American Counseling Association Competencies for Counseling with Transgender Clients

Authors

ALGBTIC Transgender Committee:

THEODORE R. BURNES, (CHAIR), ANNELIESE A. SINGH,

(PRESIDENTIAL INITIATIVE), AMNEY J. HARPER, BRANDON

HARPER, WILLIAM MAXON-KANN, DENISE L. PICKERING, SEAN

MOUNDAS, THOMAS R. SCOFIELD, ALEX ROAN,

and JULIA HOSEA, (COMMITTEE MEMBERS EMERITI)

Reviewers

LORE M. DICKEY, DARA HOFFMAN, JOANNE KEATLEY,

ARLENE LEV, VEL S. MCKLEROY, JESSE MCNULTY,

and STACEE REICHERZER

This document contains suggested competencies for use in counseling with transgender clients. These competencies are geared toward professionally trained counselors who work with transgender individuals, families, groups, or communities. These competencies are based on a wellness (e.g., Myers & Sweeney, 2005), resilience (Singh, Hays, & Watson, in press; Singh & McKleroy, in press), and strength-based approach (e.g., Bockting, Knudson, & Goldberg, 2007; Carroll, 2010; Lev, 2004; Vanderburgh, 2009) for working with transgender clients. The authors of these competencies come from diverse theoretical and professional backgrounds in working with transgender clients, advocating for transgender communities, and having relationships with transgender people.

Across this diversity of perspectives and experiences, the authors share a common approach of affirming that all persons have the potential to live fully functioning and emotionally healthy lives throughout the life span along the full spectrum of gender identity and gender expression. The authors advocate using a strength-based approach to highlight the strengths and resilience transgender individuals may have despite the significant experiences of multiple oppressions transgender people may have experienced. Further, the authors believe that counselors are in the unique position to endeavor to make institutional changes in the environments in which they work to develop safer counseling settings for transgender people.

THEORETICAL FRAMEWORK

The authors developed a theoretical framework from which they constructed these competencies. This framework in part stemmed from the authors’ acknowledgment of their biases—their own and those of the society in which they live. The authors chose to be transparent about their theoretical framework to not only share their assumptions about transgender people, but also to acknowledge that all individuals hold biases of which they are not yet aware. Therefore, the authors met as a committee weekly or biweekly for over a year to identify these biases and develop strength-based competencies. The authors also sought the expertise of seven independent reviewers who ranged in their experiences of practice, supervision, training, research, and advocacy with transgender concerns in counseling.

The authors conceptualized this approach from a theoretical orientation of counseling that integrates multicultural (Sue & Sue, 2008), social justice (Goodman et al., 2004), and feminist (Worell & Remer, 2003) approaches, which each acknowledge the influence of privilege, power, and oppression on clients’ lives. These theoretical approaches provide a lens for identifying, documenting the experiences of, and working to meet the needs of transgender clients. These approaches also provide a framework for the macrolevel implications for working with transgender individuals and communities and allowed the authors to recognize how gender identity intersects with a client's multiple sociocultural identities (e.g., race, ethnicity, sexual orientation, etc.).

In addition to their theoretical orientation to counseling, the authors strived to incorporate counselors’ multiple professional roles into the theoretical framework of these competencies. For example, the importance of social justice and advocacy as part of counselors’ work with transgender clients is acknowledged (e.g., Carroll, 2010). In developing these competencies, the authors referenced the original lesbian, gay, bisexual, and transgender (LGBT) competencies (Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling [AGLBIC], 2003), the ACA Advocacy Competencies (Lewis, Arnold, House, & Toporek, 2003), and the ACA multicultural competencies (Sue, Arredondo, & McDavis, 1992) to ensure that the current transgender competencies are grounded in the counselor role of advocacy that also integrates a multicultural approach to wellness.

An additional and important aspect of the authors’ theoretical framework stemmed from the authors’ beliefs about how these competencies should be used. These competencies should not be used in lieu of professional training in working with transgender clients, and supervision of trainees by licensed professionals. Consultation among and with professionals is essential and provides ongoing continuing education for individuals working with transgender clients. There are established World Professional Association of Transgender Health (WPATH) Standards of Care (Meyer et al., 2001—previously known as the Harry Benjamin Standards of Care) for working with transgender clients, and the authors do not intend that these competencies replace the WPATH Standards of Care, but rather that they complement them and are used in the training of counselors and establishing best practices in the counseling field with transgender clients.

Best practices for professional counselors working with clients from historically marginalized communities (e.g., AGLBIC, 2003) articulate the need for counselors to be familiar with all eight domains of these competencies to demonstrate cultural competence with transgender clients. Further, although there may be overlap among the different areas of these competencies, it will be important to review all areas to incorporate common themes of the areas as well as counseling strategies that are unique to particular sections.

