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Journal of Homosexuality
ISSN: 0091-8369 (Print) 1540-3602 (Online) Journal homepage: https://www.tandfonline.com/loi/wjhm20
A Trauma-Informed Exploration of the Mental
Health and Community Support Experiences of
Transgender and Gender-Expansive Adults
Seventy F. Hall & Maur J. DeLaney
To cite this article: Seventy F. Hall & Maur J. DeLaney (2019): A Trauma-Informed Exploration
of the Mental Health and Community Support Experiences of Transgender and Gender-Expansive
Adults, Journal of Homosexuality, DOI: 10.1080/00918369.2019.1696104
To link to this article: https://doi.org/10.1080/00918369.2019.1696104
Published online: 04 Dec 2019.
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A Trauma-Informed Exploration of the Mental Health and
Community Support Experiences of Transgender and
Gender-Expansive Adults
Seventy F. Hall, BS and Maur J. DeLaney, MSW
Department of Social Work, University at Buffalo, Buffalo, New York, USA
ABSTRACT
This study applied a trauma-informed care (TIC) framework to
explore transgender and gender-expansive (TGE) adults’
experiences with mental health and community supports.
Data were drawn from the qualitative component of a more
extensive mixed-methods study that aimed to assess TGE indi-
viduals’support needs. Participants (N= 100) were recruited
from online support groups using a combination of conveni-
ence and snowball sampling and invited to take an online
survey. Open-response questions asked participants to
describe their most positive experiences with a mental health
provider and provide recommendations for improving the
supportiveness of the communities to which they belonged.
Participants’responses were coded and sorted into five over-
arching themes: (a) trust and emotional safety, (b) environ-
mental and physical safety, (c) choice and collaboration, (d)
empowerment, and (e) cultural and gender issues. Finally, we
discussed implications for improving practice and further
developing a TIC model that meets the needs of this
population.
KEYWORDS
Transgender; gender-
expansive; trauma-informed
care; LGBTQ; community
supports; counseling; mental
health
Transgender and gender-expansive (TGE) individuals make up a fraction of
the total US adult population (0.6%) (Flores, Herman, Gates, & Brown,
2016), but suffer high rates of exposure to adverse experiences, such as
physical and sexual assault, discrimination, homelessness, and financial strain
(Factor & Rothblum, 2007; Grant et al., 2011; James et al., 2016). In the
United States, transphobia—a form of oppression characterized by intoler-
ance toward TGE individuals—is an urgent public health concern. Studies
have linked gender identity-based violence and discrimination to sexual risk
behaviors, HIV infection, attempted suicide, substance misuse, economic
insecurity, housing instability, lower educational attainment, and higher
rates of incarceration (Grant et al., 2011; Miller & Grollman, 2015; Testa
et al., 2012). TGE adults also face elevated rates of posttraumatic stress
(Reisner et al., 2016) and disparities in trauma exposure that place them at
CONTACT Seventy F. Hall sfhall@buffalo.edu Department of Social Work, University at Buffalo, Buffalo, NY
14260, USA.
JOURNAL OF HOMOSEXUALITY
https://doi.org/10.1080/00918369.2019.1696104
© 2019 Taylor & Francis Group, LLC
a disadvantage relative to their non-TGE counterparts (Factor & Rothblum,
2007; Scheer, 2017). Given that traumatic experiences are often related to
gender identity (Testa et al., 2012), feedback from TGE individuals about
how to address gender identity concerns in a trauma-informed manner is
needed. Applications of TIC are absent from the body of literature that
speaks to these issues as they relate to mental health care.
TGE adults’perspectives on the dynamics that strengthen community
support systems also remain largely unexamined. Knowledge about trauma-
informed care (TIC) at the community level could aid service providers and
advocates in their efforts to ameliorate social isolation and community
detachment, both of which have been identified as issues that TGE indivi-
duals face (Levitt & Ippolito, 2014; Metthe, 2016), perhaps as a consequence
of their daily exposure to dehumanizing conditions. For example, a TGE
individual who has problems using gender-segregated restrooms or who
suffers relentless misgendering everywhere they go might avoid leaving the
house altogether to minimize physical discomfort and instances of identity
abuse (Woulfe & Goodman, 2018). In sum, the inclusion of TGE voices in
the academic literature is crucial to prioritize individual agency, self-
identification, and trauma-informed practices within systems of care. This
article aims to fill gaps in the literature by utilizing a TIC approach to explore
TGE adults’perspectives on mental health and community supports.
Background
A note on terminology
First, our decision to use TGE as an umbrella term for a wide range of
identities warrants a discussion on terminology. Throughout this article, we
use the term gender-expansive (GE) to describe anyone whose gender identity,
or inner sense of gender, differs from their assigned sex at birth and
transgender for anyone who is both GE and has taken steps socially, hor-
monally, surgically, and/or legally to more authentically align with their
gender identity (Menvielle & Rodnan, 2011; Norwood, 2012). We use the
word cisgender when referring to individuals whose gender identities match
their assigned sexes at birth. It is important to note that although members of
our local community have embraced the terms we have chosen, discursive
practices around gender identity and expression are continually evolving and
can vary according to sociocultural context.
Conceptual framework
TIC is an organizational philosophy that incorporates an understanding of
the impact of trauma on individuals, families, and communities to design
2S.F.HALLANDM.J.DELANEY
support services that account for these influences (Harris & Fallot, 2001). We
have drawn principles from two separate TIC models to frame our analysis—
that of Fallot and Harris (2011) and that of the Substance Abuse and Mental
Health Services Administration [SAMHSA] (2014). The resulting framework
combines six principles from these two approaches: safety; trustworthiness;
collaboration; choice; empowerment (Fallot & Harris, 2011); and attention to
cultural, historical, and gender issues (SAMHSA, 2014).
