorders

• Anxiety Disorders (social anxiety, PTSD)

• Substance abuse

• Risk of suicide

• Stress associated with daily life challenges

Psychological problems that may have influenced gender identity/dysphoria

• Trauma

• Intellectual disability

• Autism spectrum

• Identity/personality disorders

• Psychotic disorders

• >>> Detailed assessment and the developmental timeline is important!

Psychological problems that make it difficult to assess gender dysphoria

• Intellectual disabilities

• Autism spectrum

• Acute psychiatric disorders (depression, psychosis, manic episode) that impair judgement and communicative abilities

• Difficulties in verbalizing inner experiences