6 Three critical tools for providing Gender Affirming Care with Youth and Adolescents and Adults
Nicholas R. Marzo, MS LPC, LMHC, CST, ACS, NCC, CCMHCE
For the purpose of this article, I am using the term transgender to mean any identity that is not cis-gender. This includes, non-binary, genderqueer, genderfluid, two spirit and any of the other words and labels people use to describe their experience of gender outside of the cisgender binary experience.
As an author, I am a middled aged, white, transmasculine genderqueer, neurodivergent, Licensed Professional Counselor, Certified Sex Therapist, Approved Clinical Supervisor whose career spans 25 years of working in various aspects of direct care and administrative oversight with a diverse population. I currently own a group psychotherapy practice in the Southeast United States that centers the experiences of those who have been marginalized or oppressed due to their gender, sexuality, or how they choose to love and engage in pleasure.
Introduction and the Role of the Therapist
Behavioral health practitioners, including sex therapists, play a key role in the identity development of transgender youth. In the role of individual or family therapist, they may serve the youth in many ways: advocate, educator, diagnostician, a safe place to explore, play and try on ideas and concepts, and, especially when the practitioner is trans themselves, role model.
One of the most difficult aspects of working with transgender youth and adolescents is navigating the large amount of information available related to transgender embodiment. We are often the first adult the youth will speak to about how they experience their gender, sharing with us both the joys and the challenges of being a trans youth in school, at home and in their community. We, therefore, have a responsibility to not only be aware of the resources available for the youth to thrive but of biases, both internal and external, which play a role in trans embodiment.
In 2015 there were 19 pieces of anti-trans legislation introduced in the United States. In 2023 that number has risen to 555, an increase of 2821% (translegislation.com/learn). This combined with a culture where children are viewed, less often as small humans with agency and self- determination and more often as property or an extension of the family system with a spoken (or unspoken expectation to uphold the values, expectations and vision of that system, we as clinicians are often left stuck to wade through client goals, parental/guardian values, standards of care, our own biases and the law to determine how we can best support the needs of trans youth. As we engage in this complex task we will arm ourselves with many tools, resources and clinical interventions. For me, as a transgender therapist and supervisor, there are three tools in my toolbox I cannot live without: Media Literacy Tools, the Stages of Change Model, and Motivational Interviewing.
The Tools
Media Literacy
As therapists we are rarely exposed to media literacy as part of our training. I was first introduced to the concept of media literacy when I engaged in my second Sexual Attitudes Reassessment taught by Bianca I. Laureano, CSE, Dr. Lexx Brown-James, LMFT, CSE and Goody Howard, MSW, MPH. Exposure to this concept changed how I practice, specifically with queer and trans youth. It gave me a tool to use as part of my own personal and professional development, and with youth, parents, and my supervisees.
What is Media Literacy?
According to the Center for Media Literacy, Media Literacy is “a 21st century approach to education. It provides a framework to access, analyze, evaluate, create, and participate using messages in a variety of forms—from print to video to the internet. Media literacy builds an understanding of the role of media in society as well as essential skills of inquiry and self-expression necessary for citizens of a democracy” (Jolls & Thoman, 2008). A research-based method for approaching all forms of media using a critical lens, Media Literacy is formed around five concepts: authorship, format, audience, content and purpose. These five concepts are framed using five questions:
- Who created this message?
- What creative techniques are used to attract my attention?
- How might different people understand this message differently?
- What values, lifestyles and points of view are represented in or omitted from this message?
- Why is this message being sent?
My intention is not to teach you Media Literacy, but instead to expose you and share some ways you can use this tool in your work with transgender youth and their families.
The first place I found myself using this tool was as a means of deconstructing some of my own biases. I was able to use these questions as a foundation to assess the biases within theories and clinical interventions I had been trained to use over decades of work, helping me to notice where they may cause harm to my clients or to supervisees. and where they may be beneficial. Right from the beginning, it did not matter what intervention I was looking at, the answer to the first question was a version of “a white, middle class cis gender person”. This combined with transgender people having been seen as mentally ill from the inception of the DSM until publication of the DSM-V in 2015 meant that many of the interventions I had been trained to use, were at risk of having a different impact than intended without significant “tweaking” using a lens of queer theory, feminist theory, and liberation psychology. Using the questions when analyzing and evaluating clinical interventions provided me with the clarity I needed to engage in critical thinking as I developed my tool box of referral sources, interventions, and community resources. This same benefit crosses over into my work as a clinical supervisor, giving me a framework to help supervisees develop their own critical thinking skills around tools and interventions they would bring into their own work. Examples of shifts in the work were application of less cognitive based interventions and more humanistic interventions. Another shift was recognizing how interventions I was taught were best used in environments such as the field of addiction held the key to working with parents of youth exploring their gender, something I will visit a bit later in this writing.