The first principle, safety, consists of both physical safety (e.g., adequate
lighting, locks on bathroom doors), and emotional safety (e.g., healthy
boundaries, identity-affirming language) (The Trauma Informed Care
Project, n.d.). The second principle, trustworthiness (e.g., transparency, con-
sistency, predictability) is considered fundamental to resolving barriers to
human connectedness caused by relational trauma, while the third principle,
collaboration, promotes relational healing by offsetting power imbalances
that resemble abuse dynamics (Harris & Fallot, 2001). The fourth principle,
choice, allows trauma survivors to reclaim a sense of control over their
environments (Harris & Fallot, 2001) and the fifth principle, empowerment,
provides individuals with tools that help them transcend obstacles to success.
The final principle—attention to cultural, historical, and gender issues—
appreciates diversity in experiences and accounts for the interlocking systems
of power, privilege, and oppression that shape them (Richmond, Burnes, &
Carroll, 2012; SAMHSA, 2014).
In sum, TIC honors the individual’s autonomy, encourages active and
equal participation in community life and mental health care, validates the
individual’s experiences, and serves to challenge and eliminate threats to
safety and structural inequities inside and outside of the immediate context
(Austin & Craig, 2015; dickey, Singh, & Walinsky, 2017; McIntyre, Daley,
Rutherford, & Ross, 2011). Such approaches are vital to making communities
trauma-informed for TGE adults, who may have encountered intolerance
and harassment related to their gender identities throughout their lives
(Graham, 2014).
Literature review
Despite the proliferation of articles written about trans-affirmative mental
health care (Austin & Craig, 2015;Burnesetal.,2010;dickeyetal.,2017;
Heck,Croot,&Robohm,2015;Mascis,2011;Mizock&Lewis,2008;
Richmond et al., 2012;Singh&dickey,2016), few qualitative studies have
been conducted on TGE adults’experiences with counselors in the United
States (Benson, 2013; Bess & Stabb, 2009; Elder, 2016; McCullough et al.,
2017). This underappreciation for TGE clients’voices is troubling, as it
seems to undermine the authority they should have over defining their
own needs and experiences. Furthermore, TGE adults’perceptions of safety,
JOURNAL OF HOMOSEXUALITY 3
trust, collaboration, choice, and empowerment are shaped by the degree to
which their counselors include their input in treatment planning and
encourage them to advocate for themselves (Elder, 2016; McCullough
et al., 2017). In other words, clients favor therapists who act with, rather
than for, them. Although the literature on community support services is
also limited, consistently high levels of satisfaction with peer support net-
works (Levitt & Ippolito, 2014;Metthe,2016; Salisbury & Dentato, 2015)
demonstrate the salience of supportive communities in the lives of TGE
individuals. In Levitt and Ippolito’s(2014) study, for example, trans indivi-
duals valued having access to supportive spaces where they could explore
gender expression.
Though less relevant, studies on health care experiences might provide
insight into power dynamics that emerge in mental health settings, as well.
For instance, in Poteat, German, and Kerrigan's (2013) study, relationships
between medical professionals and trans patients were often characterized by
mutual uncertainty whereby doctors felt ill-prepared to work with their
patients and patients doubted the competence of their providers. Some
doctors downplayed their patients’judgment and expertise to regain
a sense of power and control; one doctor even accused her patient of reading
too many articles on the Internet because she felt uncomfortable with the
patient’s use of unfamiliar medical terminology (Poteat et al., 2013). Also,
according to Nordmarken and Kelly’s(2014) ethnography, which examined
TGE patients’interactions with health care providers, many doctors still
relied on earlier versions of The World Professional Association for
Transgender Health's (2011)Standards of Care for the Health of
Transsexual, Transgender, and Gender Nonconforming People (SOC).
Specifically, participants spoke of providers who, in their attempts to follow
the SOC, refused to prescribe hormone replacement therapy without docu-
mentation from a psychiatrist verifying the patient’s gender identity
(Nordmarken & Kelly, 2014). Many consider this practice to be antiquated
because it strips patients of their rights to self-identify (Nordmarken & Kelly,
2014). Such power dynamics do not only serve to minimize choice, colla-
boration, empowerment, trust, and safety in medical settings; they may also
inform TGE clients’attitudes toward systems of care as a whole, especially
toward mental health providers, who have historically served as gate-keepers
to gender-affirming medical interventions (Mizock & Lewis, 2008).
The present study
The present study sought to explore community support needs and positive
beliefs about mental health providers among a sample of TGE adults, most of
whom resided in Western NY at the time of study enrollment. The purpose
of this research was to identify trauma-sensitive strategies to enhance
4S.F.HALLANDM.J.DELANEY
supports for TGE adults. To achieve this aim, we asked the following
research questions:
(a) How do TGE individuals describe their most positive experiences with
mental health counselors?
(b) What do TGE adults need from their support systems to feel more
connected to their communities?
(c) How do TGE individuals’ideal counseling experiences and community
support needs reflect the principles of TIC?
This study fills a substantial gap in the literature by being the first to apply
a TIC perspective to a qualitative analysis of TGE adults’experiences with
mental health and community supports. Our analysis will lay a foundation
for centering the needs of TGE individuals within the systems of care that
serve them.
Methods
Participants
Data for this study were drawn from a cross-sectional, mixed-methods
research project that used an electronic survey to assess the mental health
and community support needs of TGE adults. The current study is an
analysis of only the qualitative portion of this project. Due to the importance
of virtual communities in the lives of TGE individuals (Metthe, 2016), we
recruited participants (N=100) from online support groups using a combi-
nation of convenience and snowball sampling. Participants were eligible to
take part in the study if they were TGE, able to read and write in English, and
indicated that they were at least 18 years of age. The ages of the participants
were not collected. The sample was predominantly White (82.0%), had
completed at least some college (88.0%), and most were NY residents
(79.0%). Self-reported gender identities fit within five categories: trans men
(30.0%), trans women (22.0%), genderqueer (25.0%), non-binary (17.0%),
and other (6.0%). We used an open-response item to collect information on
participants’gender identities. Participants’responses were coded as “non-
binary,”“genderqueer,”“trans man,”or “trans woman”if they used those
words to describe their identities. We also included those who self-identified
as “transmasculine”or “transfeminine”as “trans men”or “trans women,”
respectively, unless they included the words “non-binary”or “genderqueer”
in their responses. All other responses were coded as “other.”
