Mental Health Providers

Key Tips for Service Providers

Mental health providers can support trans and nonbinary survivors by:

• Recognizing the client’s autonomy and goals for care/services. Honor what a client is seeking care for. Keep in mind that some people may want to talk about experiences with trauma but not focus on their trans identity; and some may want you to write them a letter for hormones but not discuss past experiences of trauma or harm.
• Understanding the impacts of state-sanctioned hate, anti-trans legislation, divisive rhetoric, and broader cultural transphobia on individual trans peoples’ mental health and wellbeing.
• Sharing details about your policies surrounding confidentiality, medical records, or paperwork to provide assurance of
• Being aware of systems that disproportionately negatively impact trans and nonbinary people (especially trans people of color). For example, trans/nonbinary people are more likely to experience forced institutionalization, police violence, and unjust incarceration. Avoid sending law enforcement to a person’s home whenever possible.
• Explaining your role if you are a mandated reporter, providing ample information so that the client can make informed decisions about what to share (or not). Learn more about the impact of mandatory reporting on trans/nonbinary people here (ADD LINK TO TOOLKIT SECTION).
• Being transparent and upfront about whether you provide letters or referrals for gender-affirming care.
• Discussing the potential risks and benefits of mental health diagnoses with clients before billing insurance or codifying a diagnosis. Being aware of the possible danger and safety implications some diagnostic codes may pose to trans people, especially those living in certain states with specific anti-trans legislation. (For example, some states restrict access to gender-affirming care for people who have a previous mental health diagnosis; some states will deny unrelated services if there is a diagnosis of gender dysphoria.)
• Providing trauma-informed, culturally responsive, and survivor-centered care.

Respect Survivors Goals

Mental health providers are trained to listen carefully.  When working with marginalized populations that a provider is less familiar with, sometimes providers forget their core skills of listening, respecting, and asking responsive questions.

One of the most important principles of affirming care is respecting why someone has come to see you.

Some trans clients will be seeking support to process experiences of violence or trauma. Others may simply need a letter supporting gender-affirming care, assistance navigating resources, or support for concerns unrelated to their gender identity. Still others may wish to discuss the impacts of anti-trans discrimination or political hostility.

Avoid assuming that every concern is related to someone’s gender identity—or that gender identity must become the focus of the care and support received. Follow the survivor’s priorities while remaining available to discuss other concerns if and when they choose.

Build Trust After Harm

Many trans and nonbinary people approach mental health services cautiously because of past negative experiences.

These experiences might include:

• Conversion therapy and other abuse by a provider [link to provider abuse section],
• Identity-based discrimination or abuse
• Having their gender questioned, disbelieved, or invalidated
• Forced institutionalization
• Gatekeeping around access to affirming healthcare or other services

Because of these experiences, survivors may need additional time before feelings safe enough to trust a provider.

Providers can help (re)build trust by:

• Acknowledging previous harms the client has experienced (and being mindful to not become defensive)
• Inviting survivors to describe what has and has not worked with past providers.
• Offering space to process prior provider-based harm.
• Checking in regularly about whether therapy (or group services, etc.) feels helpful
• Being flexible and collaborative
• Following through on commitments and promises
• Respecting the survivor’s autonomy
• Being patient and demonstrating trustworthiness

Transparency Around Mandated Reporting

Because many survivors have experienced systems that removed their autonomy or agency, it is especially important to explain mandated reporting requirements before situations arise.

Providers who are mandatory reporters, especially those who work with young trans people and trans people of color, should be clear with their clients about their role and mandated responsibilities.  Having clear conversations upfront can enable creative problem-solving, transparency, and better mental health outcomes.

Providers should discuss:

• What information is confidential.
• When confidentiality must be legally broken.
• What would happen if a report becomes necessary.
• How survivors can communicate concerns if they worry a conversation may venture into mandatory reporting territory.

Being transparent early helps survivors make informed decisions about what they choose to share.

Improving Access to Care

Telehealth greatly expanded access for many survivors during the COVID-19 pandemic.  Many providers continue to offer telehealth as an option to all of their clients, even if most of their services have returned to in-person.