TRANSGENDER-AFFIRMATIVE LANGUAGE

In addition to their theoretical framework, the authors consulted many different theoretical and empirical sources (e.g., Bockting & Coleman, 2007; Feinberg, 1996; Green & Dickey, 2009; Lombardi, 2001; Sue, Arredondo, & McDavis, 1992) and the seven reviewers of this document (see Appendix B to identify appropriate, transgender-affirmative language to use in these competencies). The authors of this document recommend the following as a growing list of some of the least restrictive terms available for use with transgender people, which are excerpted with permission from the Lambda Legal (2008) publication Bending the Mold: An Action Kit for Transgender Youth (see Appendix A). Although specific terms are used throughout the document, it is important to recognize the continuous evolution of language is to be expected with regard to working with transgender clients as there are many terms that are used within transgender communities.

Despite identifying and using a common language that was pervasive throughout the competencies, the authors thought it important to note that language in transgender (and any cultural) communities varies and that these competencies would not dictate “accurate” or “correct” language. In addition to language surrounding constructs of gender identity and expression, the authors also recognize that the correct use of self-identified, gender-affirming pronouns for transgender clients are also important. For example, the use of gender-neutral pronouns such as “ze” and “hir” are a critical addition to counselors’ vocabulary when working with some transgender clients. It is important to honor the set of pronouns that clients may identify with and/or select—and to use these pronouns throughout the counseling process. At the same time, counselors should also be aware that some transgender individuals do not identify with gender-neutral pronouns and identify with traditional gender pronouns. Specifically, any language used by the counselor should be directed by the client and should affirm the client's self-identified gender throughout the transition process, especially in instances where the counselor's perception of the client's gender identity and expression and the client's actual gender identity and expression differ.

The authors asserted that it was important to note that transgender people have been historically marginalized and pathologized by diagnostic and assessment systems. Then, the authors recognized that they would need to position themselves within the range of counseling approaches (e.g., pathology-based vs. strength-based) with transgender clients. Drawing from the minority stress model (Meyer, 2003), the authors believe that gender identity is in no way a mental disorder and articulate this view by placing disorder in quotes throughout the competencies (e.g., gender identity “disorder”), to draw attention to their critique of pathologizing gender identity.

Due to heterosexism and transphobia being referenced throughout the document and being central concepts to the minority stress model, it is important to clarify the difference between the two terms. Transphobia describes the irrational fear and hatred of all those individuals who transgress, violate, or blur the dominant gender categories in a given society, which may be experienced by transgender individuals in different ways from microaggressions to violence. The authors encourage counselors to also consider that transprejudice is often a more helpful term to use when describing the actual discrimination that transgender people experience. Heterosexism, on the other hand, describes the assumption that everyone is heterosexual or should be. Although many transgender individuals identify as heterosexual, they may still experience heterosexism because embedded within heterosexism is a narrow binary gender system that transgender individuals may be seen as outside of or they are questioned about their status of being a “real” man or woman. Therefore, ze/she/he may be heterosexual yet experience heterosexism through microaggressions, discrimination, harassment, violence, and so on because of being incorrectly viewed as gay, lesbian, and/or bisexual.

An important consideration in working with transgender individuals is how family is defined. Due to the heterosexism, transprejudice, transphobia, and transnegativity many transgender individuals experience, it is common for transgender people to be rejected from their family of origin; there may be conflict and/or separation from nuclear and extended families. Transgender individuals may therefore find and define family by those who perform the roles of family, despite biological or legal adoption within a family unit. This broader definition of family should be honored and integrated into the counseling process as the individual chooses. Within the transgender community, this is usually referred to as “family of choice,” and also the authors urge counselors to honor how individuals define and label family for themselves.

LIMITATIONS OF COMPETENCIES

Although this document attempts to provide a comprehensive list of competencies in counseling transgender clients, the authors also want to acknowledge that this project has limitations in its scope. These competencies are intended to be a foundation, and the authors encourage counselors to continually develop resources and knowledge that build upon limitations. Some particular limitations the authors would like to note regarding this project are specific populations and differences related to what some may label as a gender transition.

With regards to specific populations, the competencies did not permit for an in-depth application to counseling transgender youth, the elderly, or working with the family and loved ones of transgender individuals. Although many items in these competencies will be relevant for working with transgender youth and family and loved ones of transgender individuals, because it was not the focus, there are considerations that require further attention and commentary. The authors have attempted to address this issue through providing resources at the end of the document.

An additional limitation that the authors felt important to note is that the document does not break down the competencies by the specific experiences of identifying as male-to-female (MTF) or female-to-male (FTM) and those who identify with other gender descriptions (e.g., genderqueer). For instance, an important difference to note is the experiences relating to the loss of male privilege for MTF transgender individuals and the gain of male privilege for FTM transgender individuals. These experiences also vary within the range of gender identity and expression and are based on the individual's experience (e.g., how gaining male privilege is experienced by a FTM will vary widely, such as how other identities such as race/ethnicity intersect with their gender identity). Not every transgender individual will decide to make a medical and/or social transition from MTF or FTM, not all transgender people identify with the word transition, and not all transgender individuals identify within the current gender binary (male or female). Ze/she/he instead may identify as genderqueer, androgynous, gender-fluid, and so on. Regardless, it is important for counselors to be aware of the pressure all individuals experience related to fitting into the narrow gender binary and the additional challenges transgender people might face when stepping out of these gender confines.