To clarify, trans men and transmasculine individuals are people who were
assigned female or intersex at birth who identify as men or see themselves as
masculine-of-center. Trans women and transfeminine individuals are people
JOURNAL OF HOMOSEXUALITY 5
who were assigned male or intersex at birth who identify as women or see
themselves as feminine-of-center. Individuals who consider themselves non-
binary or genderqueer are those who do not feel adequately represented by
society’s binary gender system.
Procedures
Between March and August 2017, the research team posted study announce-
ments to 11 Facebook TGE support groups, nine of which served the
Western NY population. Of the remaining groups, one was based in
Central NY, and the other included members living anywhere in the
United States. The study announcement contained the survey link, details
about the study, and instructions for sharing the link with peers who might
be interested in participating. The survey was administered via Survey
Monkey and was approximately 15 minutes in length. Before joining the
study, participants reviewed a verbal consent form embedded within the
survey. We did not collect participants’identifying information because we
wanted to maintain their confidentiality due to the small size of the local
TGE community and the second author’s affiliation with one of the support
groups. Instead of signing the form, respondents clicked a button acknowl-
edging their consent to participate. After submitting their survey responses,
participants were redirected to a page that contained instructions for sharing
the survey link with other potential participants. The institutional review
board at the research team’s university approved this study.
Measures
The full survey consisted of sociodemographic questions, previously vali-
dated instruments, and two open-response items that prompted participants
to type narratives about their experiences. In constructing the open-response
questions, we intentionally used strengths-based language given that deficit-
oriented research can perpetuate stigma attached to marginalized commu-
nities (Metthe, 2016). Due to the considerable number of responses to the
qualitative portion, these items became the sole focus of this analysis. The
survey utilized the following open-ended questions asking participants to
offer recommendations for improving community spaces and to describe
their most productive interactions with mental health counselors:
(1) Think about the communities to which you belong. What qualities
would make these communities more supportive of you in the future?
(2) Think about the best experience you have had during a mental health
appointment. What made this experience positive for you?
6S.F.HALLANDM.J.DELANEY
It should be noted that we did not rely on an operational definition of
community, nor did we explicitly define this word for the participants who
took our survey. The Discussion section expounds upon the potential limita-
tions of this methodological decision.
Data analysis
One researcher, the first author, conducted all analyses using ATLAS.ti and
Microsoft Excel and met with the second author throughout the project to
discuss findings. During the initial stage of the analysis, which consisted of
several rounds of open coding, we realized that our codes were compatible
with the principles of TIC and decided to integrate this framework into the
analysis. Next, the first author searched for cases that did not fit with the
chosen theoretical lens to determine whether additional concepts needed to
be added to the framework and found that the TIC principles seemed to
sufficiently account for the range of topics that emerged in participants’
responses. The third stage of coding involved sorting codes into categories
based on their similarities (Ryan & Bernard, 2003), identifying the principle
of TIC that best represented each category, and linking the resulting code-
subcode pairs (Saldaña, 2016) to quotations. Afterward, a list of the most
frequently used codes was constructed, and ATLAS.ti’s code co-occurrence
tree explorer was used to identify codes that frequently co-occurred with
those on the list. This procedure helped the first author develop themes based
on groupings of co-occurring codes.
It is important to note that our experiences as trans scholars and the fact
that only one researcher was responsible for analyzing the data may have
introduced bias into our analysis. Therefore, we used member checking as
a measure of accountability and a means of improving the trustworthiness of
our findings. This process involved sharing the manuscript with TGE mem-
bers of an online community and asking them to provide feedback on our
interpretations of participants’quotes based on their experiences. The first
author posted advertisements on three online chat rooms for TGE indivi-
duals that invited volunteers to review the manuscript and make suggestions
for revision. Although many individuals with whom we consulted did pro-
vide recommendations that we incorporated into our manuscript, none of
these revisions concerned the content of the findings section, as everyone
who participated in member checking agreed with how we interpreted
participants’quotes.
Findings
Data analysis yielded five themes that extended across participants: (a)
emotional trust and safety, (b) environmental and physical safety, (c) choice
JOURNAL OF HOMOSEXUALITY 7
and collaboration, (d) empowerment, and (e) cultural and gender issues.
Although we also identified subthemes, their interrelatedness posed chal-
lenges to parsing them out and addressing them separately. Doing so would
have detracted from the conceptual coherence of each section. Instead, we
decided to provide holistic accounts of each theme in the sections
below. Second, it is worth noting that even though most participants
(n=70) answered both questions, not all of the individuals who participated
in our study did. Of the remaining 30 participants, 16 answered question 1
only, and 14 only answered question 2. While analyzing the data, we did not
find any meaningful thematic differences based on which questions the
participants chose to answer. Third, because this study required participants
to enter their responses online, some of the quotations included errors in
spelling, punctuation, and grammar. We have corrected some of these errors
to enhance the readability of our findings. Finally, we used the singular
pronouns they, them, and their to refer to participants, as our survey did
not request that they list their gender pronouns.
Emotional trust and safety
Overall, participants viewed trust and emotional safety as crucial to building
successful therapeutic alliances with their counselors and improving the
supportiveness of their communities. In both cases, participants wanted to
feel safe to express themselves freely in settings that validated their identities.
