This document provides information on creating inclusive practices for transgender and gender nonconforming clients. It begins by noting the lack of research and literature on serving TGNC individuals, couples and families in marriage and family therapy. It emphasizes using accurate terminology, addressing personal biases, and making the therapy space safe and respectful for all genders. The document recommends understanding gender as a continuum rather than a binary, being mindful of language, and normalizing gender diversity and exploration.

1. REVIEW OF LITERATURE
Educate yourself. Know the issues TGNC individuals, couples, and families are dealing with.
Attend workshops and inclusion discussions, read additional resources, remain curious.
Language is important. Using accurate terminology and preferred pronouns is the key toward
creating a respectful and safe space for TGNC clients.
Address your personal biases. A binary gender bias is deeply embedded in Western Culture.
Subtle or not, this bias is harmful and painful for clients, and fellow clinicians. Challenge this
dominant narrative in and out of the therapy room.
Make it clear that genderisms and transphobia have no place in the therapy room.
CREATING A SAFE SPACE
EXAMPLES OF GENDER VARIANCE
REFERENCES
CONTACT: Jacquelyn Pfeifer jpfeifer@my.adler.edu | Cadmona Hall chall@adler.edu
SPECIFIC STRATEGIES TO BE GENDER INCLUSIVE
Affirming Gender Diversity in a MFT Practice
Jacquelyn E. Pfeifer & Cadmona A. Hall PhD, LMFT, FT
Adler University
TERMS TO KNOW
Biological Sex: Refers to the objectively measurable sex chromosomes, gonads, internal reproductive organs,
and external genitalia. Typically assigned at birth as male, female, or intersex.
Gender Identity: An individual’s internal sense of being male, female, or something else. Since gender identity
is internal, one’s gender identity is not necessarily visible to others.
Gender Expression: How a person demonstrates their gender to the world (based on gender roles) through the
ways you act, dress, behave, and interact.
Cisgender: Describes a person whose birth sex and gender identity align.
Genderism: societal belief that gender is a binary, or that there are, or should be, only two genders
Transgender: An umbrella term for people whose gender identity and/or gender expression differs from what is
typically associated with the sex they were assigned at birth. People under the transgender umbrella may
describe themselves using one or more of a wide variety of terms. A few of those terms are defined below.
Gender Non-Conforming: A term used to describe some people whose gender expression is different from
conventional expectations of masculinity and femininity.
Genderqueer: A broad descriptor many people use to indicate a person does not identify as either male or
female.
Genderfluid: A gender identity which refers to a gender which varies over time. A genderfluid individual's
gender identity could be multiple genders at once, and then switch to none at all, or move between single gender
identities.
Preferred Gender Pronouns (PGP): In addition to the traditional pronouns (he/him, she/her, they/them), some
prefer gender-neutral pronouns, such as ne, ve, ze/zie and xe. Don’t assume preferred personal pronouns, it’s best
to ask.
Gender-Neutral/Gender-Inclusive: Inclusive language to describe relationships (“spouse” and “partner”
instead of “husband/boyfriend” and “wife/girlfriend”), spaces (gender-neutral/inclusive restrooms are for use by
all genders), pronouns (“they” and “ze” are gender neutral/inclusive pronouns).
How can we better serve Transgender and Gender Nonconforming (TGNG) Couples and Families?
Gender Diversity in Marriage/Couple and Family Therapy (M/CFT) Literature
There was disappointing gap in available literature regarding M/CFT work with Transgender and Gender
Nonconforming (TGNC) individuals, couples, and families. There is a recent growth in research, but it is
limited in content and methodology, e.g., many studies are based on specific Trans identities and/or focus on
diagnostics and pathology (Blumer, Green, Knowles, & Williams, 2012).
Some studies claim to have comprehensive population samples, including individuals who self-identify as
Lesbian, Gay, Bisexual, or Transgender (LGBT), but sampling may yield few Trans persons, if any, who are
actually included in the final sample (Blumer, Green, Knowles, & Williams, 2012).
Throughout the research, there was a working assumption that those who identify as a part of the LGBT
spectrum should be considered one population. This is misleading and contributes to the confusion of sex and
gender. Lumping the ‘‘T’’ with the ‘‘LGB’’ further erases Trans persons’ experiences since results may not
generalize to Trans persons. (Coolhart, D., Baker, A., Farmer, S., Malaney, M., Shipman., 2013).
According to Coolhart, Provancher, Hager, and Wang (2008) most therapist lack the training to sensitively serve
Trans clients. There has been an increase in competence working with LGB clients from mental health
professionals, but these measures often do not address competencies related to working with Trans and gender
variant clients (Perosa, Perosa, and Queener, 2008). It is apparent that the TGNC population is not getting
adequate support from the M/CFT field.
Throughout the literature there was little to no mention of a deeper exploration of the umbrella term
Transgender and the gender continuum under it. This cutting edge research is of the utmost value to M/CFTs as
gender diversity continues to become more visible. As persons in positions of power therapists have influence to
affect change in our clients lives, their relational systems, and the society in which we all exist (Blumer, Green,
Knowles, & Williams, 2012). Due to this power, it is our professional responsibility to be equipped with
excellent knowledge of the transgender and gender nonconforming experience.
Utilize Queer Theory. Queer Theory disputes the essentialist view of gender, and rejects the notion that anything outside of the binary is pathological (Stone-Fish &
Harvey, 2005). Instead it boasts that gender is constructed within a social context. They are cultural reference points that are incredibly limiting for humankind.
