This document provides an introduction to concepts related to gender identity, gender expression, and biological sex. It defines these terms and discusses their differences. It also addresses the prevalence of intersex individuals, myths and misconceptions, and theoretical considerations for counselors. Gender identity refers to one's internal gender, gender expression is one's outward presentation, and biological sex refers to physical characteristics. These do not always align. The document aims to educate on this topic which is important for multicultural counseling.

1. Gender Identity,
Gender Expression, &
Biological Sex

2. Introduction
◉Multicultural counselling and its application to
gender identity, gender expression, and
biological sex.
An issue of grave importance and relevance to the current
sociocultural and systemic climate.
A political, ethical, and theoretical necessity.
Important social justice issue that is manifested in a
community of people which experiences marginalization,
oppression, and discrimination.
Media and social media awareness of non-binary gender.

3. Introduction
Gender identity ≠ biological/ anatomical sex
≠ sexual/ romantic orientation
(Gender Spectrum, 2015; Killerman, 2013; Moleiro & Pinto, 2015; Moon, 2014;
Roughley & Morrison, 2013)

4. Introduction
◉Biological/ anatomical sex: comprised of physical characteristics such
as external genitalia, sex chromosomes (XY for males, XX for females),
gonads, sex hormones, and internal reproductive organs (Gender
Spectrum, 2015).
Spectrum or range, rather than male/ female binary.
Assigned at birth by medical professionals based on external genitals (male or
female only; intersex is not on Canadian birth certificates)
Defining male/ female: physical reproductive or sex characteristics are
consistent with current medical definitions (Gender Spectrum, 2015)
Defining intersex:“a general term used for a variety of conditions in which a
person is born with a reproductive or sexual anatomy that doesn’t seem to
fit the typical definitions of female or male… Intersex is a socially constructed
category that reflects real biological variation,” (Intersex Society of North
America, 2008, para. 1).

5. Introduction
◉How common is it to be born intersex?
Current and historical definitions of intersex persons
Medical documentation
Many medical professionals document the prevalence to be
1.7% of all live births
(Blackless et al., 2000)
Contributing factor as to why counsellors need to be
aware of intersex individuals.

6. Introduction
◉Gender identity: a person’s unique internal and
individual perception of gender and how they label
themselves (OHRC, 2014).
Sense of being a man, a woman, both, neither, or
anywhere along a continuum/ gender spectrum
(OHRC, 2014) e.g.) gender neutral/ genderless,
genderfluid, transgender.
May or may not be aligned with their biological sex
or gender expression (OHRC, 2014).

7. Introduction
◉Gender expression: a person’s external display of
gender (OHRC, 2014).
Outward appearances (dress, hair, makeup…), their
demeanor, social behavior, chosen name, or
pronoun (he/ his, she/ her, they/ their, ze/ zir…)
and other factors (Killerman, 2013; OHRC, 2014).
Generally on a scale of masculinity and femininity
(Killerman, 2013; OHRC, 2014).

8. Introduction
◉Cisgender: individuals whose biological sex, gender
identity, and gender expression align.
E.g.) female, woman, feminine → cis-woman (Killerman,
2013).
◉Transgender: individuals who are not cisgender (Killerman,
2013).
May transition culturally, socially, physically, and/or
medically to a gender in which they feel more
congruent (Everett, MacFarlane, Reynolds, & Anderson,
2012).
Different than transsexual which is a term used when
someone whose gender identity is binary of their
biological sex and is in the process of transitioning with
hormones, surgery, and other medical treatments
(Killerman, 2013).

9. Introduction
◉Two-spirit: a term used by First Nations people to
recognize individuals who possess qualities or
fulfill roles of both genders (Killerman, 2013).
“Individuals embracing these genders may have dressed;
assumed social, spiritual and cultural roles; or engaged in
sexual and other behaviors not typically associated with
members of their biological sex,” (Walters, Evans-Campbell,
Simoni, Ronquillo, & Bhuyan, 2006, p. 126).
Often occupy highly respected social and ceremonial roles
(Walters et al., 2006).

