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Psychology & Sexuality
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/rpse20
“I don’t want to say the wrong thing”: Mental
health professionals’ narratives of feeling
inadequately skilled when working with gender
diverse adults
Lauren Canvin, Jos Twist & Wendy Solomons
To cite this article: Lauren Canvin, Jos Twist & Wendy Solomons (2022): “I don’t want to say the
wrong thing”: Mental health professionals’ narratives of feeling inadequately skilled when working
with gender diverse adults, Psychology & Sexuality, DOI: 10.1080/19419899.2022.2118070
To link to this article: https://doi.org/10.1080/19419899.2022.2118070
Accepted author version posted online: 26
Aug 2022.
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Publisher: Taylor & Francis & Informa UK Limited, trading as Taylor & Francis Group
Journal: Psychology & Sexuality
DOI: 10.1080/19419899.2022.2118070
“I don't want to say the wrong thing”: Mental health professionals’ narratives of feeling
inadequately skilled when working with gender diverse adults
Lauren Canvin1, Jos Twist2, Wendy Solomons1
1. Department of Clinical Psychology, University of Hertfordshire, Hatfield, United Kingdom
2. Gender Identity Development Service, The Tavistock Centre, London, United Kingdom
Email address for corresponding author: lauren.canvin@oxon.org; laurencanvin@gmail.com
Keywords: transgender, mental health, mental health professionals, gender diverse, trans, LGBT
“I don't want to say the wrong thing”: Mental health professionals’ narratives of feeling
inadequately skilled when working with gender diverse adults
Trans, gender diverse and gender questioning adults are highly likely to experience
mental health difficulties, for multiple reasons including transphobia or minority stress.
However, gender diverse adults often describe having negative experiences accessing
mental healthcare in the UK. Concurrently, health professionals have described feeling
inadequately skilled, and lacking confidence in their ability to support gender diverse
people. There has been limited research exploring the experiences of mental health
professionals who provide care for gender diverse people in mainstream mental health
services, and even less in the UK. In this study, the accounts of seven mental health
professionals from a range of disciplines were analysed with a constructionist narrative
analysis, to better understand the nature of stories and positioning of individuals, within
the local, social and historical contexts of the narratives’ construction. This paper focuses
on participants’ narratives of feeling inadequately skilled when working with gender
diverse individuals, which were drawn on and resisted in their stories. Implications for
clinical practice and training are suggested.
Introduction
‘Gender diverse’ is an umbrella term which includes anyone whose gender identity, role or
expression is different from the gender they were assigned at birth. This includes people who
self-define as trans or transgender, as well as those who have transitioned in some way, but
do not identify with the terms ‘trans’ or ‘transgender’. There has been an international
increase in representation of gender diverse people in the media in recent years (Koch-Rein et
al., 2020), and a growing influence of trans people in the sphere of health (Pearce, 2018).
However, examples of transphobia and discrimination against gender diverse individuals are
common across the world.
In October 2020, PinkNews reported that transphobic hate crimes in the UK had quadrupled
in 5 years (Powys Maurice, 2020), and Reisner et al. (2016) reports on the high burden of
violence and victimization experienced by transgender people globally. Every year, the Trans
Day of Remembrance honours the lives of gender diverse people who have been murdered
across the world (Transgender Europe, 2020). Mizock and Hopwood (2018) describe the
economic challenges faced by gender diverse people, as a result of transphobia, and Pearce
(2018) provides several examples of how “anti-trans prejudice can have severe consequences
for trans patients” including abuse, harassment, sexual violence, and “explicitly negative
attitudes towards trans people” experienced from healthcare professionals (p. 54).
Given these contexts, it is unsurprising that that gender diverse people in the UK experience
significantly high levels of mental health difficulties. The Trans Mental Health Study
(McNeil et al., 2012; n = 889), stated that 48% of trans people in Britain reported having
attempted suicide at least once, and 84% had considered it. 55% reported being diagnosed
with depression at some point in their lives.
Gender diverse people may require support from mental health services due to questioning
their gender (Ellis et al., 2015), or the minority stress (Meyer, 1995) they may experience as a
result of moving through the world as a gender diverse person. Equally, gender diverse
people may require mental healthcare for issues completely unrelated to their gender identity.
Mental health professionals’ roles can include providing therapy, medication, or care both in
community and inpatient settings. However, the links between gender diversity and mental
health have been further complicated by the historical requirement that, prior to 2013, trans
people were initially assessed by mental health services before being referred to gender
identity services (McNeil et al., 2012; Pearce, 2018). In addition, the WPATH (2012)
Standards of Care require that two mental health professionals approve a referral for genital
reconstruction surgery. Although referrals can now come directly from a GP, many gender
diverse patients are still first referred to mental health services.