One participant claimed that the consistency with which their counselor
responded to their concerns reassured them that they could rely upon the
predictability of the therapeutic process: “My counselor …does not display
any judgment. I can expect everything I say to have the same response, and this
helps me not judge myself.”This response demonstrates that the trustworthi-
ness and reliability of the counselor can serve other functions, as well.
Specifically, counselors can help their clients eliminate self-criticism from
their internal dialogs by acting as neutral sounding boards for their clients’
thoughts and feelings.
The above themes extended to community settings, particularly LGBTQ+
spaces, where participants frequently faced rejection from members of their
own communities. Many participants outlined suggestions for remedying
this problem. For instance, one participant listed the following recommenda-
tions for improving the supportiveness of TGE community spaces:
[I recommend] avoiding unnecessary discussion of surgeries …[and] acceptance of
my stated identity without having to prove my gender identity …I get misgendered
less in non-LGBT settings because these people do not have any entitlement regard-
ing what they should get to know about me.
8S.F.HALLANDM.J.DELANEY
The distress caused by this lack of validation and acceptance from others
within the TGE community was reflected by the staggering number of
participants who reported experiences of within-group gender policing.
Many TGE individuals felt pressured to express their gender identities
according to the restrictive expectations of their peers. Those who defied
these norms risked feeling as though they were “not trans enough.”One
participant’s response summarized this phenomenon perfectly:
There are people in trans communities that do make assumptions about identities
based on choices made around transition …As a person who has chosen to do some
amount of medical transition, I find quite a few people who assume I must identify
as a man/male because of that choice …Many who would say they identify outside
the binary believe they don’t do this, but they do. I am not sure how to boil that
down to a quality other than have a high tolerance of ambiguity.
TGE individuals rely on external validation from providers to receive appro-
priate care. Early guidelines for medical practitioners obliged individuals
seeking hormone replacement therapy and surgical interventions to conform
strictly to a performative gender binary. Trans women and trans men,
respectively, were required to dress and behave in stereotypically feminine
and masculine manners. TGE individuals who failed to meet these stringent
expectations were denied these treatment options. As exemplified by the
above quote, these binary gender assumptions about masculinity and femi-
ninity can be internalized by people, including TGE individuals, who may try
to impose those standards onto others.
In their responses to the question about mental health services, several
participants endorsed a preference for working with members of the LGBTQ
+ community, whom they felt had a higher capacity to empathize with their
“concerns and fears.”In other words, participants perceived LGBTQ+ provi-
ders as more trustworthy:
My counselor is [a] happily married lesbian and has experience with …the
T community. I’ve been in and out of counseling and hospitals since I was 13. I’m
now 33 …with a person I can fully trust …and feel no need to hide sides of myself
from her.
Thus, participants were more willing to express themselves freely when the
people with whom they interacted understood their experiences and vali-
dated the challenges they faced. Acceptance and validation were especially
crucial to participants’healing processes in the aftermath of traumatic events.
One participant, who attended a trauma therapy group, illustrated this need
for acceptance and safety by stating, “[my] therapist listened …without trying
to question the validity of my feelings …She had a dog, which was helpful
when I had to recount the things that happened to me. It made me feel safer.”
Unfortunately, the positive experiences described above stood in stark
contrast to many of the participants’previous encounters with providers
JOURNAL OF HOMOSEXUALITY 9
and community supports. In comparing the acceptance and validation they
received from their current provider against the dismissive behavior of other
professionals with whom they had interacted, one respondent said,
I was expressing my frustration …dealing with an almost hostile environment [at
my university]. It felt good to finally have an adult medical professional agree that
I was experiencing a validly distressing situation after dealing with so many doctors
belittling and dismissing me.
Positive experiences stood out to respondents because they were the excep-
tion rather than the norm. This participant, along with others, associated
systems of care with invalidating, discriminatory, and even hostile behavior
from professionals. One participant said,
There aren’t many therapists who help LGBT people and mental hospital staffs don’t
give a care. I legit told them once while in hospital I wanted to kill myself while I was
there and nobody said anything or did anything.
Another participant contributed the following:
Being a therapist myself has recognized the lack of knowledge within providers and
oversight on providers who state they are trans educated/competent. I know a few
clinics near me who have refused care for individuals who are trans.
To receive necessary health and mental health services, participants often
felt the need to protect themselves against challenges, ranging from micro-
aggressions and gate-keeping to assaults on their identities. Navigating these
systems of care and other institutions required them to expend energy on
self-preservation that otherwise could have been used caring for their
mental and physical health. They viewed emotional safety and trustworthi-
ness as essential to maximizing the benefits of their interactions with
counselors and support systems.
Environmental and physical safety
In a similar vein, participants reported a need for a fun, easygoing, and non-
threatening atmosphere. “Humor,”“casual conversation[s] where [they] didn’t
feel under pressure,”and contexts in which everyone could be themselves
“without living in fear”helped put participants at ease in both mental health
and community settings. The accessibility of resources, accommodations, and
spaces influenced the degree to which participants perceived their environ-
ments as physically safe. TGE individuals with prior experiences of harassment
in restrooms might feel physically unsafe entering gender-segregated bath-
rooms (Burnes, Dexter, Richmond, Singh, & Cherrington, 2016). Several parti-
cipants, such as the one below, addressed this issue in their survey responses:
10 S.F.HALLANDM.J.DELANEY
When I told [my counselor] about an app called refuge restroom, she carried the
burden of adding the restroom in her building to the app …As trans people, we have
too much to worry about to …add every bathroom we see to an app. She …sent me
a picture of the bathroom and the signs she taped to the wall to make it easier to
find.
By engaging in these practices, this counselor demonstrated an understand-
ing that her TGE clients might feel safer about entering public spaces when
information about the accessibility of accommodations is available ahead of
time. Although many of the accessibility issues cited by participants were
LGBTQ+-related, a few others spoke to unrelated concerns, such as discri-
mination or exclusion based on sobriety, disability, language, race, and other
identity and lifestyle characteristics:
My biggest issue right now is lack of accessibility due to my disabilities, both in
location and times for when events are held. There’s also a lot of alcohol consump-
tion in most communities …I can’t really drink due to medication and being the sole
sober person is a bit awkward.