The second, and most rewarding use of these questions is with the youth. Application of the questions could be used in session to look at everything from their favorite new manga, to that tumblr post about sex, to news articles about anti trans legislation in their area. It gave me an opportunity to help them zoom out, take into consideration the intent behind a piece of media, and then zoom back in and assess the impact it has on their cognitions, nervous system, emotions and decision making.
The last, and most impactful use of these questions is with family. Most often we find that cisgender parents of a transgender youth are unable to look at any piece of information through the same lens as their child. How can they? As parents we are often living through our own narratives and projecting our own stories about who we hoped the child would be or think their child should do over who their child is and learning to see the world through their eyes and listen to their experience. These narratives may be reinforced by the rhetoric of anti-trans voices at church, on the news, in the government, etc. By exposing parents to the critical thinking questions of media literacy, a neutral approach with no agenda, therapists we offer a tool for parents to recognize which pieces of information they are consuming are aligned with their value of loving and supporting their child vs which pieces may be in contradiction to their child’s safety and wellbeing.
You can get more information and training guides on Media Literacy at the following websites:
https://www.medialit.org/ and https://mediasmarts.ca/.
Specific resources from Center for Media Literacy include the MediaLit Kit and Media Literacy for the 21st Century.
Stages of Change Model
Also known as the Transtheoretical Model (1983), developed by Prochaska and DiClemente in the late 70s, the Stages of Change model focuses on the decision-making of the individual in care and is a model focused specifically on intentional change. I was first exposed to this model in the late 90s when doing court mandated addiction work. The model, combined with Motivational Interviewing, was a core tool in helping folks to take control of their addiction and make change in their life. When I began working with trans people in individual therapy, I realized that I was continuously conceptualizing my clients using this framework. Later, as I added youth to my practice and then expanded to transgender people in early stages of transition and their cis-gender partners, the Stages of Change became more than conceptualization, it became a script for how to explain the dynamics within the family system.
The Stages of Change Model states that people move through five stages as they implement change to remove unhealthy behaviors in their lives. I will describe the stages as they were designed. As a transgender person, I would pose that despite the model being theorized in relation to “unhealthy behaviors” it is completely applicable to the process of transition and gender embodiment, where living life “cisgender person” would represent the unhealthy behavior*.
Precontemplation:
Defined: the individual is not ready nor are they intending to take action, they are unaware or unable to internalize of the impact of their behavior on self or others, this stage includes concepts of denial, pessimism that change is possible, unable to see the reward of change vs the discomfort of the current situation, filtering information which reinforces their unreadiness to change
What is may sound like in therapy: ““I’ve lived this way this long, I do not need to do this”” or “My child can wait until they are on their own insurance to start hormone therapy.” or “I gave my child this name, how could they do this to me?”
Contemplation:
Defined: the person is open to hearing new information, weighs pros and cons, engages in cost analysis of staying in current state vs implementing change towards new state, ambivalence may still be present
What this may sound like in therapy: “Oh I did not know that my anxiety and gender could be correlated”; “My child’s suicidality is linked to us not using their pronouns at home, I doubt it but sure I will read that article”; or “what will the people at church think”; “will he be safe”
Preparation:
Defined: individual is preparing to take action, they believe making change will ultimately result in a positive outcome, there may be small steps towards change
What this may sound like in therapy: “I wore a women’s t-shirt today instead of a man’s what do you think?”; “I started researching what hormones do to your body”; “i looked up our health insurance, did you know I could see that gender doctor downtown?”
Action:
Defined: the individual is implementing new behaviors in an effort to eliminate the unhealthy behavior
What it may sound like in therapy: “my chosen name is…”; “I am trying on she/her pronouns, can we use those in session for a while to see how it feels””; “I made an appointment to talk to my doctor”; “I came out to my mom”
Maintenance:
Defined: the person has sustained the behavior change for a period of six months or longer and intends to maintain it long term
What this looks like in therapy: topics about gender transition and embodiment are no longer a focus of treatment, they may come up from time to time or as a result of exploring different aspects of self, but no longer the core feature
It is important to note that this model is not linear, individuals enter and exit different stages throughout the change process. For example, it is not uncommon for a person to begin hormone therapy (ACTION), experience side effects, stop the hormones and say to their physician or therapist some variation of “I’m not trans, if I was the hormones wouldn’t have made me feel this way” (Pre-contemplation). From here the therapist or physician would review education about the impact of hormones on the body and mind and use Motivational Interviewing interventions to explore ambivalence which could move the individual back into contemplation, preparation, or action.