There is a growing amount of literature around gender diverse people’s experiences of mental
health care. In the Trans Mental Health Study (McNeil et a., 2012), 63% of British trans
people surveyed experienced one or more negative interactions in general mental health
services. Similarly, Ellis et al. (2015) analysed survey data from 621 trans people in the UK,
a third of whom reported being dissatisfied or very dissatisfied with their mental health care.
Participants described experiences such as their clinician not being educated on trans issues,
and their gender identity being seen as a symptom of mental illness. Gender diverse adults in
Australia also described issues such as misgendering, the need to educate their clinicians, and
experiencing discriminatory comments (Riggs et al. 2014).
To further understand the challenges faced by gender diverse individuals accessing mental
health care, it is important to explore the perspectives and experiences of mental health
professionals who provide this care. However, research in the area is limited (Richards et al,
2014). Canvin et al. (2021) systematically reviewed research into mental health
professionals’ experiences of providing care for gender diverse individuals. The authors of all
12 studies included in the review concluded that there is a need for better training for mental
health professionals working with gender diverse individuals. Several participants in the
studies described their uncertainty working with this population, and some reported
stigmatizing beliefs or practices, such as imposing moral or religious views, or seeing gender
identity as a target for intervention (often referred to as conversion therapy).
Canvin et al. (2021) also noted some limitations in the literature around mental health
professionals’ experiences supporting gender diverse people, and areas requiring further
study. This included specific research into the experiences of mental health professionals in
the UK – a country with free at the point of use, state funded mental health care - as all
studies reviewed took place in the USA or Australia. In addition, research which qualitatively
explored mental health professionals’ own accounts, as opposed to an assessment of
competence, was particularly limited.
This paper presents a subsection of the findings from a larger piece of qualitative research
into the experiences of mental health professionals in the UK who have supported gender
diverse adults (Canvin, 2020). The broader research project described wider narratives drawn
on and resisted by participants, such as narratives of separating different parts of a person
(e.g. gender and mental health), and narratives of standing up to higher powers. The findings
in the current paper describe mental health professionals’ narratives of feeling inadequately
skilled, exploring how mental health professionals position themselves and their ability to
support gender diverse adults.
As this research aims to explore the stories mental health professionals tell about supporting
gender diverse clients, narrative methodologies were used to analyse the data (e.g. Esin et al.,
2014; Riessman, 2008). The analysis explored the stories mental health professionals told
about their experiences, as well as the wider narratives, discourses, and social/historical
contexts which shape their stories. Attention was paid to the ways gender and mental health
were constructed, and the ways participants positioned themselves in their stories, in the
interview, and in relation to wider discourses and debates.
Method
Participants
To be included in the research, participants had to be mental health professionals who worked
(currently or previously) in the public sector. Relevant professions included community
psychiatric nurses, social workers, support workers, care co-ordinators, psychiatrists,
psychologists, occupational therapists, or other allied health professionals. The mental health
professionals could be qualified, in training, or have no formal mental health qualification. A
purposeful sampling approach was used in order to obtain participants from a range of mental
health professions, and healthcare settings. Participants were required to have had experience
supporting at least one adult in the public sector who self-identified as trans, gender diverse,
or were questioning their gender identity. Recruitment primarily took place through social
media (e.g. Facebook groups dedicated to mental health professionals), word of mouth, and
mental health professionals passing on the research advert to colleagues via email.
The total sample consisted of 7 mental health professionals, aged 27-54. 5 of the 7
participants identified as female, and 2 as male. All 7 participants identified as cisgender, 5 as
heterosexual or straight, 1 as demisexual and 1 did not disclose their sexual orientation. 4
participants described themselves as White British, 1 as White, 1 as British, and 1 as Mixed
(Caucasian and East Asian). 4 participants were located in the East of England, 1 in the
Midlands, 1 in the South West and 1 in London. The sample consisted of 2 Clinical
Psychologists, 1 Trainee Clinical Psychologist, 1 Consultant Psychiatrist, 1 Mental Health
Nurse, 1 Social Worker, and 1 Art Therapist. The professionals ranged from 1-27 years in
their current occupation.
The professionals spoke of their experiences working in a range of different mental health
settings such as Community Mental Health Teams, Forensic Mental Health Hospitals, and
Single-Sex Inpatient Wards. The Mental Health Care provided included psychological
assessment, therapeutic work, and providing care on inpatient wards. 4 participants had only
worked with one gender diverse person, whereas 3 had worked with several gender diverse
adults.