ORGANIZATION OF COMPETENCIES

Using the theoretical framework articulated above, the authors developed domains of competencies for counseling with transgender clients. The competencies are organized according to the Council for Accreditation of Counseling and Related Educational Programs standards (CACREP; 2009). They are divided into eight domains that align with the eight training domains of CACREP standards, as the expectation that the CACREP standards are the minimum standards for the delivery of ethical and competent counseling supervision and training of the counseling profession. In this document, the authors have encouraged counselors to move beyond competence into the role of conscientious consumers of these standards by becoming social change agents and allies for transgender clients. It was the authors’ intention that counselors will recognize and celebrate the rich histories, lives, and pride of transgender clients and communities.

The competencies incorporated a multicultural counseling competency framework that includes knowledge, skills, and awareness (KSA) areas (Sue et al., 1992). This framework was used for the LGBT competencies (AGLBIC, 2003), and the authors find it appropriate to similarly structure these competencies for working with transgender clients as a beginning step. Although the KSA structure was the existing framework for organizing these competencies, the authors also recognized that this document will evolve and require revision over time. Thus, these competencies will require periodic evaluation and revision to reflect current theory, research, practice, and counseling frameworks regarding transgender clients. Therefore, the authors also set an intention to welcome feedback from those reading and using these competencies. This feedback may be e-mailed to the current ALGBTIC president (e-mail found at www.algbtic.org) at any time, which will then be directed to the ALGBTIC Transgender Committee chair. The authors also recognized that there are also many interactions among the three areas of the KSA competence model, and therefore all eight domains of these competencies respectively integrate all three areas (vs. identifying specific and respective competencies of knowledge, skills, and awareness for each of the eight CACREP domains).

Using an organizational structure that integrates the eight CAREP domains and draws from the content and spirit of the ACA multicultural (Sue et al., 1992) and the ACA Advocacy Competencies (Lewis et al., 2003), the authors recognized that it is inevitable that references for various CACREP domains and KSA areas overlap and could become cumbersome in utilizing the competencies. Therefore the authors have listed all references at the end of the entire document for readers’ reference and further professional development. Also, the authors made no links in the body of the text to specific references. Rather, counselors should use the reference section as critical tools to obtain resources for their continued professional development in theory, research, practice, training, advocacy, and resilience of transgender clients.

FOUNDATIONAL LITERATURE

As part of the initial development of these competencies, the authors recognized the importance of using empirical research as a basis from which the competencies could be identified. Such a process stemmed in part from calls from the professional literature that stressed the importance of using current empirical and theoretical literature in the development of guidelines for multicultural practice and training (Association for Assessment in Counseling and Education, 2002). The authors also included sources in their review of the literature with which they believed readers should engage for their own professional development as counselors use these competencies.

• American Counseling Association Advocacy Competencies (Lewis et al., 2003)

• American Counseling Association multicultural competence (Sue et al., 1992)

• American Counseling Association Ethics Code (2005)

• Council for Accreditation of Counseling and Educational Related Programs (2009)

• World Professional Association of Transgender Health standards of care (Meyer et al., 2001)

• American Psychological Association Report of the Task Force on Gender Identity and Gender Variance (2009)

A. Human Growth and Development

Competent counselors will:

• A. 1. Affirm that all persons have the potential to live full functioning and emotionally healthy lives throughout their life span while embracing the full spectrum of gender identity and expression, gender presentation, and gender diversity beyond the male-female binary.

• A. 2. Identify how respective developmental periods throughout the life span (e.g., youth, adolescence, elderly) may impact the concerns and process that transgender clients present in counseling.

• A. 3. Affirm transgender mental and medical health care (e.g., hormone therapies, sex reassignment surgery, safe and transgender-positive general medical services) through the entire life span, not just during the initial assessment process or during transition.

• A. 4. Understand the biological, familial, social, cultural, socioeconomic, and psychological factors that influence the course of development of transgender identities.

• A. 5. Identify the gender-normative assumptions present in current life-span development theories and address these biases in assessment and counseling practices.

• A. 6. Understand how stigma and pressures to be gender conforming may affect personality development even in the face of the resiliency and strengths of transgender individuals. Further, understand how these factors influence decision making in regards to employment, housing, health care, and manifestation of psychological disorders of transgender individuals.

• A. 7. Recognize the influence of other contextual factors and social determinants of health (e.g., race/ethnicity, education, religion and spirituality, socioeconomic status, sexual orientation, role in the family, peer group, geographical region, etc.) on the course of development of transgender identities.

• A. 8. Be informed of the various ways of living consistently with one's gender identity, which may or may not include physical or social gender transition, and how these options may affect transgender individuals throughout their development. Be aware of the sociopolitical influences that affect the lives of transgender individuals, and that stereotyping, discrimination, and marginalization may shape one's developmental processes, self-esteem, and self-concept.

• A. 9. Recognize that the normative developmental tasks of many transgender individuals may be complicated or compromised by one's self identity and/or sexuality confusion, anxiety and depression, suicidal ideation and behavior, nonsuicidal self-injury, substance abuse, academic failure, homelessness, internalized transphobia and transprejudice, SID/HIV infection, addiction, and other mental health issues.

