The process of gender transitioning is life-changing, and it is also a unique experience for each person who makes the decision to do so. Some individuals may only change their name, some may explore different options for gender expression to determine what feels right for them, and others may choose to pursue medical or surgical interventions. For many transgender/gender expansive folx, counselors may provide the only safe space to share their thoughts and feelings and feel validated.

We recently spoke with Angela Brooks-Livingston, MA, NCC, LCMHCS, LCAS, CCS, who works with adolescents, adults, and couples who identify as LGBTQIA+, about special considerations for counseling clients who are transitioning and how to support their personal journeys. Brooks-Livingston has clients who identify as gender expansive, some who are interested or working toward transitioning, and some who do not have that as a goal. Understanding is key to making a connection, they say.

“Not all clients who identify as transgender or gender expansive want to pursue medical transition. Transition is an individual journey for each client and the role of the counselor is to support the client on that journey, never to tell the client how they have to do it or need to do it. Some clients will start with changing pronouns and/or name, some may socially transition, and some may start to present more in the gender that fits for them. Some clients will start with a physical intervention that helps them feel more comfortable in their body. This can be hormone therapy or a particular surgery, such as a bilateral mastectomy. The important thing to remember is that it is the client’s decision.”

As individuals explore their options during transition, counselors can help by providing a nonjudgmental, safe space; validating these clients; and expanding their knowledge, Brooks-Livingston says.

“It is imperative for the counselor to educate themselves on sex, gender, affectional orientation, relationships, and the intersection of all these identities in order to help the client work through the bias ingested from the macro system about the preferred gender binary, and people needing to be on one side of the binary or the other.”

Transgender clients face many distinctive challenges, she continues.

“Something unique I see when working with transgender/gender expansive clients is assisting them in coming to their own ideas regarding their own gender expression. At the beginning of their transition journey, some transgender clients progress from one side of the gender binary to the other. Once they are confident and solid in their own expression, they begin to step away from that binary thinking and find their authentic gender expression. For example, some transgender women I’ve worked with, when they were at the beginning of their journey, felt they were not valid in their female identity if they did not uphold the ideals of femininity. They want to express their gender as ultrafeminine and avoid anything masculine. After some time, they come to the realization that they can define femininity and womanhood for themselves, outside of what society says is feminine or woman.

“While working with clients, I challenge the binary thinking and process how the client wants to express their gender outside the binary. I normalize the need to be safe in the current societal climate. At times, this means clients conform to the gender binary. This can bring up thoughts of doubt, sadness, and invalidation. I offer unconditional positive regard and encouragement to clients about how living safe is still living authentically.”

The difficulties and fears that transgender clients experience can have a profound effect on their mental health and well-being.

“This challenge of confidence in their own, authentic gender expression seems to exacerbate their symptoms,” Brooks-Livingston says. “Depression or anxiety can increase when clients do not feel solid in their identity, along with not feeling safe in the world. When clients are exploring gender identity and expression and coming to their own understanding around it, being in this world is extremely scary and unsafe. I find myself holding space for the powerlessness of fear and the excitement of authenticity.”

They encourage counselors to keep an open mind and to examine and question their own gender identity and expression.

“Think about why you identify the way you do, is it authentic for you? Are there elements of your gender identity and expression that don’t feel authentic? Educate yourself on gender identity and expression, the gender binary, and the difference between sex and gender,” she says. “Be open to this education reshaping how you identify your own gender. This personal education can then inform the counselor as they work with clients in the gender expansive community. Explore with the client their ideas and validate the experiences.”

Counselors should bear the following in mind when working with clients at different levels of transition:

• Internal: “Validate the client’s own experience and do not push the client to a particular identity. It is up to the client to find their authentic path. Counselors are there as a traveler on that journey, not a leader.”
• Social: “Safety! Talk about how the client can remain safe as they start this transition. Help the client identify their support network. Talk about boundaries around not respecting a name change or pronoun change.”
• Legal: Counselors must recognize that there are legal components to transitioning that clients may need to consider, such as legally changing one’s name. There are some resources that can help.
• Physical (medical and non-medical): “It is important to talk through bodily changes with clients, whether it is hormones or types of surgery,” they continue. “Sometimes clients can have unrealistic expectations of what hormones can or will do to the body. Counselors can use the World Professional Association for Transgender Health (WPATH) Standards of Care to help with this. The standards have information that speaks to hormone therapy and changes the client can expect. Any surgery is a change for the body and can cause deep feelings for clients. It is best practice to have a follow-up session to discuss the results with the client, along with any grief that may come up about the physical changes.”

Understanding the daily social challenges of transgender and gender expansive clients, including safety risks, is essential. Trauma is common.

“Situations that cisgender people take for granted can be anxiety provoking and crippling for transgender people, such as using a public restroom, being asked to present your government-issued identification, filling out a job application, and meeting new people,” Brooks-Livingston says. “Some transgender people will avoid these situations because of the fear of not being safe. This is a part of the trauma of oppression, and clients need the safety of the counseling relationship to process the intense feelings that accompany this trauma. This constant exposure to trauma of oppression affects physical health and mental health. Counselors can work with clients from a trauma perspective, work on mindfulness skills and ways to practice soul-care to combat the effects.

“Clients have several identities, and some of these can be part of additional marginalized groups such as race, religion/spirituality, ability, socioeconomic status, etc.,” she continues. “Systemic discrimination exists in many places, and transgender/gender expansive folx experience these systemic barriers from many angles.”

Counselors can take several actions to create a safe and welcoming space and help these clients feel more at ease.

“In a physical space, have flags, stickers, or pictures in your office that represent the community,” they suggest. “In a virtual space, have your pronouns listed next to your name, and ask for the client’s name and pronouns they want to be called. Be aware of your intake documentation; do not use checkboxes for identification terms. Leave a blank space for the client to write it in. If you have a website, list resources for the community and links to local resources, podcasts, and books that are helpful for clients and families.” 

In addition to being familiar with the WPATH Standards of Care, Brooks-Livingston recommends that counselors working with transgender and gender expansive clients seek specific trainings.

“The National Board for Certified Counselors is a good place to look for trainings by competent trainers and continuing education credit. I also offer trainings, as well as consultation and supervision.”

They also recommend the following resources:

• Folx Health
• Campaign for Southern Equality
• OutCare
• Society for Sexual, Affectional, Intersex, and Gender Expansive Identities (SAIGE) Competencies
• The Gender Quest Workbook: A Guide for Teens and Young Adults Exploring Gender Identity, by Rylan J. Testa, PhD

Angela Brooks-Livingston, MA, NCC, LCMHCS, LCAS, CCS, works with clients who identify as part of the LGBTQ+ community. They earned their master’s degree in clinical mental health counseling from Appalachian State University, where she also received certificates in addictions counseling and expressive arts therapy.