Materials
Narrative data is typically gathered through a conversation between an interviewer and
interviewee (Reissman, 2008; Wells, 2011), designed to elicit talk from the participant in a
storied form. The semi-structured narrative interview style used in this research followed the
procedure of Jovchelovitch and Bauer (2000), by first introducing the participant to the
interests of the interviewer (their experiences working with gender diverse individuals),
followed by a phase of uninterrupted narration from the participant, only then asking
questions to prompt additional areas of experience and clarification.
The proposed study design and initial draft of the interview guide were commented on by 22
gender diverse individuals through an online survey, and their feedback was incorporated into
the materials used for the research. The survey respondents gave largely positive feedback
about the design and aims of the study. The interview guide was described as “clear” and
“good that it is semi-structured”. Following the survey, the gender ‘non-binary’ was
specifically referred to in the interview guide as one respondent mentioned that they were
unsure whether the participants were being asked about experiences working with non-binary
people.
The survey respondents were also invited to suggest questions for the mental health
professionals interviewed. From their responses, the following question was added to the
interview guide: Has there been a time when you have supported trans, gender diverse or
questioning people when other professionals showed a lack of knowledge? How did you
manage this?
Other questions relevant to the findings presented in this article included: Can you share with
me an experience that was difficult or challenging?; Can you share with me an experience
which you felt went well?; How confident did you feel in your ability to support a trans,
gender diverse, or gender questioning person initially? Participants were also asked What
additional training, education or resources do you feel you might need?
Although one interview took place face to face, the majority of the interviews took place
online (2) or by phone (4), to maximise time-efficiency for time-poor mental health
professionals, and allow for the collection of data across a wider geographical area (Lo
Iacono et al., 2016). Participants chose how they wished to be interviewed.
Reflexivity Statement
The research team consists of three practicing Clinical Psychologists, two of whom work
with gender diverse individuals. There is a mixture of trans and cis people in the research
team, with a range of sexual orientations.
As mental health professionals, we the research team consider ourselves as members of the
participant group included in this study. We can relate to shared experiences of working with
limited resources, the shared language of mental health and illness, and the shared working
culture. Our positions as both mental health professionals and queer people/allies in relation
to this research, create both strengths and barriers. We may be more attuned to the specific
contexts, languages and references made by the participants when telling their stories.
However, we recognise that these positions can also create barriers to listening and analysing
from an outsider or neutral position.
Ethical Considerations
This research was approved by the University of Hertfordshire Ethics Committee
(LMS/PGR/UH/03782). The participants’ identities were kept confidential through
anonymisation. To protect the confidentiality of the gender diverse individuals that the
participants spoke of, the participants were asked to change the names and identifying
information as they spoke, and further information was redacted in the transcripts. To manage
any disclosure of unethical practice, resources were prepared and offered to all research
participants at the end of the interview, describing current best practice guidelines for
appropriately working with gender diverse people.
Procedure
Immediately prior to the interview, each participant was asked to sign an online consent form
as well as consenting verbally. Before the narrative interview began, the participants were
reminded of issues of confidentiality for both themselves, and the clients they were about to
discuss. Participants were invited to choose pseudonyms for both themselves and their clients
to protect anonymity. The interviews ranged from 30 to 60 minutes in length. After the
narrative interview had finished, all participants were offered the latest guidelines around
working with gender diverse people in mental health care settings from the British
Psychological Society (BPS), and World Professional Association for Transgender Health
(WPATH). Field notes and reflections were made during and after each interview by the lead
author.
The analysis was informed by Constructionist Narrative Analysis (Esin et al., 2014), which
attends to the complexities of how people story their experiences: not just what is said, but
with attention to how and to whom, attending to different social and historical contexts. Early
stages of analysis identified thematic narrative content in each account (Wells, 2011), such
as stories of conflict with colleagues, or stories of the team being ill-equipped to support a
gender diverse person, which were developed through multiple readings. Further reading
then attended to and noted positioning (Harre & van Langenhove, 1999), such as how each
participant positioned themselves in their stories, in relation to their clients, and their work
context. The analysis also noted when participants positioned themselves in certain ways
(e.g., as ‘professional’, ‘knowledgeable’ or ‘inexperienced’) – both in relation to narrative
content (e.g. stories of first experiences working with gender diverse clients) and in relation
to the local context of the interview (Wells, 2011; e.g., presenting the self as ‘professional’ at
the start of the interview). Finally, analysis attended to historical and social contexts that
could be discerned in talk (Esin et al 2014), including organisational and professional
contexts, broader social and political discourses, and how participants positioned themselves
in relation to these (e.g., positioning themselves in line with or in opposition to medicalised
discourses of trans identities).