• A. 10. Understand how transgender individuals navigate the complexities of self and others with regard to intimate relationships throughout the life span.

• A. 11. Understand that the typical developmental tasks of transgender seniors often are complicated or compromised by social isolation and invisibility, medical problems, transgender-related health concerns, family-of-origin conflicts, and often limited career options—especially for those with developmental disabilities.

• A. 12. Recognize that gender identity formation, self-acceptance of transgender identity, and disclosure of transgender status are complex processes and events that are not necessarily permanently resolved and may be experienced repeatedly across one's life span.

B. Social and Cultural Foundations

Competent counselors will:

• B. 1. Understand the importance of using appropriate language (e.g., correct name and pronouns) with transgender clients; be aware that language in the transgender community is constantly evolving and varies from person to person; seek to be aware of new terms and definitions within the transgender community; honor clients’ definitions of their own gender; seek to use language that is the least restrictive in terms of gender (e.g., using client's name as opposed to assuming what pronouns the client asserts are gender affirming); recognize that language has historically been used to oppress and discriminate against transgender people; understand that the counselor is in a position of power and should model respect for the client's declared vocabulary.

• B. 2. Acknowledge that the oppression of transgender people is a component of sexism, heterosexism, transphobia, and transprejudice and reflects a worldview and value system that undermines the healthy functioning and autonomy of transgender people.

• B. 3. Understand that transprejudice and transphobia pervades the social and cultural foundations of many institutions and traditions and fosters negative attitudes, high incidence of violence/hate crimes, and overt hostility toward transgender people.

• B. 4. Recognize how internalized prejudice and discrimination (e.g., transphobia, racism, sexism, classism, religious discrimination, ableism, adultism, ageism) may influence the counselor's own attitudes as well as those of her/his/hir transgender clients resulting in negative attitudes toward transgender people.

• B. 5. Recognize, acknowledge, and understand the intersecting identities of transgender people (e.g., race/ethnicity, ability, class, religion/spiritual affiliation, age, experiences of trauma) and their accompanying developmental tasks. This should include attention to the formation and integration of the multiple identity statuses of transgender people.

• B. 6. Understand how the specific intersection of sexism, heterosexism, and transphobia may affect clients’ lives. For example, sexism (how patriarchy promotes gender stereotypes and roles and how power and privilege are distributed to reinforce the binary gender system), transphobia (internalized fears or negative self-concept), transprejudice (discrimination against transgender people), and heterosexism (conflating sexual orientation and gender identity) are different. Counselors should understand also how heterosexism impacts both those who identify as homosexual and heterosexual, because ze/she/he may be viewed as being outside of the gender binary or as “really a man/woman” and therefore are seen as gay, lesbian, and/or bisexual).

• B. 7. Understand how the specific intersection of racism, sexism, heterosexism and transphobia and transprejudice influences the lives of transgender people of color (e.g., increased risk for HIV/AIDS and overrepresentation of transgender people of color in HIV infections) and recognize the negative stereotypes used against transgender people of color.

• B. 8. Acknowledge how classism affects the lives of transgender people through increased rates of homelessness, restricted job opportunities and increased marginalization within the work place, and lack of federal employment protections.

• B. 9. Identify transgender-positive resources (e.g., support groups, websites, brochures) that address multiple identities of transgender people (e.g., youth, differential ability, people of color).

• B. 10. Use empowerment and advocacy interventions (see ACA Advocacy Competencies) when necessary and/or requested with transgender clients (e.g., employment and education discrimination, transgender people of color, housing discrimination).

• B. 11. Educate themselves and others about the damaging impact of colonization and patriarchy on the traditions, rituals, and rites of passage specific to transgender people across cultures over time (e.g., Hijras of India, Mahu of Hawaii, Kathoey of Thailand, Two-Spirit of Native American/First Nations people).

• B. 12. Recognize that spiritual development and religious practices may be important for transgender individuals, yet it may also present a particular challenge given the limited transpositive religious institutions that may be present in a given community, and that many transgender individuals may face personal struggles related to their faith and their identity.

C. Helping Relationships

Competent counselors will:

• C. 1. Understand that attempts by the counselor to alter or change gender identities and/or the sexual orientation of transgender clients across the life span may be detrimental, life threatening, and are not empirically supported; whereas counseling approaches that are affirmative of these identities are supported by research, best practices, and professional organizations—such as the American Counseling Association, American Psychological Association.

• C. 2. Recognize that the counselors’ gender identity, expression, and concepts about gender are relevant to the helping relationship, and these identities and concepts influence the counseling process and may affect the counselor/client relationship.

• C. 3. Be aware that, although the client is transgender and may have gender-related concerns, the client's primary concern and reason for seeking counseling services may not be related to gender identity and/or gender dysphoria.

• C. 4. If gender identity concerns are the reason for seeking treatment, counselors acknowledge experience, training, and expertise in working with individuals with gender concerns at the initial visit while discussing informed consent and seek supervision and consultation as necessary.

