Service Provision with Transgender, Transsexual, Nonbinary, and Other Gender Diverse Populations

Originally Published in NASW-NJ FOCUS, March 2022

By Zander Kieg, LCSW

“In hindsight, I wish I had been working with a Gender Therapist who would have assisted me with navigating a very unfamiliar and challenging social transition from dyke to dude.”

My first encounter with a mental health practitioner to discuss issues related to being a transsexual was in 2007. Two years earlier I had started gender-affirming hormones and legally changed my name and sex through the CA Court System, and one year earlier I had undergone “top surgery” (aka chest reconstruction or double mastectomy). That encounter in 2007 was to be approved for “bottom surgery” (aka Phalloplasty or Metoidioplasty) and the clinician my HMO insurance provider scheduled me with was “LGBT-friendly,” which turned out to mean she was a lesbian but had zero knowledge about gender transition or gender-affirming surgeries. We met three times. The first session was a typical intake session. The second session consisted of me educating her on the various types of surgery, the pros, and cons of the surgeries, and the availability of surgeons around the country. The third session was her informing me that a recommendation for surgery was going to be submitted to the committee that oversaw the process for the HMO system.

Many of you might be asking yourself, “How did he access hormones and surgery without “getting a letter” from a clinician?” While living in San Francisco, I was able to access a physician who had been working with transgender patients for 12 years and did not require a biopsychosocial assessment prior to prescribing gender-affirming hormones. I took that prescription sheet to my primary care provider at the Veterans Affairs Outpatient Clinic who, after consulting with an endocrinologist for 20 minutes, transferred my prescription into the VA Pharmacy System. I was handed off to the Injection Clinic RN to receive my first intramuscular injection that day. At the time I felt fortunate because I knew many others who had waited months or even years to access medical transition, but in hindsight, I wish I had been working with a Gender Therapist who would have assisted me with navigating a very unfamiliar and challenging social transition from dyke to dude. It’s one thing to be called “sir” as a masculine woman more often than seems reasonable, but it's a whole other thing to live in the world as a man versus a woman. And, it turns out, it’s nothing like my female family members, friends, and women’s studies professors alluded to. Having a psychotherapist to talk with would have made the whole process more manageable.

For those of you who are less familiar with trans social care, the letter I am referring to is often written by a licensed mental health clinician based on a World Professional Association for Transgender Health (WPATH) Standard of Care recommended best practices for working with individuals seeking gender-affirming hormones and/or surgeries. WPATH recommends that individuals seeking these services complete a comprehensive biopsychosocial assessment with a provider to ascertain their readiness and preparedness to initiate and navigate such life-altering changes. Too often this step is skipped, and like in my case, could have benefitted the client along their journey. Without a safe residence and supportive network to call upon, many trans people become isolated during the early stage of their gender transition. And with the alarming suicidal ideation statistics available, avoiding social isolation is paramount during this process.

Working with gender diverse clients is a rewarding yet demanding endeavor as the landscape of who is included under the “Transgender Umbrella” expands and the accepted parlance is ever-changing. The notion of many identities all configured under an umbrella is a wonderful visual image and an easy way to introduce the topic of transgenderism, but it does not begin to truly describe the differences within that diverse community, which may lead some to believe that being trans or nonbinary is easily describable and relatable. It is not. And, there are many competing and conflicting theories attempting to capture the dominant paradigm of thought for who trans people are and how trans people want to be treated. We are not a monolith.

We are very diverse—as any group of people is. Providing Culturally and Linguistically Appropriate Services (CLAS), therefore, mandates continuous engagement with professional development education and training programs.

On May 1 st I will be leading a workshop during the NASW-NJ Shape the Future of Social Work Virtual Annual Conference focused on how to be a Culturally and Linguistically Appropriate Service provider with transgender, transexual, nonbinary, and other gender diverse populations. I will be discussing the CLAS Standards, issues related to poor health literacy, the shifts, and struggles with terminology, continuing education resources, the Multi-Modal aspects of a gender transition, and some contemporary issues to be aware of. I look forward to seeing you there!

About the Author:

Zander Keig, LCSW is the NASW 2020 Social Worker of the Year, CA NASW 2018 Social Worker of the Year, and WPATH 2020 Harry Benjamin Distinguished Educator of the Year.