Following this multi-layered analysis of individual accounts, the analysis drew together
patterns of convergence (and divergence, or resistance) of wider narratives across interviews,
with additional attention to the different ways in which positioning, local, social, and
historical contexts were drawn on. Of the wider narratives (e.g., separating different parts of a
person, standing up to higher powers), narratives of ‘feeling inadequately skilled’ are
considered in more detail in this paper, as it highlights an area of particular clinical
importance, a barrier to gender diverse people accessing adequate mental health care, as well
as identifying an area for improvement.
In keeping with the constructionist approach (Esin et al., 2014) which acknowledges the
inevitable influence of researchers in co-constructing narratives and their analysis, authors
engaged reflexively with the work throughout the project (e.g., using journal entries,
engaging in reflexive conversations with the research team, and others) to develop ideas and
to consider the impact of personal motivations and social positions (e.g., in relation to gender,
professional experience and other social ‘GRACES’; Burnham, 2018) in project conception,
development, data construction, analysis and writing; highlighting possible ‘blindspots’ and
alternative understandings which could then be considered. This careful data collection and
analysis also contributes to analytic rigour (Tracy, 2010).
Analysis
The analysis below describes a subsection of the findings from a larger study exploring the
narratives of mental health professionals who have supported gender diverse adults. In this
article, participants’ narratives of feeling inadequately skilled are explored in detail.
Locating narratives of feeling inadequately skilled in colleagues
In the narrative interview, opportunities were opened up for participants to reflect on their
own skills and confidence, as well as those of their colleagues. In their stories, many
participants drew on and/or resisted narratives of feeling inadequately skilled when working
with gender diverse clients. Towards the start of his interview, Dan told a generalised story
about his experiences of his colleagues:
Dan: There’s been a lot of hesitation from my colleagues initially… who just don’t
know how to work with this population, and taking that perspective that that there is
something inherently different about trans or gender non-conforming young people,
and feeling very deskilled and not able to kind of work with them, that kind of feeling
that their more generalist skills don’t fit, or won’t be good enough…I think the main
one I tend to notice is when a trans person is referred to us, very quickly it’s a “[Dan]
can assess them”. It’s a sense that “oh I don’t know this, so I couldn’t possibly”, so to
immediately pass on to psychology, or myself as the local gender expert.
In his talk, Dan explicitly speaks to the narrative of feeling inadequately skilled, drawing on
ideas of clinicians’ feeling that their skills aren’t good enough to work with this population.
He uses the word “deskilled” – a term commonly used across healthcare settings, to describe
a clinician’s experience of their skills not proving adequate to a particular situation, new
client group, or new and unfamiliar setting (e.g. Alonso, 2000; Billings et al., 2021). Dan
positions his colleagues as feeling inadequately skilled, and by describing himself as the
“local gender expert”, he positions himself as the person with the skills. Dan also talks of his
colleagues seeing gender diverse people as “inherently different”, and this being a potential
reason for them feeling inadequately skilled, which is reminiscent of discourses which
ascribe an innate pathology to queer identities (Pearce, 2018).
Jenny also drew on narratives of colleagues feeling inadequately skilled. To illustrate, she
told a story of attending a training course unrelated to gender identity:
Jenny: I was talking to a bunch of really experienced clinicians who had a lot of
knowledge about working with people, working therapeutically, and they just didn’t
have competence to apply what they already knew, to a new context.
She linked this to how clinicians might feel about working with gender diverse people:
Jenny: it's almost as if you put someone who's gender questioning in front of a really
experienced clinician and they go, “Oh, I couldn’t possibly do that. I don't know what
to do!” Yeah, do you? I mean, they’re a gender questioning person, but they’re still a
person, just like everyone else you work with!
Both Jenny and Dan draw on the idea that clinicians might struggle to see how their clinical
skills can be applied when working with gender diverse adults, however Jenny challenges
this, reminding clinicians that “they’re still a person”, implying that a person’s gender status
shouldn’t be a barrier to clinicians using their general clinical skills.
These stories were also told in the organisational context of mental health services under
financial pressure, with a focus on “turnover” (Jenny). Gender diverse clients might be
referred from mental health services to other NHS services, or “signposted elsewhere”
(William), in order to reduce waiting times for other patients. Later in his talk, Dan described
the Gender Identity Clinic as a “magical clinical” where his colleagues believe other
clinicians “should be doing all the digging”. The existence of these specialist services may
strengthen narratives of feeling inadequately skilled, and contribute to clinicians’ difficulty in
applying their general clinical skills, as they may see themselves as not having the specialist
skills needed to support gender diverse individuals.