• C. 5. Acknowledge with the paucity of research on efficacious theoretical approaches for working with transgender populations, counselors are urged to conduct routine process monitoring and evaluation of their service delivery and reevaluate their theoretical approach for working with transgender individuals.

• C. 6. Acknowledge that, although gender identities and expressions are unique to individuals, they can vary greatly among and across different populations of transgender people. Further, a transgender client's gender identity and/or expression may evolve across their life span.

• C. 7. Acknowledge that physical (e.g., access to health care, HIV/AIDS, and other health issues), social (e.g., family/partner relationships), emotional (e.g., anxiety, depression, substance abuse), cultural (e.g., lack of support from others in their racial/ethnic group), spiritual (e.g., possible conflict between their spiritual values and those of their family's), and/or other stressors (e.g., financial problems as a result of employment discrimination) often interfere with transgender people's ability to achieve their goals. Therefore, it is important assist them with overcoming these obstacles and regulating their affects, thoughts, and behavior throughout this coping process.

• C. 8. Recognize and acknowledge that, historically, counseling and other helping professions have compounded the discrimination of transgender individuals by being insensitive, inattentive, uninformed, and inadequately trained and supervised to provide culturally proficient services to transgender individuals and their loved ones.

• C. 9. Create a welcoming, affirming environment for transgender individuals and their loved ones by creating a counseling space that affirms transgender people's identity (e.g., placing transgender-positive magazines and literature in the waiting room, etc.). Respect and attend to the entire individual—not just his or her gender identity-related concerns.

• C. 10. Facilitate an open discussion to identify the effects of transprejudice and discrimination experienced by transgender clients and assist them in overcoming potential internalized negative attitudes about themselves and their gender identities.

• C. 11. Proactively seek consultation and/or supervision from professionals competent in working with transgender individuals (please refer to WPATH's Standards of Care regarding guidelines for professional competency) to ensure that the counselors’ own biases or knowledge deficits do not negatively affect the helping relationship.

D. Group Work

Competent group counselors will:

• D. 1. Maintain a nonjudgmental, supportive stance on all expressions of gender identity, gender expression, and sexuality and establish this as a standard for group members as well.

• D. 2. Facilitate group members’ understanding that mental health professionals’ attempts to change a member's gender identity (e.g., conversion or reparative therapies) are not supported by research and, moreover, may have detrimental and/or life-threatening consequences.

• D. 3. Involve members in establishing the group treatment plans, expectations, and goals, which should be reviewed periodically throughout the group. These should foster the safety and inclusion of transgender members.

• D. 4. Provide education and opportunities for social learning about a wide array of choices regarding coming out and transitioning if indicated or warranted.

• D. 5. Recognize the impact of power, privilege, and oppression within the group especially among the counselor and members and between members of advantaged and marginalized groups.

• D. 6. Consider diversity (e.g., gender identity and expression, sex assigned at birth, sexual orientation, mental and physical ability status, mental health concerns, race, ethnicity, religion, and socioeconomic class) when selecting and screening group members and be sensitive to how these aforementioned diverse identities may affect group dynamics.

• D. 7. Be aware of the unique status of an individual who may be the only transgender group member and create a safe group environment in which that person can share her or his experiences if feeling comfortable. In this case, it is especially important to foster a sense of security within the group through the use of respectful language toward the transgender member (e.g., correct pronouns and name; gender-affirmative terminology of transition interventions).

• D. 8. In gender-specific groups (e.g., inpatient treatment settings, substance abuse treatment, etc.), counselors should support transgender individuals attending the gender group with which they identify with rather than, for instance, insisting that a transgender person attends a group setting according to the sex that person was assigned at birth.

• D. 9. Acknowledge the impact of institutionalized and personalized transphobia and transprejudice on transgender members’ comfort with disclosing and reflecting on their experiences that occur inside and outside of group.

• D. 10. Actively intervene when either overt or covert hostility toward transgender-identified members threatens group security and cohesion. This applies to transgender-specific groups and any group that has transgender members.

• D. 11. Recognize that although group support can be very helpful for transgender clients, peer pressure from group members to conform to specific conceptions of gender identity and expression may emerge within the group and should be addressed by the counselor.

• D. 12. Coordinate treatment with other professionals working with transgender members, while maintaining confidentiality within the group.

• D. 13. Refer clients to other mental and physical health services when either initiated by the group member or due to clinical judgment that the member is in need of these interventions.

• D. 14. Be aware of how their own gender identities, beliefs about gender, and lack of knowledge about transgender issues may affect group processes.

• D. 15. Seek consultation or supervision to ensure that the counselor's potential biases and knowledge deficits do not negatively affect group dynamics.

• D. 16. Will ideally have previous experience working with transgender individuals in non-transgender-specific and transgender-specific groups. If no previous counseling experience with transgender individuals exists, consultation and supervision with mental health professionals who are competent and have more experience working with transgender issues are even more critical.

