Advocating for the LGBTQIAA in Psychotherapy By Jason Linder, LMFT on 4/12/19 - 10:59 AM

I trace my commitment to serving underserved communities to my Jewish heritage. As a Jewish person, I am a member of a resilient minority group that experienced centuries of oppression and genocide. This cultivated inside me a sensitivity to discrimination and connected me to a passion for social justice. I have become active in my university’s LGBTQ+ club and feel that it is my civic duty to advocate for LGBTQIAA+ (lesbian, gay, bisexual, transgender, queer, questioning, intersex and allies) clients so they can be better served.

I’m also sensitive to others’ suffering because I grew up with a speech impediment. As a child, most people didn’t understand that my stutter was involuntary; peers told me to “slow down,” and “just relax and speak.” People didn’t understand my suffering, and I agonized in silence until I learned how to mostly overcome it. Since overcoming it, I’ve hoped to prevent similar suffering in others.

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How would you feel if the general public regularly imposed a gender and/or sexual orientation on you that did not accurately represent who you feel you are?

You don’t have to have suffered like I did to make a difference for the LGBTQ+ community, which is estimated to be 10% (and this only reflects those who feel safe to report) of the world’s population. We all have experienced a little taste of what it feels like to be discriminated against. This community has been fighting an uphill battle for their lives, with their jobs, families, and interpersonal relationships constantly at risk. They endure constant mislabeling, violence and judgment. The most covert, perhaps, is people assuming it to be a choice when it's not. Here are some questions to think about in your practice:

Do you assume couples are monogamous? Do you assume all your clients are cisgender? Do you assume heterosexuality if someone is currently in a heterosexual relationship? Do you assume the client you’re talking to is heterosexual? For example, have you, knowingly or unknowingly, asked if a female client has a boyfriend instead of a “partner(s)?”

The he-she binary inadvertently erases trans people. There is more variation to human gender than merely “ladies and gentlemen” or “men and women.” Since the vehicle of change for psychotherapists is primarily language, we can start by using inclusive, respectful, and empowering language. You can start by using person-first language, identifying your pronouns, calling out the use of terms like “mankind” and “he/she” and the existence of mostly binary bathrooms (unlike other gender-inclusive countries like Canada with primarily unisex public bathrooms). There’s even a case to call history [his-story], “her-story,” “their-story,” or our-story.” No wonder LGBTQIAA+ youth have a high suicide rate. Here’s a case example.

Al is a 14-year-old, assigned female at birth, but who identifies as a male. He has a pronounced trauma history; his father abandoned him to raise another family and, at 5 years old, his mother left him with his grandmother. He was placed in homeschool in 2017, has been isolated, and voiced suicidal ideation in the initial assessment. Virtually all his social contact has been online chatting with other trans youth.

Early in treatment, Al mentioned wanting a doctor’s note for hormone therapy. Not infrequently, psychotherapists working with trans clients receive requests for documentation that a trans person has diagnosable gender dysphoria that has caused substantial mental health issues such as suicidal ideation, and is “mentally fit” for hormone therapy and to make decisions about their own body. This helps doctors/insurers understand that hormone therapy and gender reassignment surgery can support, instead of hinder, a client’s mental health. Insurers and/or doctors may request them.

Contrary to traditional belief, I considered that it was both ethical and empowering to provide Al with this note sooner rather than later in the therapy. Here’s why.

We are not gate-keepers who decide what clients can do with their bodies. We shouldn’t block Al’s access to resources that a cis-person could access without a therapist’s permission. Best practice for me is that if a client wants a letter, I give them one. If a cis-male came in asking for a letter for their doctor to be on hormones and had limited social support, we would not impose stipulations. A trans person is equal to a cis-person and already has enough challenges to overcome to be who they are and have control over their body.

A therapist’s role is to not stigmatize. For example, if we require Al have 6 sessions before writing a hormone letter, it would be stigmatizing something that has nothing to do with mental illness. It would also be operating outside of the scope of our practice because we wouldn’t be determining if their mental stability is interfering with their identity. It is also not our role to determine if Al is sane to make the hormone decision, even if he’s a minor, without his prefrontal cortex fully developed. After we write the letter, it is the role of the medical doctor to determine if the client is medically able to start hormones and the doctor’s job to monitor the client’s physical body.

Al and I agreed that he is likely avoiding social situations because of the chronic mis-gendering he endured, and the invisibility of his identity navigating the world as a trans-person who is not presenting nor is perceived the way he desires. Hormones may be the catalyst that would help Al to make friends once he starts feeling comfortable in his own skin. Isolated, experiencing oppression, lack of control, depressive symptoms and desiring hormones (probably to look a certain way)—not accessing hormones could likely increase depression symptoms and suicidal ideation. After writing the letter, I provided Al with ample resources to connect with other trans-youth.

My role was to support Al where he was at, not dictate where he should be. Since Al was able to make decisions, there was no reason to limit when he started hormones.

I cannot emphasize enough Dr. Martin Luther King’s timeless notion that “our lives begin to end the day we become silent about things that matter.”

* I consulted on this case with Van Ethan Levy, Associate Marriage and Family Therapist, Associate Professional Counselor, and member of the community, who uses the pronouns Van/they.

File under: The Art of Psychotherapy, Child & Adolescent Therapy