Locating narratives of feeling inadequately skilled in themselves
While Dan and Jenny more frequently ascribed feeling inadequately skilled to others (in
contrast to their own more expert position), the other participants aligned with feeling
inadequately skilled themselves, to a greater or lesser degree. Most of the participants seemed
more open to describing their own difficulties in their stories once the interview had
progressed, and we had built a rapport. This could also be seen as the speakers taking time to
establish credibility as professionals in their narratives (e.g. Edwards & Potter, 1992; Labov,
2010), before telling stories of their own personal challenges or difficulties. Thus, positioning
themselves as knowledgeable and thoughtful professionals, though with identified gaps, and
understandable uncertainties in their professional repertoire.
Elena both drew on and resisted the narrative of feeling inadequately skilled, when asked
about her confidence working with gender diverse people. She took a position of uncertainty:
Elena: I didn't- maybe I didn't have enough experiences at work to make me very, very
confident. And I might not be never completely confident because it’s just something that
I can't relate to completely. I can empathise, and I can see it, and I can advocate for it, but
it's not- it’s very- it’s different to me but- Well, I don’t know! But then giving care is
giving care. You know, if you’re delivering care then it should be- it's the same but it’s
just the- you just worry for them…I still get that little like anxiety alert, Oh God, I don't
want them to get hurt or do this or do that or whatever. And, even protecting them from
like certain people in the team, you know, like those kind of things.
Elena’s talk moves back-and-forward between positioning herself as feeling inadequately
skilled if she “can’t relate” to a person, and resisting this narrative, saying “but then giving
care is giving care”. This was then accompanied by an expression of risk and anxiety about
gender diverse people on her (acute mental health male inpatient) ward coming to harm,
saying “I don't want them to get hurt”. She seemed to be speaking to the broader social
context of victimisation of gender diverse people (e.g. Reisner et al., 2016), including from
mental health staff (Ellis et al., 2015) which she said could also happen on her male acute
ward. It seems that this anxiety about gender diverse clients coming to harm may also
contribute to her lack of confidence, and feeling inadequately skilled.
Jane also drew on the narrative of feeling inadequately skilled. She explicitly mentioned her
“limited experience” before most of her answers to the questions, seemingly as a caveat to
her answers, and positioning herself as a non-expert. When asked about her confidence, she
told a story of seeking supervision for her work with a gender diverse patient:
Jane: So, limited experience, as I said, but I think the first one was very much- I made
contact with the local specialist quite quickly to just say, "You know this is- these are
my thoughts, what do you think? Am I doing the right thing?" Um, I was asking for
supervision quite a lot because it was- it was outside of my experience really
Despite mentioning her limited experience, she speaks less of her feelings of being
inadequately skilled and not knowing what to do, and more of taking the active step of
seeking support from the “local specialist”, in a manner a mental health professional might be
expected in professional discourse when facing a situation beyond their training or
experience (e.g. BPS, 2018).
Fears of getting it wrong
William drew on the narrative of feeling inadequately skilled when he was asked how he felt
working with his gender diverse client:
William: I felt initially slightly, um, uncomfortable in the sense that, you know, I
don't want to say the wrong thing, and I don’t want to offend them, and I don't want
to, um, I don’t want to appear ignorant.
William describes initially feeling uncomfortable due to his fears of saying the “wrong
thing”, or offending his client. William also expressed concern about appearing “ignorant”.
Similar narratives of healthcare professionals experiencing a threat to their expertise and
power when working with gender diverse individuals have been outlined in the qualitative
study by Poteat et al. (2013). Towards the beginning of the interview, after mentioning that
he’d had some training on gender identity which helped him have some confidence
(potentially positioning himself as somewhat knowledgeable, and professionally trying to
seek out new knowledge), William described some of the questions that he wrestled with
when working with his client:
William: I was aware I might not always know the right questions to ask, um for
example, I wasn’t sure about the extent to which I should be exploring about surgery
and kind of, you know, what surgery they’d had or what they want to have or um,
whether that was at all relevant to their mental state
In his talk, William questions his role in exploring “surgery” with his client. As described
above, prior to 2013, community mental health professionals had a significant role in
assessing gender diverse individuals prior to making a referral to a Gender Identity Clinic
(Pearce, 2018), and still have a role in approving some surgeries (WPATH, 2012). This
complicated and changing landscape of mental health professionals’ role in gender diverse
patients’ pathways may have led to William’s confusion about his role, and may further
contribute to clinicians’ experiences of feeling inadequately skilled. However, William’s
narrated worries about “surgery” could also be understood as an example of cisgender
people’s intrusive curiosity about genital surgery, and gender diverse people’s bodies, which
is widespread in popular discourse, and medical communities (e.g. Carabez et al., 2016).