E. Professional Orientation

Competent counselors will:

• E. 1. Understand and be aware that there has been a history of heterosexism and gender bias in the Diagnostic and Statistical Manual (DSM). For instance, counselors should have knowledge that homosexuality was previously categorized as a mental disorder and that currently “gender identity disorder” remains in the DSM.

• Know the history of how the helping professions have negatively influenced service delivery to transgender individuals, their families, and significant others through heterosexism and gender bias and specifically know the history of when “gender identity disorder” was inserted into the Diagnostic and Statistical Manual (DSM) and when homosexuality was removed as a mental health disorder.

• E. 2. Acknowledge and address the gatekeeper role and subsequent power that mental health professionals have historically had in transgender clients accessing medical interventions and resulted in mistrust of mental health professionals. This power difference needs to be minimized in the counseling relationship with transgender clients.

• E. 3. Ascertain the needs and presenting concerns of transgender clients, including transgender identity development, gender confusion, gender transition, gender expression, sexuality, anxiety, and depression related to transgender life experiences, family/partner relationships, substance abuse, transgender health issues, and presenting concerns unrelated to gender.

• E. 4. Understand the related ACA ethical guidelines (e.g., nonmaleficence, fidelity, competence, etc.) relevant for counseling individuals who are exploring issues related to gender identity, gender expression, and sexual orientation.

• E. 5. Seek consultation or supervision to ensure that personal biases do not negatively affect the client–therapist relationship or the treatment outcomes of the transgender individual.

• E. 6. Be familiar with and know how to assist transgender clients access community resources where appropriate.

• E. 7. Facilitate access to appropriate services in various settings for transgender individuals by confronting institutional barriers and discriminatory practices.

• E. 8. Seek professional development opportunities to enhance attitudes, knowledge, and counseling skills related to transgender individuals.

• E. 9. Recognize the importance of educating professionals, students, and supervisees about transgender issues and challenge misinformation and bias about transgender individuals.

• E. 10. Support a positive, public dialogue that affirms individual gender expression and gender identity.

• E. 11. Serve as advocates for transgender individuals within professional counseling organizations, and specifically advocate for antidiscrimination policies concerning transgender individuals.

• E. 12. Collaborate with health professionals and other individuals, groups, agencies, as indicated by the individual to provide comprehensive care.

F. Career and Lifestyle Development Competencies

Competent counselors will:

• F. 1. Assist transgender clients with exploring career choices that best facilitate identity formation and job satisfaction.

• F. 2. Recognize that existing career development theories, career assessment tools, employment applications, and career counseling interventions contain language, theory, and constructs that may be oppressive to transgender and gender-conforming individuals.

• F. 3. Acknowledge the potential problems associated with career assessment instruments that have not been normed for the transgender community.

• F. 4. Challenge the occupational stereotypes (e.g., sex work, entertainment careers, etc.) that restrict the career development and professional decision making of transgender clients, or respect decisions to remain in entertainment careers, while also be prepared to affirm that these are valid jobs for those who are satisfied working in these fields.

• F. 5. Acknowledge and understand how the interplay of discrimination and oppression against transgender individuals adversely affect career performance and/or result in negative evaluation of their job performance and thus may limit career options resulting in underemployment, less access to financial resources, and overrepresentation in certain careers.

• F. 6. Demonstrate awareness of the high degree of discrimination that transgender individuals have historically experienced in the workplace and how this discrimination may affect other life areas (e.g., housing, self-esteem, family support).

• F. 7. Demonstrate awareness of and skill in addressing employment issues and challenges for transgender individuals who have experienced a medical and/or social transition, those who may choose to transition, and those who may not opt to transition while in the workplace and recognize the diversity of experiences for transgender individuals who choose to transition while in the workplace.

• F. 8. Explore with clients the degree to which government (i.e., federal, state, and/or local) statutes, union contracts, and workplace policies protect workers against employment discrimination based on gender identity and expression. In cases where there is no protection of transgender employment rights, provide information on advocacy and support efforts.

• F. 9. Link clients with transgender mentors and resources that increase their awareness of viable career options.

• F. 10. Provide employers with consultation and education on gender identity issues and ways to facilitate workplace changes, such as restrooms, locker rooms, staff education, and creating a respectful, inclusive environment.

• F. 11. Assist with empowering transgender individuals to advocate on their own behalf as appropriate in their workplace context (i.e., microlevel or macrolevel) and/or offer to engage in this advocacy with the client's consent if the client would benefit from a direct workplace psychoeducation/training on transgender issues and safety in the workplace.

• F. 12. Advocate for gender identity and gender expression antidiscrimination policies in the workplace as they are applicable on microlevel (e.g., in the workplace) and macrolevels (e.g., in the local and larger communities where we live, with policy makers and legislators, etc.).

G. Appraisal

Competent counselors will:

• G. 1. Determine the reason for counseling services at the initial visit (e.g., exploring gender issues, career issues, relationship issues, evaluation and referral for medical services, or other mental health services).

• G. 2. Identify challenges that may inhibit desired treatment (e.g., cognitive impairment, serious mental health concerns such as psychosis or personality disorders, medical issues, developmental disabilities, etc.).