In sum, physical safety included features of the environment that served to
mitigate perceived threats, as well as actions from counselors and community
members that showed their commitment to making spaces safer for TGE
individuals. Both resources and accommodations themselves, and the ability
to access information about their availability helped TGE participants in our
study feel safer in their communities.
Choice and collaboration
Participants’views of both the therapeutic alliance and community dynamics
matched principles of TIC that promoted collaborative decision-making and
opportunities to assert one’s autonomy and feel heard by others. As in Ali’s
(2014) description of TGE-affirmative therapy, participants’counselors used
client feedback to shape interventions, tuned into the complexities of their
presenting problems, and deferred to clients’expertise on issues pertaining to
their well-being. Relationships that were characterized by equitable interac-
tions served to offset the power differentials between providers and their
clients. Having the power to make important decisions allowed participants
to feel in control of their treatment. For instance, one participant pointed to
their therapist’s use of self-disclosure as a strategy for shifting power imbal-
ances: “she told me she also came from an alcoholic home and it brought her
down to my level. [It] was less of a counselor to patient relationship and more
of a person to person relationship from then on.”
Efforts to dismantle power imbalances were equally important at the
community level, where the voices of some were more likely to be excluded
than others, and systemic inequities had created disparities in access to
JOURNAL OF HOMOSEXUALITY 11
services. For example, one participant noted that they would “like to see trans
women and people of color pushed to the front in terms of services over White
people and trans mascs/men.”This participant’s view contrasted with that of
another participant, who recommended “more acceptance for non-binary
individuals [and] less transmasculine and non-binary people being ignored
and spoken over by transfeminine voices.”Participants felt that inclusivity and
representation of marginalized identities were needed to resolve divisions
within the community. Some expressed feeling alienated from the LGBTQ+
community based on their gender identities, while others focused on the
exclusionary behaviors of other TGE people. In particular, participants cited
“issues with trans spaces only supporting those who fell within the binary or
suggesting genderqueer was just a phase before becoming ‘fully’trans,”and
called for “more non-binary acceptance from the greater trans community.”
Another participant desired “better education about trans and gender non-
conforming in the Latinx community …better linguistic terminology in
Spanish and more language inclusiveness.”These quotes confirmed the need
for greater collaboration among members of participants’communities and
participants’desires to repair fissures caused by racial/ethnic segregation.
Empowerment
Although participants valued self-advocacy, they also appreciated when their
counselors and larger institutions advocated on their behalves. For example,
contrary to the view of providers as gate-keepers (Mizock & Lewis, 2008),
some participants described their counselors as allies who increased their
access to medical interventions and fought for a more TGE-friendly world
overall. In addition to counselors, a few participants identified the education
system, religious groups, and policymakers as crucial to initiating discourse,
abolishing “hate …[and passing] stricter laws on discrimination.”They
viewed constructive dialogue as important to promoting social justice. In
the words of one participant, “folks …who are cisgender seem shocked to
learn that I …[am] trans. I …love to school them and open up that dialogue
so maybe it’s not such a bad thing as long as people are communicating.”
Participants also expressed a need to engage in advocacy work with other
members of the TGE community, and recognized the importance of solidar-
ity, unity, and “breaking down racial segregation so that [their] …community
[would be] …stronger.”
Participants described several other strategies for empowering TGE indi-
viduals, as well. Some felt that processing their emotions with their counse-
lors heightened their self-awareness and contributed to their personal growth
beyond the immediate therapeutic context. Others found that bringing their
loved ones to therapy sessions helped them communicate with them more
effectively. For instance, one participant described a session with their
12 S.F.HALLANDM.J.DELANEY
counselor during which they were able to deconstruct cognitive distortions
that adversely affected their social interactions:
I was like, “none of my friends like me!”and he was like, “don’t your friends want to
spend time with you and tell you they like you?”and I was like “they’re lying!”and
he was like “why would they spend energy lying about that …?”It’s more than just
like, “no you’re wrong, here’s what’s really happening.”It made me realize for myself
that I was wrong.
Other participants recalled coping skills that helped them manage distressing
emotions or TGE-specific resources that their counselors had provided as
transition support. Interestingly, in response to the community supports
question, participants identified these types of resources as vital to enhancing
the supportiveness of their communities. Thus, based on participants’
responses, it seems that mental health providers can play an essential role
in carrying out participants’recommendations.
Cultural and gender issues
Several participants stressed the need to ensure that institutions and mental
health providers were reasonably informed about TGE issues. They preferred
providers who “remained open-minded without imposing their thoughts on
[their clients’genders] and didn’t see [them] as an example out of a text book.”
Most participants who reported positive experiences described instances in
which their counselors appreciated their subjective experiences, whereas
those who spoke negatively of providers described encounters with stereo-
types and discriminatory behavior. One individual, who was unable to
identify any positive experiences with a mental health provider, gave the
following response:
She only wanted to talk about my transition which at the time was not why I was
seeing her. Any time I wanted to talk about something she changed the subject to my
transition like I was some kind of science experiment.
Outside of the therapeutic context, participants faced challenges across
a wide range of institutional settings, including the health care system and
the workplace, where “‘business casual’…sometimes requires women to wear
blouses and feminine shoes.”Another participant said the following about
their experiences with health professionals and society as a whole:
There must be comprehensive sensitivity training in all workplaces and especially in
healthcare professions. I have been misgendered, disrespected, or dismissed by many
health care providers …and have been made to practically beg for care that would
support my transition. All people must be educated on transgender and gender-
expansive experience because it’s a life or death issue.