While William mentioned worrying about saying the “wrong thing”, two other participants
spoke about the negative impact of “fear” of getting it “wrong” in their stories. For example,
Jenny was asked what sort of training, education or resources she or her service might have
needed. Shortly after speaking of other professionals feeling inadequately skilled, Jenny
added:
Jenny: I do wonder if there’s this scary-ness associated with people who question
their gender or who are trans or anything else along the spectrum, that you might
somehow get it wrong? And I think in that fear, we are getting it wrong
Similarly, after Anna was asked what sort of training, education or resources her team might
need, she replied:
Anna: I think just kind of basic- providing a space to have a conversation about it and
maybe kind of like myth busting as well. I think what stops people from having
conversations is, um, a fear that you are saying the wrong thing. So, then you don’t
end up saying anything at all.
Both Anna and Jenny locate this fear of getting it wrong in other people, positioning
themselves as people who are cognizant of this problem. They both gave these answers when
asked what additional training might have been useful for their service, opening space for
them to speak from a de-centred position, the service perspective, rather than an individual
one. However, in these excerpts, both Anna and Jenny moved from speaking about “people”
to speaking about “we” or “you”, thus including everyone (and themselves) as having the fear
of getting it wrong. This hesitancy and fear may be coming from a broader context of
hesitancy when clinicians talk to clients they see as ‘different’ from them, for example those
of a different race or ethnicity. This has also been described as “the discrimination of the
restraint in risk-taking” (Gunaratnam, 2007, cited by Nolte, 2007), when people become
overly careful not to offend, inhibiting the openness and curiosity they might offer to other
clients (Nolte, 2007).
The participants may also be speaking to a fear of being seen as ‘getting it wrong’, when
working with or talking about gender diverse individuals, and the potential fear of being
judged personally or professionally, if they do ‘get it wrong’. Poteat et al. (2013) describe
how the lack of training around transgender topics can create uncertainty in healthcare
providers, which disrupts the “traditional clinical relationship in which medical providers are
expected to be a knowledgeable medical authority” (p. 25). Therefore, medical professionals
may experience a professional dilemma around expressing ‘not knowing’ whilst also
maintaining professional credibility (i.e., as someone who ‘ought’ to know), again leading to
hesitancy when working with or talking about gender diverse individuals. This fear of being
seen as ‘getting it wrong’ may be further exacerbated by the currently challenging and highly
polarized political climate around transgender rights and healthcare in the UK, as clinicians
may worry about how they will be seen if they do ‘get it wrong’. Some professionals may be
further concerned by examples of healthcare professionals being publicly criticised, or their
professional reputations questioned, in the context of their work with gender diverse
individuals, again contributing to clinicians’ hesitancy, or fears of getting it wrong.
Thoughts on training
All participants were asked if they have accessed any specific training for working with
gender diverse individuals, and what additional training, education or resources they felt they
might need. Many of the participants spoke of directly challenging the narrative of feeling
inadequately skilled, with “proper training” to “just get the facts right” (Elena), covering “the
basics” (Dan), and information about gender diverse people’s “lived experience” (Linda).
The participants may have understood there to be some “facts” and truths about working with
gender diverse people, which mental health professionals should be educated in.
Several of the participants also spoke about “opening up dialogues” (Jenny), “providing a
space to have a conversation” (Anna), a “sort of discussion” (Jane). William described
training he had received where the trainers “created an environment” which “enabled us to
kind of ask anything that we were unsure about or kind of not feel judged”. The participants
seemed to speak about learning through discussion and exploration of different ideas and
perspectives, which may be easier in an environment where participants don’t feel “judged”.
Language
All the participants drew on medicalised language in their stories, to describe their
organisations, operating procedures, and pathways, or to describe their clients’ difficulties,
diagnoses or treatment. Most of the participants also seemed to use a ‘case presentation’ style
of talking when introducing their clients, and the care they were provided. This may have
been due to the shared tacit knowledges and specialist vocabularies available to both the
participants and interviewer, as mental health professionals (Wells, 2011), or perhaps as a
way for the participants to establish credibility in their narratives (Edwards & Potter, 1992;
Labov, 2010), by using ‘expert’ terminology.
Some participants also spoke of gender diversity within a medical framework, referring to
gender experiences as a “condition”, or as the “root cause” of their clients’ mental health
difficulties. However, other participants actively resisted a medicalised or biological
framework for understanding both mental health and gender diversity, explicitly drawing
attention to how these ideas may be socially constructed, and speaking more of gender
experiences as identity rather than pathology.
Although some participants used dated or gender essentialist language at times (assuming
gender is dependent on the sex assigned to a person at birth; Serano, 2007) such as ‘cross-
dressing’, or ‘a man living as a woman’, most participants spoke from a constructionist (e.g.