10. Introduction
◉Third Gender = A person whose gender
identity is neither male nor female but a third
option. Several cultures have different terms
to describe their transgender or third gender
populations
○ Examples include:
■ Eunuch
■ Hijras
■ Kathoey → Ladyboys

11. Introduction
Gender identity/ expression, biological sex, sexual/
romantic orientation closely tied in the LGBPTIQQAA2S+
community so it is important for counsellors to recognize
and learn about the community if they are to work with
them.

12. Introduction
◉Genderbread person!

13. Multicultural-Diversity Constructs/ Theoretical
Background
◉Gender expansive practices and policies.
◉Political and ethical considerations around
gender (Arthur & Collins, 2010).
◉Cultural awareness of self, cultural awareness of
other, and a culturally sensitive working alliance
in relation to sex, gender identity, and gender
expression (Collins & Arthur, 2008).

14. Multicultural-Diversity Constructs/ Theoretical
Background
◉Total acceptance of non-binary or genderqueer
persons aside from support for equal marriage
(Roughley & Morrison, 2013).
◉Don’t identify them until they identify to you!
The general rule is...there are no rules! :)
◉Historical/ present day use of othering” for
anyone outside of social and gender norms e.g.)
Conversion/ reparative therapy (Roughley &
Morrison, 2013).
◉Self-disclosure, in the community, allies in the
community (Everett et al., 2014).

15. Multicultural-Diversity Constructs/ Theoretical
Background
◉Client’s perspective outside of a
heteronormative, cisgendered lens and consider
various intersectionalities (Davies & Barker, 2015).
◉Be aware of hypervigilance, shame, and
resilience of clients (Davies & Barker, 2015).
◉Understand the importance of discourse and
microagressions by the dominant group unto the
non-dominant group (Smith, Shin, & Officer, 2012).
Uphold dynamics of privilege and oppression.
Especially dangerous in a helping setting.

16. About this templateMyths and Misconceptions
What does cis mean? What does it mean to be cissexist? Cisgender means an individual’s gender reflects the
biological sex they were born with. Biological sex is based
on an individuals external genitalia, chromosomes, internal
and external reproductive organs, secondary sex
characteristic, and horomones (GLAAD, 2015).
What is cissexism? Cissexism is when someone who is cisgender assumes
everyone has the same experience as them and that
individuals who do not are inferior or peculiar. An example
of this is when a trans woman uses a men’s washroom
(Grant, Mottet, Harrison, Herman, & Keisling, 2011). The
considered defamatory term “bathroom bill” refers to
individuals who oppose non-discrimination laws that
protect transgender people by providing them with a
private gender-neutral bathroom that anyone can use, and
the term “bathroom bill” is said to incite fear and panic an
individual may face when encountering a transgender
person in a public washroom (GLAAD, 2015).
Sex and gender aren’t really different are they? It doesn’t
really matter does it?
Yes they are different. Sex refers to your biological sex,
but sex does not determine your gender. Gender is a
social construct created to identity male and females and
is associated with gender roles and gender expression
(GLAAD, 2015). To simplify, think of sex in the biological,
predetermined at birth way, whereas gender is more
linked to masculinity and femininity, which are based on
characteristics. (Grant et al., 2011).

17. About this templateMyths and Misconceptions
Aren’t all drag queens transgender? Drag queen is a term usually used to refer to a gay male
who dresses up as a female on occasion for personal
satisfaction or for entertainment purposes (GLAAD, 2015).
Drag queen it is often incorrectly used to refer to all
transgender women (Grant et al., 2011). Cross-dressers are
typically heterosexual men who occasionally wear
women’s clothes, makeup, and accessories and do not
want to permanently change their sex (GLAAD, 2015).
Cross-dresser replaces the term transvestite, and
transvestite should not be used unless someone
specifically self-identifies that way (GLAAD, 2015).
Transgender, transsexual, tranny, what’s the difference? Transgender is used as an umbrella term that refers to
individuals whose gender identity or gender expression
does not align with their assigned sex at birth, including
transsexuals, androgynous individuals, genderqueers,
cross-dressers, and other gender non-conforming people
who identify as transgender (GLAAD, 2015). Some (not all)
of these individuals desire to transition gender, and some
(not all) want to medically alter their bodies as part of the
process. Transsexual is an older term that was created in
the medical and psychological fields, and it is not an
umbrella term like transgender. Transsexual is still
preferred by some people who have permanently
changed their body to align with their gender, or
individuals who desire to change and may be
accomplished through surgical and or hormone therapy,
or other methods (GLAAD, 2015).

