It’s an understatement to say that transgender and nonbinary people need access to therapy. Because of the widespread oppression they face — including experiencing higher risk of harassment, violence, homelessness, as well as their need to navigate discriminatory healthcare systems to access gender-affirming care — trans people experience mental illness at significantly higher rates than the general population. According to a 2019 report published by the Centre for Suicide Prevention, trans folks are twice as likely to think about and attempt suicide than their LGB counterparts.
Many trans and nonbinary folks aren’t able to pursue therapy in the first place, due to barriers like cost, location, insurance coverage, and stigma, among others. But many of those who do have access find it difficult to come by providers who can treat them with skill and compassion, due in part to a lack of trans-related training and education for therapists. “Schools offer minimal training on gay and lesbian issues and generally none whatsoever on trans issues,” Laura A. Jacobs, a genderqueer psychotherapist and member of the Manhattan Alternative Wellness Collective, writes to them. “Anyone can post ‘I work with trans people’ on their website.”
In order to tackle these barriers, therapists who are trans-inclusive and trans or nonbinary themselves have begun to create their own resources to make themselves more easily identifiable. In the past few years, nationwide networks including MyTransHealth and the National Queer and Trans Therapists of Color Network have sprung up. In addition, providers on Psychology Today are able to specifically note that they’re “trans-allied” to indicate their experience with trans issues. Jacobs confirms that there are some options for nonbinary clients in “more metropolitan and progressive areas,” but “[trans] communities still need so much more than is available.”
I talked with seven trans and nonbinary people to hear about their personal experiences and specific obstacles when trying to obtain sufficient mental healthcare. The overwhelming majority expressed that they’ve felt alienated from their providers, even if these professionals claim that they're able to deal with “LGBTQ+ issues.” Many say that they’ve been misgendered, invalidated, and discouraged from transitioning medically. Others say that they’ve had educate their own providers on certain nuances and terminology related to gender identity. And some of them speak to the added complication of needing a therapist who can also help them with issues related to race and trauma. Here are their experiences, in their own words.
Leah (she/her), 25, New York
I saw a therapist for around four years. I chose her in part because her website explicitly listed LGBTQ+ issues and gender identity as areas of specialization. At first, she was really supportive when I talked about playing with my gender presentation. But when we started engaging with the possibility that my gender itself was at stake, she was a lot less affirming. The first time I seriously brought up pursuing transition, she tried to redirect the discussion. She told me that I should be cautious about transitioning because trans people have a higher risk of suicide. During my time seeing her, I was coming to terms with surviving domestic violence, and I think she thought my desire to transition came out of that experience, while I see it the other way — that I was a target for that abuse because of the ambivalence I felt towards my body and my gender. Eventually, I stopped talking to her about transition or gender identity entirely. I made all of those decisions on coming out, starting electrolysis, and taking hormones independently of her. When I started transitioning medically, I stopped seeing her.
The whole experience really soured me on therapy overall; I feel a lot less willing to take a chance on new providers if they're cisgender, even if they say that they are skilled with gender identity-related issues. Most providers are cis, so it really limits my options, and that's even before factoring who's in-network vs. out-of-network and what's going to happen when I go off my family's insurance next year. It's frustrating because transitioning can be very hard, and I don't feel like I really have a space to process these experiences in any sort of depth.
Leo (he/him), 21, San Francisco and New York
When I was 17, I got a therapist in secret. I was about to start testosterone and get surgery. I tried to find the best in-network [provider], because I have private insurance. I ended up with a woman who's also queer and shares the same faith as I do; I'm Black and Jewish. My therapist was validating and supportive, but she wasn’t trans. It would be cool to have a trans therapist of color, and she's also not of color. I have a friend who’s transmasculine and has a therapist who's transmasc just like him, but that guy's white. It works for my friend because he's white. But for me, I wouldn't feel comfortable meeting with a white man, regardless of him being trans or not. There's not a lot of queer trans people in the [mental heath] field or they’re just getting into the field because they're very young. They're limited in terms of giving back to their specific communities.