Eliason & Schope, 2007) and affirmative (e.g. Keo-Meier & Ehrensaft, 2018) perspective
when talking about their clients, respecting their identified genders, and recognizing the
impact of social contexts on their clients’ gender possibilities (Pearce, 2018). Gender critical
ideas (e.g. Brunskell-Evans & Moore, 2019) such as questioning whether one should accept a
person’s gender identity, came up rarely, and were mostly resisted in the participants’
narratives. One participant wrestled between critical and affirmative perspectives when trying
to understand their client’s distress. This is a similar picture to that found in the research
literature, that clinicians generally describe affirmative practices, with good intentions
(Kawano et al., 2018), and tend to have positive attitudes towards gender diverse clients
(Kanamori et al., 2017), as opposed to constructing gender diversity as pathological,
immoral, or unnatural. However, gender critical perspectives on gender diversity are re-
emerging in the literature, and mainstream culture (e.g. Brunskell-Evans & Moore, 2019),
painting a more complex picture of narratives for clinicians to draw on when understanding
their clients’ experiences.
Discussion
The participants in this study expressed different positions in relation to the narrative of
feeling inadequately skilled. Some participants spoke of the narrative explicitly, locating this
‘feeling’ in other clinicians, and challenging the narrative, saying that clinicians do have the
skills to support gender diverse individuals. Other participants moved between aligning with
feeling inadequately skilled, and challenging this narrative, whereas others aligned with
feeling inadequately skilled throughout their talk. Several participants began their interview
taking more of a de-centred position, reflecting on, or criticising the actions of their
colleagues, before later moving on to reflecting on their own skills, confidence, and
decisions, perhaps once they had established credibility in their narrative (Edwards & Potter,
1992; Labov, 2010), or felt safe opening up to a stranger.
Narratives of healthcare professionals feeling inadequately skilled when working with gender
diverse people are prevalent in the literature. One of the physicians in Snelgrove et al.’s
(2012) qualitative study into physician-side barriers to providing trans healthcare was quoted
as saying that they “didn't know where to go or who to talk to” (p. 4), which became a
centralising theory of the research. Similarly, in Poteat et al.’s (2013) study, most of the
healthcare providers mentioned feeling “ambivalent about or unprepared for transgender
patients” (p. 26).
Looking at mental healthcare specifically, O’Hara et al. (2013) reported that all the
counsellors in their study “initially felt incompetent to work with transgender people because
of their lack of exposure and knowledge” (p. 246). Similarly, Rutter et al. (2010) described
how two student counsellors in their study “felt worried that they did not know enough
information to help the clients” (p. 73). Therefore, the findings from the current study seem
in line with the research literature. However, the current study goes further by exploring how
mental health professionals position themselves and their abilities when working with gender
diverse individuals, and the influence of fears of getting it wrong on clinical practice.
Despite the prevalence of narratives of feeling inadequately skilled in healthcare settings,
particularly when working with gender diverse people, some participants challenged this
narrative. They argued that clinicians should be able to apply their general clinical skills
when working with gender diverse people, and clinicians’ fear, hesitation, or assumption of
‘inherent difference’ are the problem. This could also be described as “the discrimination of
the restraint in risk-taking” (Gunaratnam, 2007, cited by Nolte, 2007) where an individual’s
fear of offending inhibits their openness and curiosity with clients. In addition, Poteat et al.
(2013) suggest that due to their uncertainty, healthcare providers’ might then stigmatise and
discriminate against gender diverse patients, to regain their medical authority and power in
the clinician-patient relationship.
Several studies investigating mental health professionals’ experiences supporting gender
diverse adults assess clinicians’ ‘competence’, preparedness or ‘knowledge’ for working with
this population (e.g. Johnson & Federman, 2014; Lutz, 2013; Riggs & Bartholomaeus, 2016a;
2016b). In these studies, the clinicians’ ‘competence’ is assessed against certain criteria and
knowledge. Several of the participants in this study echoed this idea, saying that there are
certain ‘facts’ clinicians need to know in order to provide care for gender diverse clients.
Salpietro et al. (2019) termed this ‘essential knowledge’, such as awareness of gender
concepts and transitioning. However, the participants in the current study also mentioned the
importance of having space to have ‘open conversations’ without the fear of being judged or
‘getting it wrong’, when developing skills to provide care for gender diverse clients. This had
not been captured in the literature previously.