• G. 3. Understand that gender identity and expression vary from one individual to the next, and that this natural variation should not be interpreted as psychopathology or developmental delay.

• G. 4. Examine the legitimate power that counselors hold as helping professionals, particularly in regards to assessment for body modifications, and seek to share information on the counselor's gatekeeping role (e.g., writing letters supporting body modifications) so it is not a restrictive influence but rather seeks to better serve transgender people's needs.

• G. 5. Understand the power that counselors have in meeting the needs of transgender individuals in regards to making decisions about hormonal or surgical interventions. Therefore, it is important to collaboratively discuss the potential length of counseling services and costs as a part of the informed consent process.

• G. 6. Recognize that the goal of treatment is to provide a comprehensive psychosocial mental health assessment, which should encompass all life areas, for all transgender individuals whether they are seeking medical interventions and/or body modifications.

• G. 7. Examine how their own biases and privilege may influence their assessment with each transgender individual. Such bias might include sexism, heterosexism, transnegativity, promoting medical interventions, or a particular course of treatment.

• G. 8. Utilize supervision and consultation as tools to help counselors minimize biases and avoid misuse/abuse of privilege and power (e.g., in regards to providing approval for transgender individuals to obtain medical treatment and/or body modifications).

• G. 9. Understand how heterosexism and sexism are promoted and maintained within society, and how these dynamics influence the assessment of transgender individuals.

• G. 10. Consider in the differential diagnosis process how the effects of stigma, oppression, and discrimination contribute to psychological symptoms but do not necessarily indicate pathology for transgender individuals. Consider these effects when collaboratively deciding client's readiness for body modifications.

• G. 11. Apply ethical standards when utilizing assessment tools such as tests, measurements, and the current edition of the DSM-IV-TR, and recognize that these assessments have often not been normed with transgender people. As many assessments are also products of a sexist and heterosexist culture and may reinforce a pathological or transgender-negative perspective on transgender people, determine which assessments are in the best interest of transgender people (i.e., ones that do not equate mental health with being gender conforming) and employ a collaborative assessment approach when possible.

• G. 12. Be sensitive to and aware of the ongoing debate regarding gender identity “disorder” being listed as a medical condition in the current edition of the DSM and be willing to communicate to transgender individuals the position the helping professional takes, and to have open and honest discussions about how this may affect the work you do together.

• G. 13. Be familiar with WPATH's Standards of Care principles to guide but not dictate treatment for individuals with gender identity and expression concerns, including gender dysphoria.

• G. 14. Be prepared to face ethical dilemmas with the appraisal of transgender people, especially because theories and practices with transgender people continue changing and evolving, and creating many ethical dilemmas.

• G. 15. Seek out the perspectives and personal narratives of the transgender community as essential components to fully understanding appropriate assessment of transgender people.

• G. 16. Recognize that the presence of a co-occurring mental or physical health disorder does not necessarily preclude counseling for gender concerns or medical treatments but may or may not require stabilization or additional treatment.

• G. 17. Recognize that transgender people with mental health concerns (e.g., severe mental health issues such as personality disorders) and/or cognitive challenges experience significant bias and discrimination and may benefit from discussions about the impact of mental health stigma on their daily lived experiences and their selection of body modifications.

H. Research

Competent counselors will:

• H. 1. Be aware of existing transgender research and literature regarding social and emotional well-being and difficulties, identity formation, resilience and coping with oppression, as well as medical and nonmedical treatment options.

• H. 2. Consider limitations of existing literature and existing research methods regarding transgender individuals such as sampling, confidentiality, data collection, measurement, and generalizability (e.g., LGB literature applying results and content to transgender individuals).

• H. 3. Be aware of the gaps in literature and research regarding understanding the experiences of and assisting of transgender individuals and family members.

• H. 4. Have knowledge of qualitative, quantitative, and mixed methods research processes and potential future research areas related to transgender concerns in counseling (e.g., individual experiences of transgender people, counselor awareness and training on transgender concerns, reduction of discrimination toward transgender individuals, advocacy opportunities for positive social change in the lives of transgender individuals).

• H. 5. Consider how critical consumption of research may assist with understanding needs, improving quality of life, and enhancing counseling effectiveness for transgender individuals.

• H. 6. Formulate research questions collaboratively with transgender individuals and communities, taking into account transgender participants and transgender issues/concerns.

• H. 7. Construct surveys or any data-gathering forms that include gender demographic information options that provide participants with the opportunity to disclose their declared or affirmed gender identity while concurrently not conflating gender identity and sexual orientation.

• H. 8. Be familiar with current transgender-affirmative terminology and be aware of the importance of using the least restrictive gender language that adheres to participants’ declared or affirmed pronouns/names.

• H. 9. Involve transgender-identified individuals in research regarding transgender issues/concerns when appropriate and possible—while attending to and being reflective of transgender research participants’ lived experiences.

• H. 10. Recognize research is never free of positive or negative bias by identifying the potential influence personal values, gender bias, and heterosexism may have on the research process (e.g., participant selection, data gathering, interpretation of data, reporting of results, DSM-IV-TR diagnosis of gender identity “disorder”), and seek to address these biases in the best manner possible.