Helen (they/them), 24, Philadelphia
I found a therapist [who was a cis woman] who said she was specifically LGBTQ+ inclusive. I never felt invalidated by her. She did help me figure out how to come out to my parents. But it was just a little weird and frustrating, because even though she labeled herself as inclusive and accepting, it didn’t necessarily mean that she was trained to deal with trans or non binary people. Even though I came out [as nonbinary] to her and she was totally accepting, she would still misgender me. She would say, "Please call me out on it. I'm forgetting. I totally don't mean to." I get that. But for me as a therapy patient, it was a little bit weird to have to be on top of my therapist. It was more labor to do — labor that I already have to do and am often scared to do.
Emma (she/her), 43, San Francisco
I just finished up 4 years of therapy related to my coming out and transitioning relatively later in life. When I initially came out, I looked up the nearest counselors who listed themselves as LGBT-friendly and called like a dozen of them. My minimum criteria was that they had to have had experience with at least one trans patient, and when pressed, most admitted they had none whatsoever and also that they had not received any "continuing education" that would make them in any way qualified other than that they treated cis queers. I settled for seeing a cis gay man who said he'd treated "a couple" of trans patients. The first (and only) session with him was a total disaster. He talked about cis gay drag performers and he freaked me out by using the word "trannies" when talking about my people. When I left his office, I had an epiphany: There was nothing wrong with me. There was something wrong with the world. Being trans wasn't going to be my problem, other people were going to be my problem. At once I felt pride and dread.
I resolved to find a trans person to be my therapist, and I found her. She helped me to free myself from a lifetime of internalized homophobia and transphobia, helped free me from shame-driven self-destructive behavior. She shepherded me through all the emotional turmoil of second puberty, dysphoria, and figuring out the right antidepressants. None of my previous cis therapists can compare because being trans is so far outside of their life experiences that they can't truly understand or empathize with us.
EJ (they/them), 21, Berkeley
My overall experience with therapists when I was a teen was pretty bad. I think my age invalidated what I was expressing to some professionals. I had one therapist incorrectly diagnose me at the age of 15 with bipolar, with no second opinions, after I told her that I felt like I didn't fit in with either genders. She told me and my family that I needed to be heavily medicated. Luckily, my parents didn’t think it sounded right either and brought me to a couple of psychiatrists.
I found my current therapist as I was looking for a Dialectic Behavior Therapy group. When I had a phone call with my therapist before meeting her and she asked for my pronouns, it instantly helped me feel more open to her. DBT is the most effective and queer friendly form of therapy I have ever experienced, but every session costs about $150-250 every week. It is often way too expensive to do unless you have the resources to do so. I did not for a while, but within the last 6 months I have. It’s been a completely different world.
Michelle (she/her), 43, Calgary
Overall, the counselors in Canada that are trans-friendly are good, but few in number. The issue I have found is that [transitioning] is still a personal decision that shouldn’t require so much intervention. If I want to start HRT, which is a huge decision to begin with, counselors represent another hurdle where my fate is in the hands of whether a counsellor believes I am trans. (Canada has almost a two-tier health care system where you can get anything for free if you wait 2 years or just pay and go right away.) Counselors run $200-250 an hour. Should I really have to pay thousands of dollars to have them say no, because of what they feel? It should be about what I feel! I question a society where the individual can no longer make a decision that only impacts themselves and have to defer to a psychologist for a decision on how I or anyone else should live my life.
Lu (they/them), 23, Brooklyn
By the second session [with my older white woman therapist], I noticed that like she would really try to get me to talk about transitioning, and put it above what I needed to urgently address that day. She started saying things about how younger generations are there to teach her. She was like, “I'm always learning.” But there's obviously the problem of knowing that trans people have existed forever and it's not a new phenomenon. You can use the internet. You can go out into the world and you can learn on your own. [She once tried to push me to talk about HRT], and it felt really strange and scary and like she was treating me as an object of study. I was like, "I'm going to hand you money at the end of this?"
If you or someone you know is going through a crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or contact the Trans Lifeline by calling 877-565-8860.
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