Implications for clinical practice
All participants, spoke of the need for more and improved training for mental health
professionals providing care for gender diverse individuals. As well as ‘essential knowledge’
(Salpietro et al., 2019) related to gender diversity, participants called for training which opens
up a non-judgmental space for discussion. Space for discussion is particularly important as
narratives around both gender diversity and mental health are complex and in constant flux,
making it difficult to speak from a place of certainty or ‘truth’. It may be helpful for training
to consider and discuss some of the stories commonly told by mental health professionals and
gender diverse individuals seeking mental healthcare. In addition, professionals could
consider how they may use their general clinical skills when working with gender diverse
individuals (Israel et al., 2008; Lutz, 2013; Salpietro et al., 2019). Several participants in this
study spoke of gender diverse individuals having to wait a long time to be seen by specialist
gender services, therefore it is important that mainstream mental health services feel
empowered to support people during this waiting time, as well as those who are not waiting
for services.
Limitations
The interviewer’s position as a mental health professional, conducting research with the hope
of improving mental healthcare for gender diverse individuals, is likely to influence the
stories told by participants. This position was also made clear in the recruitment materials,
which may have attracted people who also have a particular interest in improving mental
healthcare for this population. Participants and stories from a more gender critical perspective
could be obtained by using more neutral recruitment material, and explicitly mentioning to
participants that all perspectives were welcome.
As in previous studies in this area, most of the participants were white, heterosexual, and
female. However, this reflects the demographics of mental health professionals in the UK
(NHS Digital, 2020). Although it is somewhat expected that the sample would represent these
proportions, the research is limited by the paucity of narratives from people outside these
demographics. The research would also have been made richer by including narratives of
clinicians with diverse gender identities. This also would have avoided the separation of
‘trans people’ and ‘clinicians’, which is commonly seen in research into trans healthcare
(Richards et al., 2014).
The demographics of the gender diverse clients discussed by the participants were also
limited. Most stories told were about transwomen and gender questioning people assigned
male at birth, and none of the participants spoke about other intersecting identities such as
their clients’ race or ability. One participant spoke about intersections of gender identity,
mental health, and class. Similarly, only one participant told a story about someone who
identified as non-binary. Therefore, stories of mental health professionals’ work with these
populations are not adequately represented in this research.
Finally, there are limitations of conducting interviews via Skype and over the phone. Firstly,
the sound quality was inaudible at times, which meant some of the participants’ talk was
missed (King & Horrocks, 2010). In addition, Lo Iacono et al. (2016) describe how non-
verbal cues (e.g. facial expression, body language) can be difficult or impossible to read,
particularly in phone interviews, and that it may be more difficult to build rapport during
Skype or telephone interviews. This also may have influenced the kinds of stories and
positions the participants offered.
Further research
As this research was limited by the demographics of mental health professionals who took
part, and the gender diverse clients they spoke of, further research could use purposeful
sampling methods to recruit a more diverse range of participants, who have worked with
more diverse clients, so that a richer variety of stories are heard. Stories of supporting
transmen, and non-binary clients, and those with other marginalised intersecting identities
would be particularly valuable. In addition, this research only focused on clinicians working
in the public sector. Several service user consultants mentioned that research involving
clinicians working in private and third sectors would also be beneficial, as many gender
diverse individuals seek mental health support outside the public sector.
Additional ideas for further research come from the findings of the research itself, outlining
some recommendations for training mental health professionals supporting gender diverse
clients. It may be useful to conduct research which explores the helpfulness of training which
provides the space for open discussion, as well as the ‘essential knowledge’ (Salpietro et al.,
2019) for working with gender diversity.
Conclusions
Narratives of feeling inadequately skilled have been drawn on and resisted in the stories told
by the participants in this study. Some participants mostly located the feelings of being
inadequately skilled in their colleagues, whereas others spoke of their own feelings of
uncertainty in working with gender diverse clients. Some participants moved between
positioning themselves as inadequately skilled, and challenging this narrative, whereas others
challenged it throughout their stories, firmly saying that clinicians do have the skills to work
with gender diverse people. The participants’ accounts also describe how mental health
professionals’ fears of getting it wrong when working with gender diverse individuals may
impact on their clinical work. All participants gave suggestions for improving training for
mental health professionals, drawing on both education about ‘the facts’, as well as opening
space for discussion. Although participants often used medicalised, gender essentialist or
dated language at times, they mostly spoke from a respectful position, with good intentions
and a concern for supporting their clients in the most helpful way. It is important that training
for mental health professionals supporting gender diverse adults is improved, for
professionals to feel more adequately skilled when supporting their clients, particularly given
the high rates of mental health difficulties within this population, and the long waiting times
to access gender identity clinics.
Data Availability Statement
The authors confirm that the data supporting the findings of this study are available within
the article, and the original doctoral dissertation: Canvin, L. (2020). Narratives of Mental
Health Professionals Supporting Trans, Gender Diverse and Gender Questioning Adults.
Doctoral dissertation, University of Hertfordshire.
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