• H. 11. Make transgender-focused research available to the transgender community served by making a study's results and implications accessible for the community, practitioners, and academics alike.

APPENDIX A

The authors of this document recommend the following as a growing list of some of the least restrictive terms available for use with transgender people, which are derived from the Lambda Legal (2008) publication, Bending the Mold: An Action Kit for Transgender Youth and reproduced below with permission of Lambda Legal.

• Biological Sex, Sex: a term used historically and within the medical field to refer to the chromosomal, hormonal, and anatomical characteristics that are used to classify an individual as female or male.

• Classism: a system of institutionalized practices and individual actions that benefits people who have wealth and power.

• Crossdresser: a person who, on occasion, wears clothing associated with another sex, but who does not necessarily desire to change his or her sex. Many crossdressers identify as heterosexual but can have any sexual orientation.

• Drag King / Drag Queen: a performer who wears the clothing associated with another sex, often involving the presentation of exaggerated, stereotypical gender characteristics. The performance of gender by drag queens (males in drag) or drag kings (females in drag) may be art, entertainment, and/or parody.

• FTM (Female to Male), Transgender Man: terms used to identify a person who was assigned the female sex at birth but who identifies as male.

• Gender: a set of social, psychological, and emotional traits, often influenced by societal expectations, that classify an individual as feminine, masculine, androgynous, or other.

• Gender Binary: the concept that everyone must be one of two genders: man or woman.

• Gender expression: The outward manifestation of internal gender identity, through clothing, hairstyle, mannerisms, and other characteristics.

• Gender Identity: the inner sense of being a man, a woman, both, or neither. Gender identity usually aligns with a person's sex but sometimes does not.

• Gender Dysphoria: an intense, persistent discomfort resulting from the awareness that the sex assigned at birth and the resulting gender role expectations are inappropriate. Some consider gender dysphoria to be a symptom of gender identity disorder, a health condition recognized by the American Psychiatric Association. Many transgender people do not experience gender dysphoria.

• Genderqueer: a term used by some people who may or may not identify as transgender, but who identify their gender as somewhere on the continuum beyond the binary male/female gender system.

• Gender-Nonconforming: behaving in a way that does not match social stereotypes about female or male gender, usually through dress or physical appearance.

• Gender Role: the social expectation of how an individual should act, think, and feel, based upon the sex assigned at birth.

• Gender Transition: the social, psychological, and medical process of transitioning from one gender to another. Gender transition is an individualized process and does not involve the same steps for everyone. After gender transition, some people identify simply as men or women.

• Hormone Therapy: administration of hormones and hormonal agents to develop characteristics of a different gender or to block the development of unwanted gender characteristics. Hormone therapy is part of many people's gender transitions and is safest when prescribed and monitored by a health care professional.

• MTF (Male to Female), Transgender Woman: terms used to identify a person who was assigned the male sex at birth but who identifies as female.

• Oppression: the acts and effects of domination of certain groups in society over others, caused by the combination of prejudice and power. Systems of oppression include racism, sexism, homophobia, and transphobia.

• Post-Op, Pre-Op, Non-Op: terms used to identify a transgender person's surgical status. Use of these terms is often considered insulting and offensive. Surgical status is almost never relevant information for anyone except a transgender person's medical providers.

• Privilege: social and institutional advantages that dominant groups receive and others do not. Privilege is often invisible to those who have it.

• Racism: a system of institutionalized practices and individual actions that benefits white people over people of color.

• Sex Reassignment Surgery (SRS): any one of a variety of surgeries involved in the process of transition from one gender to another. Many transgender people will not undergo SRS for health or financial reasons, or because it is not medically necessary for them.

• Sexism: a system of institutionalized practices and individual actions that benefits men over women.

• Transgender or Trans: an umbrella term used to describe those who challenge social gender norms, including genderqueer people, gender-nonconforming people, transsexuals, crossdressers, and so on. People must self-identify as transgender for the term to be appropriately used to describe them.

• Transphobia: the irrational fear of those who challenge gender stereotypes, often expressed as discrimination, harassment, and violence.

• Transsexual: a person who experiences intense, persistent, long-term discomfort with their body and self-image due to the awareness that their assigned sex is inappropriate. Transsexuals may take steps to change their body, gender role, and gender expression to align them with their gender identity.

APPENDIX B

List of Reviewers and Their Affiliations

• lore dickey, MA, counseling psychology doctoral student at the University of North Dakota

• Dara Hoffman, MA, LPC, professional counselor in private practice

• Joanne Keatley, PhD, director of the Center for Excellence of Transgender HIV Prevention at The University of California, San Francisco

• Arlene Lev, LCSW, social worker and author of Transgender Emergence

• Vel S. McKleroy, MPH, behavioral scientist at The Centers for Disease Control and Prevention and Transgender Working Group Leader

• Mr. Jesse McNulty, MS, special education school teacher, feminist activist, and Georgia Safe Schools Coalition member

• Stacee Reicherzer, PhD, LPC, professional counselor and Walden university counselor educator