2 Examining our biases and assumptions

Best-practice models for developing cultural competence in therapeutic work with marginalised people involve reflecting on your existing beliefs. This section looks at societal beliefs and ideas about trans people, and about sex and gender more broadly, that may influence the way practitioners interact with trans people, address them, think about them, and therefore respond to their experiences, whether they are themselves cis or trans. As you go through this section, remember to stop and think about your own beliefs and ideas on these topics. Consider how unconscious beliefs might prevent you from fully meeting a trans client and entering their frame of reference.

Figure 2.1: How bias disrupts the therapeutic relationship

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Empathy: If I'm meeting my idea of the person rather than the person themselves, then empathy is lost. Congruence: If I don't realise my biases, I won't be congruent or fully authentic with the client. Unconditional Positive Regard: If I have a bias, it is also a judgement, and unconditional positive regard is lost.

Figure 2.1: How bias disrupts the therapeutic relationship

The next activity explores how sex and gender concepts apply in counselling through a video of an early session with a trans client, Patrick. Patrick, played by a trans actor, is in therapy with Jake, an experienced psychotherapist and trans man.

For this and other training videos, Patrick received a client case history, and both he and Jake were given key themes to guide their interaction. Patrick was asked to improvise in response to these cues and Jake was asked to respond as he would to a real client (with one exception). Most of the videos are intended to be extracts from the very first counselling session. The videos in Activities 3.4, 4.3 and 5.3 depict parts of the 12th session after the therapeutic relationship has been established.

If you know little about the trans experience, empathy for trans clients may be harder. This is important because therapist empathy is regarded as a core predictor of the effectiveness of therapy across all therapy types (Watson, 2016). Cis practitioners may find the following visualisation exercise helpful for developing empathy.

In 2019, the World Health Organization (WHO) declared definitively that being trans is not a mental illness, echoing the declassification of homosexuality back in 1990 (World Health Organization, 2021).

The minority stress model: Historically, it was assumed that being trans meant being mentally ill; the same thing was assumed about being gay. However, research has shown that it is not being trans that is associated with having mental health problems but rather how trans people are treated. In short, greater social stigma correlates with poorer mental health among trans people. A landmark study published in the prestigious medical journal The Lancet corroborated this understanding, prompting the WHO decision (Robles et al., 2016; see also Price et al., 2024; Drabish and Theeke, 2022).

This understanding of the mental health of trans people aligns with the ‘minority stress model’ initially developed by Meyer (2003), which understands mental health disparities for marginalised groups as being explained by the stressors caused by living in a hostile social context: experiencing bias, microaggressions, harassment, discrimination and targeted violence.

Targeted violence: Some ICTA participants reported experiencing physical threats and expressed fear about high levels of violence against trans people. Hate crimes against trans people have tripled in the past decade. (Home Office, 2024).

Stonewall reports that young trans people are particularly at risk of hate crime, with 53% having experienced hate crime in a one-year period (Stonewall, 2018), while Galop reports a significantly higher number of transfemmes (a term used to refer to trans women and feminine-presenting AMAB non-binary people) are affected by hate crime (Bradley, 2020).

Internationally, statistics for violence against trans women who also experience racism are particularly high (Human Rights Campaign Foundation, 2019).

Microaggressions: Microaggressions are everyday behaviours or terms that, intentionally or not, convey hostile or prejudicial messages based on group identity. (Sue et al., 2007). Microaggressions often reflect prevailing societal understandings of particular groups or identities; in the UK increased prejudice towards trans people is indicated by an 18% drop since 2019 (to 64%) in the number of people who describe themselves as ‘not at all prejudiced’ against people who are transgender (National Centre for Social Research, 2023).

The extensive research on microaggressions evidences their clear negative impact on the mental health of marginalised people, including trans people (e.g. Kimber et al., 2024). It is important to understand the significant impact of microaggressions as they can be:

• Insidious – often unnoticed or minimised by those unaffected.
• Systemic – rooted in broader societal bias.
• Cumulative – daily exposure makes them especially harmful to mental health.

So far, we have talked about targeted violence and microaggressions. Both are examples of the discrimination/transphobia experienced by trans people. Philosopher Talia Bettcher (2009, pp. 98–99), argues that transphobia stems from a ‘basic denial of authenticity’. She believes that this denial underpins the majority of anti-trans bias. In a world where trans people are sufficiently commonplace and well researched to be understood to be having a genuine experience, rather than being an unexplained anomaly. This bias undermines what Bettcher calls ‘first-person authority’ − the right of every trans person to define their own experience.

You have been learning about the discrimination that is experienced by trans people. Negative societal views can lead trans people to internalise these beliefs.

Internalised transphobia refers to a trans person wholly or partly believing negative stereotypes about trans people or applying them subconsciously to themself. Internalised oppression is likely to increase the risk of mental health difficulties and lower self-esteem (Ventriglio et al., 2021; Iantaffi and Bockting 2011). It is a part of the concept of minority stress as conceptualised by Meyer (2003).

ICTA participants talked about the impact of internalised transphobia on them:

• ‘I think a huge part of being trans is trying not to be trans. I kind of felt what was the worst possible thing that I could be… when I grew up all trans people were weirdos. So, I didn’t want to be trans.’
• ‘I would cross-dress as a teenager, in my 20s and 30s, but secretly. And I always had, it gave me a great feeling at the time but then was followed by remorse, guilt, shame and all those negative feelings.’
• ‘I wasted years of my life… I was still internalising a huge amount of transphobia and shame and guilt… [my faith saw it as] sinful and wrong and harmful.’

Internalised transphobia can be powerful, often causing shame and other harmful emotions. Therapists must avoid reinforcing transphobia − whether through microaggressions, stereotypes, denial of authenticity, or accepting internalised beliefs as truth.

In the next activity, you will learn more about what ICTA participants said about their experience of navigating transphobia.

This section examined societal assumptions about trans people and contrasted them with evidence and lived experience. It also explored discrimination against trans people and its impact on mental health.

Now, continue to 3 Supporting clients through transitioning.