Mental health clinicians are seeing increasing numbers of transgender and gender-diverse (TGD) clients, but many lack the expertise to treat them in a manner that affirms their identity and lived experiences. University of Nebraska–Lincoln researchers have devised a dozen practical guidelines to help.

“The guidelines should be applicable to clinicians working in geographic areas with limited resources for TGD communities but should be useful even to clinicians with more experience in treating clients,” said Debra Hope, Aaron Douglas professor of psychology and lead author of a new paper that outlines the recommendations.

The recommendations spring from researchers’ collaboration with representatives of Nebraska’s transgender and gender diverse community.

“For a long time, nobody in the mental health community knew anything about transgender [needs] … and if somebody showed up, they had to educate their therapist,” Hope said.

Progress came slowly but steadily. Then “people with good hearts … still didn’t know anything really, but they’re at least open and willing to listen,” she said.

“We’re well past that. Now it’s time for people to actually be competent and to be prepared to provide those services — both physical health and mental health.”

The research effort began about eight years ago, as TGD clients began showing up in greater numbers at the university’s Rainbow Clinic, which offers mental health services to residents of the Lincoln community who identify as lesbian, gay, bisexual, transgender or queer.

Resources for clinicians were available, but they largely were not based on science or research, Hope said. Most also were based on work in urban coastal areas, which did not reflect the realities of individuals living in communities with different cultural, social and legal climates.

A consultation with a member of the local TGD community confirmed the need.

“He said, ‘The services out there are terrible. Didn’t you know the services are terrible,’” Hope said.

She responded “Well, I said, ‘We can work on that.’”

Funding from the National Institutes of Health funded a project to interview clinicians who specialize in TGD services and treating members of the community.

The 12 adaptations of practice are included in an article in Professional Psychology: Research and Practice and available on the university’s psychology department website.

“What we need to do is think carefully about is our TGD clients’ identity, how that influences how they interact with the world, and how that influences how the world interacts with them,” Hope said.

In some cases, that might mean helping clients get connected socially with others, to find “affirming places they can go” and unsafe places they should avoid. It also might mean helping clients find work, especially in areas, like Nebraska, where legal protections are scant or nonexistent.

“TGD folks may come to therapy partially for issues around gender identity but they also may come for anxiety, depression or substance abuse. … Part of the therapist’s job is to figure out how relevant their gender identity is. It’s always relevant to some extent but one of the mistakes therapists make is they either overemphasize it or they’re uncomfortable, so they ignore it. It’s about finding that balance,” Hope said.

“Each person has their own journey on their gender. There’s no standard path. It may well be that someone is going to start hormone therapy, planning surgery, etc. That has huge implications. There also are people who won’t do that. So being sensitive to what journey people are on, you can help them navigate it.”

Hope said the research team plans to do clinician training and workshops, including online training. They will continue to work closely with members of the TGD community to adapt the guidelines.