JOURNAL OF HOMOSEXUALITY 13
Many recommended community education as a tool for expanding public
awareness of TGE issues, especially those that set TGE individuals apart from
the greater LGBTQ+ community.
They hoped that such interventions would encourage society to embrace
gender-expansive language. For example, one participant identified their
counselor’s existing familiarity with non-binary gender identities as positive
“because it contrasted with [a previous counselor] …who had no familiarity
with non-binary identities and indicated that [their] identity was a result of
trauma.”This participant and others appreciated when people asked for and
respected their pronouns. Most participants tried to be understanding of
people who lacked extensive knowledge of gender identity, as long as they
showed a willingness to educate themselves. Overall, however, they preferred
interacting with providers and community members who had at least some
prior experience with the TGE population, as they found the task of educat-
ing people to be exhausting.
Discussion
Implications of findings
This analysis used a TIC framework to conceptualize TGE adults’mental
health and community support needs. Our analysis yielded five themes that
were similar across settings: trust and emotional safety (i.e., acceptance,
validation, freedom of expression); environmental and physical safety (i.e.,
non-threatening atmosphere, accessibility); choice and collaboration (i.e.,
offsetting power imbalances, collaborative decision-making); empowerment
(i.e., advocacy, community building, coping skills); and cultural and gender
issues (i.e., appreciation of subjectivities, community awareness). Given that
these themes were so interrelated, this discussion will address our most
noteworthy findings from a holistic perspective. First, even though we inten-
tionally asked participants to describe positive experiences with their mental
health providers, many juxtaposed these with unpleasant interactions. These
accounts of mistreatment from providers were not surprising; it is estimated
that roughly 25% of trans adults avoid seeking health care due to fears of
discrimination (James et al., 2016). Experiences with mental health profes-
sionals can be traumatizing for TGE clients (Elder, 2016), so establishing
trust can be challenging. As a result, many participants specifically sought
providers who were members of the LGBTQ+ community. However, the
participants in both our study and others found providers who were experi-
enced and knowledgeable, but open-minded and humble, to be safer and
more trustworthy regardless of whether they shared their identities (Benson,
2013; Bess & Stabb, 2009; Elder, 2016).
14 S.F.HALLANDM.J.DELANEY
Another notable finding concerned the preponderance of responses about
within-group gender policing and segregation along racial and gender iden-
tity-based lines, which detracted from safety, trust, collaboration, and
empowerment within community spaces. A large number of participants
claimed that non-binary individuals, in particular, endured a substantial
amount of pressure to conform to the gender binary. Previous research
suggests that this may be a pervasive problem for TGE individuals (Bess &
Stabb, 2009; Davis, 2009; Metthe, 2016). For example, Davis’(2009) field
study showed that trans people often rated one another as “trans enough”
based on their adherence to the gender binary. This finding has significant
implications for how facilitators lead group therapy sessions and support
group meetings. Strategies to combat restrictive gender ideals are crucial in
such contexts due to the disparities in emotional distress that non-binary
individuals have been found to experience relative to binary trans men and
women (James et al., 2016). Support services may help TGE individuals
challenge the internalized transphobia (Ali, 2014; Austin & Craig, 2015)
that contributes to gender policing. Also, although participants of all iden-
tities seemed to share a common goal of supporting gender diversity, off-
setting power imbalances, increasing unity, and participating in advocacy
work, it is important to note that trans clients who participate in frequent
activism may be more susceptible to the adverse impacts of transphobia on
mental health (Breslow et al., 2015). Counselors may need to facilitate skill-
building in this area so that advocacy can serve a stress-reduction function
for TGE clients (Ali, 2014).
Finally, participants viewed accessibility as a critical component of physical
and environmental safety. This finding aligned with the results of the study
by Burnes et al. (2016), in which trans participants identified knowledge of
restroom availability as a protective mechanism against trauma exposure.
Our participants, by contrast, took a more intersectional approach to their
discussions of accessibility, citing the need to accommodate physical disabil-
ities, sobriety, linguistic diversity, and many other dimensions of identity that
posed obstacles to accessibility. Such narratives indicate that allies of TGE
communities should consider the impacts of other concerns that intersect
with and exacerbate gender identity-based oppression.
Several implications specific to the principles of TIC are worth mentioning
here. First, participants recommended mental health care and community
supports that promote gender self-identification and advocacy on the part of
organizations to provide accessible, non-gendered facilities in their buildings.
Such improvements would uphold the safety of TGE individuals. Second,
findings indicated that opportunities to make treatment decisions and build
community amongst one’s peers might foster the principles of choice and
collaboration. Third, concerning empowerment, respondents appreciated
those who advocated with them and on their behalves. They also placed
JOURNAL OF HOMOSEXUALITY 15
value on self-advocacy and community solidarity. Finally, participants per-
ceived education to be a necessary vehicle for expanding cultural awareness
of TGE issues among both providers and the general public. This informa-
tion can be used to develop guidelines for applying TIC to TGE systems of
care and to design studies aimed at empirically testing the use of this frame-
work with the TGE community.
Limitations
Several study limitations are worthy of discussion. First, our use of snow-
ball sampling limited us to a homogenous population of support group
attendees and their peers. Like in the general population, TGE individuals
vary with respect to race, socioeconomic status, ability, age, and several
other sociodemographic markers. The lack of diversity in our sample calls
into question the quality of our recommendations and the cultural sensi-
tivity of our study design. Second, the study’sonlinesurveyformat
precluded us from asking follow-up questions that could have added
texture to our understanding of participants’responses. Third, we failed
to collect data on participants’ages, so our findings may not account for
generational differences that likely informed participants’attitudes toward
contemporary issues, support needs, and gender identity and expression
in general. For instance, older adults in Elder’s(2016) study cited prior
instances of physical, emotional, and sexual abuse in psychiatric institu-
tions during the 1950s. In comparison to their older counterparts, TGE
individuals from younger generations might never have encountered such
hostile conditions.