Applying this model to the individual’s family system is also useful. When an individual is coming out to their family or partner(s) they are in the ACTION phase of the model. The person receiving the information is likely in the pre-contemplation or contemplation phase. In the context of relationship counseling, I may hear the cis-gender partner say some version of “this is moving too fast, I don’t understand”, in turn they experience “anxiety” or an attachment wound, feeling a sense of betrayal or abandonment or that their relationship is at risk because they are in the Pre-Contemplation phase. Through this lens we can find common ground and help all of the individuals in the system achieve empathy and compassion for each other’s experiences related to transition in the pursuit of hope and the common goal of love, for Self and for each other.
I highly recommend that behavioral health professionals who are working with transgender people complete at least a basic training in the transtheoretical model or read Prochaska and DiClemte’s book The Transtheoretical Approach: Crossing Traditional Boundaries of Therapy.
Motivational Interviewing (MI)
Hand in hand with critical thinking skills and the Stages of Change model is Motivational Interviewing. According to the Motivational Interviewing Network of Trainers, MI is an evidence-based approach for behavior change. This approach is best used when one or more of the following is present: ambivalence is high and people have mixed feelings about change; confidence is low due to doubt that change is possible; desire is low due to uncertainty; or importance is low due to the individual being unable to determine the benefits and disadvantages of change.
With training and consistent practice, MI becomes a form of communication within the overall context of therapy. It honors the individual’s experience and promotes a partnership between client and therapist. In the case of transgender people, their therapist is often the only brave space they have available to explore, consider the possibilities, dream and imagine what their life could be without the pressure of performing to the expectations of others. It promotes evocation, acceptance, and compassion on the part of the therapist, believing that the client knows best and work can happen within the framework of the clients values, hopes, dreams and desires, free of judgment or pathology with a core focus on the client’s well-being using a person centered lens.
The Core skills applied in MI are OARS:
Open Questions: exploring the person’s experiences and ideas using evocative questions
Affirmation: affirming successes and noting abilities for skill transfer to invite hope
Reflections: while MI does not focus on empathic reflections as a skill, these will invite a deeper emotional response from the client
Summarizing: allows the client to confirm that you understand their experience
Attending to language of change: bringing client attention to sustain language/behavior vs change language/behavior
Exchange of information: both the client and the therapist are experts and share resources and insights (Miller & Rollnick, 2013)
Motivational Interviewing becomes a key foundation tool in the clinician’s toolbox due to the inherent challenges transgender people face in their efforts to embody their gender. Throughout history transgender people have faced systemic oppression, including genocide and erasure of our history and identities across time and cultures. Now, in the early 21st century, as more and more transgender youth and adults are recognizing and attempting to embody their gender they are facing the stress of the most public of these acts of genocide. Due to social media and algorithms that seek to control content and induce specific emotional responses, transgender people and their families are faced with sorting through polarizing information, as the facts get lost in peer reviewed research less easy and more difficulty to consume. It is at this intersection where Media Literacy, the Transtheoretical Model and Motivational Interviewing become a key tool in the clinician’s toolbox for working with transgender youth and their families.
Attempting to facilitate change that completely deconstructs and reconstructs one’s personal identity, how they move through are perceived in the world, requires both a top down and bottom-up approach. It is my experience these are the core skills needed to attend to the cognitive dissonance we see in the therapy room during the transition process. While they in no way encompass ALL of the tools needed, each of them alone or combined with another will give the therapist new skills for working with transgender youth and their families as they navigate the difficult waters of change.
*How a person chooses to identify, express, embody, and possibly even evolve their gender over time is a very personal choice. I do not subscribe to any “one true way” only to the way the client presents that is consistent with their understanding of Self.
Discussion Questions:
- How do you think you can apply Media Literacy in your own practice? In your own professional development?
- As you contemplate where you are in your own understanding of transgender youth and their behavioral healthcare needs, what stage of change are you currently in?
- As you consider your supervisor, what stage do you think they may be in? How might you approach this with them if it is different than yours?
- Imagine working with a youth who is in action and a parent who is in pre-contemplation? What self as therapist issues arise? How can you tend to those issues in your own self care practices?
References
Jolls, T. & Thoman, E. (2008). An overview and orientatno guide to media literacy education. Center for Media Literacy. https://www.medialit.org/sites/default/files/01a_mlkorientation_rev2_0.pdf
Miller, W.R. & Rollnick, S. (2013) Motivational Interviewing: Helping people to change (3rd Edition). Guilford Press.
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390-395. http://dx.doi.org/10.1037/0022-006X.51.3.390
Trans Legislation Tracker. (2023). Tracking the rise of anti-trans bills in the U.S. https://translegislation.com/learn