18. About this templateMyths and Misconceptions
If a cis man is in a relationship with a transwoman, doesn’t
that make him gay?
o No. This is negative as it is basically saying a
transwoman is not a real woman, and it is considered
derogatory. Once an individual has identified as a sex,
such as a transwoman, they are now for all purposes a
woman (Grant et al., 2011).
All transgender individuals undergo surgical sex changes. No. The term “sex change” is considered offensive to
some and not all transgender individuals get surgery. Sex
reassignment surgery is the preferred term. There is also
not “one” surgery to change one’s body to align with one’s
identity (Grant et al., 2011).
What is the difference between Gender Identity Disorder
and Gender Dysphoria?
Gender identity disorder was a term included in the DSM-
V that the body’s physical characteristics at birth differ for
the gender an individual believes they are, the term was
later changed to gender dysphoria to reduce stigma that a
patient is “disordered.” The new term is gender dysphoria
is now in the DSM 5 (American Psychiatric Association,
2013).

19. ● 41% of those surveyed reported
attempting suicide, compared to 1.6%
of the general population
● Respondents reported had four times
the rate of HIV infection compared to
the general U.S. population
● 30% of the sample reported they
were daily smokers, compared to
20.6% of the general U.S. population
● 78% of grade-school children who are
transgender or gender non-
conforming reported harassment, 35%
were physically assaulted, and 12%
reported sexual assault
● 16% of respondents felt compelled to
work in the underground economy
doing such work as selling drugs or
sex for income
● 19% reported encountering housing
discrimination; they were denied a
home because of their gender
identity
● 46% said they were uncomfortable
seeking help from the police
● 15% who had been to jail or prison
reported being sexually assaulted
● 43% maintained relationships with
their family, while 57% were rejected
Marginalization of Transgender Individuals

20. Social Supports

21. Counselling
Techniques
Gender Identity, Gender Expression, &
Biological Sex

22. Counselling Techniques
◉Gender affirmative treatment
◉Addressing trans-specific issues (therapeutic
relationship)
◉Nature of the gender concerns
◉Gender history & development of gender identity
◉Evaluating capacity to make care decisions
◉Client history & current concerns
◉Exploration of gender expression
◉Identity management decision-making
◉Transgenders-specific elements in general
counselling

23. Why come to counselling?
◉Therapists working with transgender or gender nonconforming clients:
Gender incongruence or gender dysphoria
Hormone therapy
Surgery to change primary and/or secondary sex characteristics
General psychotherapy (self-esteem, family, “coming out”,
transitioning, questions, issues related to identity, everyday
problems)

24. Why come to counselling?

25. Gender Affirmative Treatment
◉Therapists working with transgender or gender nonconforming clients:
respecting the positive views of transgender clients
client’s self-defining identities and the impact of normative gender
society on their lives
accepting of stigmas
understanding of terminology and concepts
societal assumptions about gender influence the experiences of
clients
awareness of implications of surgery and/or hormone therapy

26. Trans-specific issues (therapeutic rapport)
◉In addition to the regular techniques used to build therapeutic rapport:
discuss privacy issues in setting appointment times
developing self-advocacy strategies
identify appropriate resources
how/whether to share gender history for employment
anti-trans prejudice and discrimination

28. “Minnesota Republicans Seek to End Trans-
Inclusive Sports Teams”

29. Nature of the gender concern
◉It is important to evaluate the client’s perspectives related to gender
concerns. Here are some useful questions:
What is the nature of the gender concerns?
Are there obsessive/compulsive features?
Are there delusions about sex or gender?
Is there evidence of Asperger’s disorder?
Is there evidence of dissociation?

30. Gender History & Development of Gender
Identity
“As clients become aware of previously hidden or constraining aspects of
their gender identity or sexuality, psychologists may provide acceptance,
support, and understanding without making assumptions or imposing a
specific sexual orientation or gender identity outcome” (APA, 2009)

31. Gender History & Development of Gender
Identity
◉Family
How do you define ‘family’?
How would you characterize your relationship with your family
members when you were a child, and now?
Do you have any concerns related to family?