Finally, we purposefully asked vague questions so as not to impose our
definitions of community onto participants. Our decision to use this
approach resulted in a high degree of diversity in how participants inter-
preted our question about community supports. We lack a thorough under-
standing of why participants chose to mention some aspects of community
and not others. Perhaps they simply assumed that we were asking for the
types of information they gave in their responses. We could have avoided
this problem had we asked participants to provide their own definitions of
community and then prompted them to use these definitions to answer
subsequent questions.
Conclusion
Despite the limitations described above, this article makes a valuable contribu-
tion to the literature on gender identity and expression. Our findings shed light
on support characteristics that reflected the principles of safety, trust, empow-
erment, collaboration, choice, and appreciation of cultural and gender issues as
16 S.F.HALLANDM.J.DELANEY
they applied to TGE-specific concerns. The extent to which participants dis-
cussed negative experiences when asked about positive ones suggests that there
is a need for knowledgeable, TGE-friendly providers. TIC provides a useful
framework for discussing this need. Most importantly, this study was the first
to apply a TIC framework to a qualitative exploration of TGE adults’experi-
ences with mental health and community supports. We hope that this research
lays the groundwork for future efforts to develop a TIC model that can more
effectively address the needs of this vulnerable population.
Disclosure statement
No potential conflict of interest was reported by the authors.
ORCID
Seventy F. Hall http://orcid.org/0000-0001-7266-4496
References
Ali, R. M. C. (2014). A transpositive approach to therapy with transgender clients: An
exploration of therapists’subjective experiences (Master’s thesis). Retrieved from http://ir.
lib.uwo.ca/etd/
Austin, A., & Craig, S. L. (2015). Transgender affirmative cognitive behavioral therapy:
Clinical considerations and applications. Professional Psychology: Research and Practice,
46(1), 21–29. doi:10.1037/a0038642
Benson, K. E. (2013). Seeking support: Transgender client experiences with mental health
services. Journal of Feminist Family Therapy,25(1), 17–40. doi:10.1080/
08952833.2013.755081
Bess, J. A., & Stabb, S. D. (2009). The experiences of transgendered persons in psychotherapy:
Voices and recommendations. Journal of Mental Health Counseling,31(3), 264–282.
doi:10.17744/mehc.31.3.f62415468l133w50
Breslow, A. S., Brewster, M. E., Velez, B. L., Wong, S., Geiger, E., & Soderstrom, B. (2015).
Resilience and collective action: Exploring buffers against minority stress for transgender
individuals. Psychology of Sexual Orientation and Gender Diversity,2(3), 253–265.
doi:10.1037/sgd0000117
Burnes, T. R., Dexter, M. M., Richmond, K., Singh, A. A., & Cherrington, A. (2016). The
experiences of transgender survivor of trauma who undergo surgical and medical
transition. Traumatology,22(1), 75–84. doi:10.1037/trm0000064
Burnes, T. R., Singh, A. A., Harper, A. J., Harper, B., Maxon-Kann, W., Pickering, D. L., …
Hosea, J. (2010). American counseling association competencies for counseling with trans-
gender clients.Journal of LGBT Issues in Counseling,4(3–4), 135–159. doi:10.1080/
15538605.2010.524839
Davis, E. C. (2009). Situating “fluidity”(trans) gender identification and the regulation of
gender diversity. GLQ: A Journal of Lesbian and Gay Studies,15(1), 97–130. doi:10.1215/
10642684-2008-020
JOURNAL OF HOMOSEXUALITY 17
dickey, L. M., Singh, A. A., & Walinsky, D. (2017). Treatment of trauma and nonsuicidal
self-injury in transgender adults. Psychiatric Clinics of North America,40(1), 41–50.
doi:10.1016/j.psc.2016.10.007
Elder, A. B. (2016). Experiences of older transgender and gender nonconforming adults in
psychotherapy: A qualitative study. Psychology of Sexual Orientation and Gender Diversity,
3(2), 180–186. doi:10.1037/sgd0000154
Factor, R. J., & Rothblum, E. D. (2007). A study of transgender adults and their
non-transgender siblings on demographic characteristics, social support, and experiences
of violence. Journal of LGBT Health Research,3(3), 11–30. doi:10.1080/15574090802092879
Fallot, R. D., & Harris, M. (2011). Creating cultures of trauma-informed care: Self-assessment
and planning protocol. Retrieved from Community Connections website: http://www.com
munityconnectionsdc.org/training-and-store/store#!/Creating-Cultures-of-Trauma-
Informed-Care-CCTIC/p/80215860/category=22725096
Flores, A. R., Herman, J. L., Gates, G. J., & Brown, T. N. T. (2016). How many adults identify
as transgender in the United States? (June 2016 Report). Retrieved from the Williams
Institute website: http://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-
Adults-Identify-as-Transgender-in-the-United-States.pdf
Graham, L. F. (2014). Navigating community institutions: Black transgender women’s experi-
ences in schools, the criminal justice system, and churches. Sexuality Research and Social
Policy,11(4), 274–287. doi:10.1007/s13178-014-0144-y
Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Keisling, M. (2011).
Injustice at every turn: A report of the national transgender discrimination survey.
Washington, DC: National Center for Transgender Equality and National Gay and
Lesbian Task Force.
Harris, M., & Fallot, R. D. (Eds.). (2001). Using trauma theory to design service systems. In
H. R. Lamb (Series Ed.), The Jossey-Bass psychology series: No. 89. New directions for mental
health services. San Francisco, CA: Jossey-Bass, Inc.
Heck, N. C., Croot, L. C., & Robohm, J. S. (2015). Piloting a psychotherapy group for
transgender clients: Description and clinical considerations for practitioners. Professional
Psychology: Research and Practice,46(1), 30–36. doi:10.1037/a0033134
James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The report
of the 2015 U.S. transgender survey (December 2016 Report). Washington, DC: National
Center for Transgender Equality.