View gender as a continuum. This is multidimensional, allowing third gender, fourth gender, fifth gender, agender or genderless, as well as many other possibilities and
combinations, thus much more accurately reflecting the true diversity of human genders. It is important that clinicians and researchers use multidimensional assessments
of gender identity and cease their over-reliance on a binary understanding of gender (Dargie, Blair, Pukall, & Coyle, 2014)). See image to the right for a limited example
of the gender continuum.
Language, Language, Language! Be mindful of language designed to invalidate. Before assuming a pro-noun ask what would be preferred and when.
Normalize Gender Diversity, Fluidity, and Exploration. The dominant culture renders gender diverse people as “other” and “abnormal”, as gender transgressors and
subjecting them to ostracism, hatred, physical and sexual assault, self-hate, suppression of their true selves, and even murder (Nealy, 2008). This population is in dire
need of a safe space for exploration and freedom of expression.
Self of the Therapist Work! Be mindful of ways your biases are impacting the client.
Acknowledge Gender Dysphoria for what it is. A stigmatizing, pathologizing diagnosis held by the mental health system at large that seeks to control and dictate lives
of gender diverse persons (Nealy, 2008).
Client Resources:
RadRemedy.org, Advocates for Youth, GLSEN,
www.glaad.org/, http://itspronouncedmetrosexual.com/, http://www.revelandriot.com/,
http://transqueerwellness.org/
Reproduction & Marriage: Cultural shifts due in part to the Women’s Rights Movement and other calls for social change mean that it is more common today
for women to choose not to get married or have children. In some communities this is still an expectation and any woman acting outside of these expectations is
considered gender variant.
Stereotypical Gendered Occupations: Our society still hold many binary gendered views about acceptable occupations. For example women who choose to
work in the hard sciences, or work specific trades (construction, plumbing) are often seen as gender variant. Men who choose to work in fashion, healthcare as
nurses, social services, etc are often seen as gender variant.
Grooming- There have been cultural shifts around “appropriate” dress and grooming standards regarding gender. External expression has continued to include
specific rules of appropriate expression for males and females most specifically rigid regarding behaviors that are not allowed.
Awareness- Recognition that that a person’s sense of gender does not reflect their external appearance. There is a schism between the person’s experience
of themselves and the dominant cultural narrative about gender.
Information seeking/Reaching out- Looking for information and resources to support an emerging new narrative about gender variance.
Disclosure to significant others- Sharing and ‘coming out’ to important people.
Exploration: identity & self-labeling- A process of determining how the person would like to express their gender.
Exploration: transition issues/possible body modification- Deciding how to orient themselves in a gender narrow world. Exploring possibilities about
modifying the body.
Integration- Processing the previous experiences, integrating this awareness into current life and moving forward with a vision and hope for the positive
gender expression in the future (Lev, 2004).
TRANSGENDER IDENTITY DEVELOPMENT
FAMILY EMERGENCE STAGES
1. Discovery & Disclosure- When family members discover the gender variance of a loved one. This may include shock, betrayal, and confusion. Even when awareness of gender variance is present the realization of its importance can feel
emotionally devastating.
2. Turmoil- Family patterns may be disrupted. Members may become withdrawn or emotionally volatile. It can be a time of intense conflict and stress.
3. Negotiation- Family members realize the gender variance will not vanish. Families begin to compromise and determine what they are most comfortable living with and what limits the family can set regarding gender expression.
4. Balance- This does not mean permanent resolution of gender issues. This means there is no longer turmoil and secrecy. A key factor is families recognizing the difference between secrecy and privacy. There is integration of gender variance
into the normal life of the family (Lev, 2004).
Blumer, M. L. C., Green, M. S., Knowles, S. J. and Williams, A. (2012), Shedding Light on Thirteen Years of Darkness: Content Analysis of Articles Pertaining to Transgender Issues In Marriage/Couple and Family Therapy Journals. Journal of Marital & Family Therapy, 38: 244–256. doi: 10.1111/j.1752-0606.2012.00317.x
Coolhart, D., Baker, A., Farmer, S., Malaney, M., & Shipman, D. (2013). Therapy with Transsexual Youth and Their Families: A Clinical Tool for Assessing Youth's Readiness for Gender Transition. Journal Of Marital & Family Therapy, 39(2), 223-243. doi:10.1111/j.1752-0606.2011.00283.x
Coolhart, D., Provancher, N., Hager, A., & Wang, M. N. (2008). Recommending transsexual clients for gender transition: A therapeutic tool for assessing readiness. Journal of GLBT Family Studies, 4, 301–324. http://dx.doi.org/10.1080/15504280802177466
Dargie, E., Blair, K. L., Pukall, C. F., & Coyle, S. M. (2014). Somewhere under the rainbow: Exploring the identities and experiences of trans persons. Canadian Journal Of Human Sexuality, 23(2), 60-74. doi:10.3138/cjhs.2378
Lev, A (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. New York: Haworth Press.
Nealy, E. C. (2008). Working with LGBT Families. In. M. McGoldrick & K. V. Hardy, (Eds.), Re-visioning Family Therapy: Race, culture, and gender in clinical practice. (pp. 289-299) New York: Guilford.
Perosa, L. M., Perosa, S. L., & Queener, J. (2008). Assessing Competencies for Counseling Lesbian, Gay, Bisexual, and Transgender Individuals, Couples, and Families. Journal Of LGBT Issues In Counseling, 2(2), 159-169. doi:10.1080/15538600802125613
Stone Fish, L. & Harvey, R. (2005), Nurturing Queer Youth: family therapy transformed. W.W. Norton, New York.
Professional Resources:
www.genderspectrum.org, http://transallyship.weebly.com/,
http://www.impactprogram.org/, Association for Lesbian, Gay,
Bisexual, and Transgender Issues in Counseling
RESOURCES