“Covid was helpful because it seemed to encourage folks to provide more virtual services, so I was able to find a therapist that was more knowledgeable of trans issues.”[ii]

To address financial barriers, such as lack of employment/income or insurance, offering a sliding scale can increase access for clients:

“My gender therapist stopped taking my insurance, so I kind of stopped seeing her because. I couldn’t afford it.”[iii]

Trans and nonbinary people have many different access needs, including physical or language access. For example, Deaf and Hard of Hearing survivors will likely need access to an interpreter:

“ASL is a part of health services. When you’re receiving face-to-face therapy, you need those interpreters. So that is another barrier just finding that additional layer just to receive access to care.”[iv]

“I needed to find a therapist to write a letter of support for me to start T. I looked across my state and I found one therapist who worked with trans folks. Just one, that was it. No others available. So I went ahead and reached out to this person, and I said that I was deaf, and they said they didn’t want to provide interpreters. They refused to provide interpreters. So they said, ‘Sorry, I can’t work with you.’”[v]

Providers can improve accessibility by:

• Offering telehealth whenever possible.
• Accepting a range of insurance plans.
• Using sliding-scale fees.
• Providing accessible offices and communication.
• Ensuring qualified interpreters are available for Deaf and hard of hearing clients.

Harm Reduction Approaches to Care

Many survivors cope with violence and trauma in ways that may carry short and long-term risks, including substance use, restrictive eating, self-harm, survival sex, or other behaviors.

A harm reduction approach recognizes that these coping strategies may help someone survive while also acknowledging their potential long-term implications. Rather than demanding immediate change – which inherently takes agency away from clients – providers work collaboratively with survivors to reduce harm, increase safety, and build additional coping strategies over time.

In two webinars focusing on mental health, therapists talked about working with clients who might be actively self-harming or using substances to cope. Using a harm reduction approach to care means understanding the risks in someone’s life and helping them to reduce risks, while supporting coping behaviors.

One nonbinary survivor shared:

“The first therapist that I really felt like got it was a social worker who had a background in HIV case management, so she was familiar with the harm reduction approach and people trading sex. Even though as a social worker, there’s mandatory reporter things, laws are different in each state and professionals certainly have different ideas of what counts as something to report, but she did a really good job, or seemed to understand a lot more. the support that I needed.”[vi]

Diagnosis: Benefits and Risks

Mental health diagnoses can both expand and restrict access to care.

Potential benefits include:

• Insurance coverage.
• Access to treatment.
• Medication.
• Disability accommodations.
• Community resources.

Potential risks include:

• Increased stigma.
• Reduced autonomy.
• Misuse of diagnoses by healthcare systems.
• Denial of transition-related care.
• Barriers to gender-affirming care in some states, including some legal risks.

Trauma-informed and trans-affirming care includes having open conversations with clients about potential diagnostic codes used, who will have access to this information, and strategies to reduce potential harm.

Trans survivors may have concerns about diagnoses related to gender identity or to trauma.

For trans clients with insurance, some insurance companies are denying any care associated with diagnostic codes for gender dysphoria.  As a result, if a trans survivor is seeking therapy for coping with anxiety post-assault, adding an additional diagnostic code for gender dysphoria may result in all therapy care being denied.  Similarly, trans clients who are medically transitioning might be working with a gender-focused therapist for letters of recommendation for care.  Unfortunately, some providers still hold past trauma or unresolved trauma against clients wishing to pursue legal name changes, hormones, or surgery to affirm their gender.

Every client will have different needs and priorities.  Different states will have varying laws, restrictions, or exclusions to care.  Having transparent discussions with clients will allow for the best outcomes for both clients and providers.

Transgender people have been pathologized extensively by mental health institutions. Some providers consider being transgender as a mental illness (which it is not). Physical healthcare providers may force a trans/nonbinary person to receive therapy in order to receive physical healthcare. In a listening session with FORGE, a trans woman shared how she had been diagnosed with a mental illness instead of receiving gender-affirming care while trying to access hormone therapy.

“I did have a horrible experience when I did finally decide to go into care, cause I started my transition on the black market. I was like, you know what, I wanna get my levels checked out. And when I went to ask my doctor, and I was young at this time, I was like 19, 18, and they looked at me, they called me by my deadname, and it was like, ‘You need to see a psychiatrist. You need to see a therapist.’

“…I’m like, ‘What do you mean? I just need some estrogen, some T blockers.’ They said, ‘No, you need to go see the therapist.’ And they diagnosed me with a mental illness. And this was before everything became so, you know, ‘affirming.’ But I was diagnosed with a mental illness just for trying to go for a regular checkup.” [vii]

In order to build trust, it is critical to recognize the autonomy of trans and nonbinary survivors. Someone who is only looking for access to gender-affirming care may also benefit from other resources and referrals. Making diagnoses and treatment plans should be a collaborative effort with survivors’ input.

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