32. Gender History & Development of Gender
Identity
◉Gender concerns
Are there any kinds of supports you feel might be helpful as a
__________ (trans, asexual, etc.) person?
Are there any cultural or religious conflicts for you as a transgender
person?
Have you ever sought to change your body through hormones/
surgery?

33. Capacity to make care decisions
◉“Decision-making capacity is the ability to understand relevant
information and to appreciate the reasonable foreseeable
consequence of a decision” (Appelbaum & Grisso, 1988)
◉Health care professionals must normally obtain informed consent
before treating an adult patient. Clinicians should confirm the client’s
capacity to make care decisions as part of the initial evaluation
(Bockting et al., 2006)

35. Document client history & current concerns
◉Comprehensive assessments usually include:
instruments to evaluate general mental and physical health
person’s past experiences of anti-trans prejudice or discrimination
internalized messages related to these experiences
anticipation of future victimization (Coolhart, Provancher, Hager, & Wang, 2008)
introduction of coping strategies and sources of resilience (Hendricks & Testa,
2012; Singh et al., 2011)

37. Exploration of options for gender expression
The HBIGDA Standards of Care (Meyer et al., 2001) possible options for transgender
identity expression
• participation in peer support/self-help groups or in the transgender community
• counselling to explore gender identity and to deal with pressures relating to work,
family, etc.
• learning about transgenderism from the Internet, guidelines for care, lay and
professional literature relating to legal rights, etc.
• participation in peer support/self-help groups or in the transgender community
• permanent changes to appearance: surgical reconstruction of face/chest/genitals,
electrolysis/laser removal of facial/body hair
• integration of gender awareness into daily living
• temporary and potentially reversible changes to appearance: changes in
hairstyle/makeup, temporary removal of facial/body hair

38. Implementing identity management skills
◉After the client has decided on a course of action, therapists may focus
on helping the client implement their decision to gender expression/
identity management:
“coming out” (disclosing transgender identity) to family, friends, co-workers,
teachers/students, cultural or social community peers, or others in the transgender
person’s life is an important step
“coming out” for gay/lesbian vs. transgender
visible changes in social role and physical appearance
taking calculated risks in disclosure (Coleman, 1982; Horton, 2001), starting with people
who are most likely to be accepting
adjustment of learning a new gender role and also the discrimination and harassment
that is frequently experienced by someone who is visibly gender-variant

39. Counselling for loved ones
◉Trans/non gender conforming people, partners, families, friends, and
communities can benefit:
responses upon disclosure range from excitement to disgust, depending on an
individual’s perspectives, their relationship with the transgendered person, cultural
beliefs about gender variance, and the timing and means of disclosure
when transgender issues have been a secret and are disclosed late in a relationship,
there can be feelings of betrayal and questioning of intimacy, as with the disclosure of
any large secret (Reynolds & Caron, 2000)
mixed emotions from loved ones - denial (stage 1) , shock, post-traumatic reactions,
trying to bargain with the transgender person or a higher power for the gender issues
to disappear, anger (stage 2), grievance (stage 3), self-discovery (stage 4), acceptance
and welcoming (stage 5), pride (stage 6)

40. Transgenders-specific elements in general
counselling
◉Common issues experienced by transgender clients;
body image problems
multiple losses resulting in cumulative grief
sexual concerns
social isolation
spiritual or religious concerns
substance use issues
difficulty coping with historical or current violence/abuse

41. NUANCES

42. NUANCES
Consensus among all staff regarding education and
commitment to support of LGBTQ+ community
◉Adjust mission statement to clearly state
agency’s allied support
◉Training for all staff on education on
specific counselling considerations as well
as language use
◉Education and training in providing medical
and culturally relevant referrals
❏ see following checklist

43. NUANCES

45. NUANCES

46. (planned parenthood, 2006)

47. NUANCES
Post visible LGBTQ+ brochures, books, posters, and
psychoeducational material to signal to clients that
the agency is aware of specific concerns and
considerations.

48. NUANCES
Intake forms // Pronoun use
Gender:
Preferred pronoun:

49. NUANCES
Gender-neutral bathrooms

50. NUANCES
Support groups
Awareness of relevant resources within the
community
http://www.fyrefly.ualberta.ca/YouthResources
(My GSA, 2012)