Levitt, H. M., & Ippolito, M. R. (2014). Being transgender: The experience of transgender
identity development. Journal of Homosexuality,61(12), 1727–1758. doi:10.1080/
00918369.2014.951262
Mascis, A. N. (2011). Working with transgender survivors. Journal of Gay & Lesbian Mental
Health,15(2), 200–210. doi:10.1080/19359705.2011.553782
McCullough, R., Dispenza, F., Parker, L. K., Viehl, C. J., Chang, C. Y., & Murphy, T. M.
(2017). The counseling experiences of transgender and gender nonconforming clients.
Journal of Counseling & Development,95(4), 423–434. doi:10.1002/jcad.12157
McIntyre, J., Daley, A., Rutherford, K., & Ross, L. E. (2011). Systems-level barriers in
accessing supportive mental health services for sexual and gender minorities: Insights
from the provider’s perspective. Canadian Journal of Community Mental Health,30(2),
173–186. doi:10.7870/cjcmh-2011-0023
Menvielle, E. J., & Rodnan, L. A. (2011). A therapeutic group for parents of transgender
adolescents. Child and Adolescent Psychiatric Clinics of North America,20(4), 733–743.
doi:10.1016/j.chc.2011.08.002
18 S.F.HALLANDM.J.DELANEY
Metthe, A. J. (2016). “Resisting disconnection”: An exploratory study of transgender adults’
experiences of community support and resilience (Master’s thesis). Retrieved from http://
scholarworks.smith.edu/theses/1751/
Miller, L. R., & Grollman, E. A. (2015). The social costs of gender nonconformity for
transgender adults: Implications for discrimination and health. Sociological Forum,30(3),
809–831. doi:10.1111/socf.12193
Mizock, L., & Lewis, T. K. (2008). Trauma in transgender populations: Risk, resilience, and
clinical care. Journal of Emotional Abuse,8(3), 335–354. doi:10.1080/10926790802262523
Nordmarken, S., & Kelly, R. (2014). Limiting transgender health: Administrative violence and
microaggressions in health care systems. In V. L. Harvey & T. H. Housel (Eds.), Health
care disparities and the LGBT population [ProQuest Ebook Central version] (pp. 143–146).
Retrieved from https://ebookcentral.proquest.com
Norwood, K. (2012). Transitioning meanings? Family members’communicative struggles
surrounding transgender identity. Journal of Family Communication,12(1), 75–92.
doi:10.1080/15267431.2010.509283
Poteat, T., German, D., & Kerrigan, D. (2013). Managing uncertainty: A grounded theory of
stigma in transgender health care encounters. Social Science & Medicine,84,22–29.
doi:10.1016/j.socscimed.2013.02.019
Reisner, S. L., Hughto, J. M. W., Gamarel, K. E., Keuroghlian, A. S., Mizock, L., &
Pachankis, J. E. (2016). Discriminatory experiences associated with posttraumatic stress
disorder symptoms among transgender adults. Journal of Counseling Psychology,63(5),
509–519. doi:10.1037/cou0000143
Richmond, K. A., Burnes, T., & Carroll, K. (2012). Lost in trans-lation: Interpreting systems
of trauma for transgender clients. Traumatology,18(1), 45–57. doi:10.1177/
1534765610396726
Ryan, G. W., & Bernard, H. R. (2003). Techniques to identify themes. Field Methods,15(1),
85–109. doi:10.1177/1525822X02239569
Saldaña, J. (2016). The coding manual for qualitative researchers (3rd ed.). Thousand Oaks,
CA: Sage Publications Inc.
Salisbury, M. E., & Dentato, M. P. (2015). An exploratory study examining needs, access, and
competent social services for the transgender community in Phoenix, Arizona. Journal Of
Human Behavior In The Social Environment,26(2), 119–136. doi:10.1080/
10911359.2015.1052911
Scheer, J. R. (2017). Trauma-informed care for sexual and gender minority survivors of
intimate partner violence (Doctoral dissertation). Available from ProQuest LLC. (UMI
No. 10288819)
Singh, A. A., & dickey, L. M. (2016). Implementing the APA guidelines on psychological
practice with transgender and gender nonconforming people: A call to action to the field of
psychology. Psychology of Sexual Orientation and Gender Diversity,3(2), 195–200.
doi:10.1037/sgd0000179
Substance Abuse and Mental Health Services Administration. (2014). Guiding principles of
trauma-informed care. SAMHSA News,22(2). Retrieved from https://www.samhsa.gov/
samhsaNewsLetter/Volume_22_Number_2/trauma_tip/guiding_principles.html
Testa, R. J., Sciacca, L. M., Wang, F., Hendricks, M. L., Goldblum, P., Bradford, J., &
Bongar, B. (2012). Effects of violence on transgender people. Professional Psychology:
Research and Practice,43(5), 452–459. doi:10.1037/a0029604
The Trauma Informed Care Project. (n.d.). Trauma-informed organizational self-assessment
[PDF file]. Unpublished instrument. Retrieved from http://www.traumainformedcarepro
ject.org/resources/Trauam%20Informed%20Organizational%20Survey_9_13.pdf
JOURNAL OF HOMOSEXUALITY 19
The World Professional Association for Transgender Health. (2011). Standards of care for the
health of transsexual, transgender, and gender nonconforming people (Vol. 7). Retrieved
from https://www.wpath.org/media/cms/Documents/Web%20Transfer/SOC/Standards%
20of%20Care%20V7%20-%202011%20WPATH.pdf
Woulfe, J. M., & Goodman, L. A. (2018). Identity abuse as a tactic of violence in LGBTQ
communities: Initial validation of the identity abuse measure. Journal of Interpersonal
Violence. Advance online publication. doi:10.1177/0886260518760018
20 S.F.HALLANDM.J.DELANEY
