4 Creating a safe space for trans clients

In the previous sections you learned about the discrimination that trans people face and what transitioning potentially involves. This section considers how we can make the space inside the therapy/consultation room safer for trans people than the space outside.

Creating a sense of safety for clients is clearly important. Trust is recognised as a key facet of successful therapy (Allen, 2021, Fonagy and Allison, 2014) with a question on the most widely used questionnaire to assess therapeutic alliance including: ‘My therapist and I trust each other’ (Hatcher and Gillapsy, 2006). Trust helps build the therapeutic relationship, and the therapeutic relationship is one of the key drivers of therapy outcomes (Norcross and Lambert, 2019). Trust is also especially critical for any population that is marginalised as the experience of discrimination is very likely to create barriers to trust (Luchenski et al., 2018).

To begin to consider what a ‘safe therapy space’ might mean for a trans client, try the next activity.

In 2017, all the major professional bodies overseeing psychological professions signed up to an updated version of this existing document. The Memorandum of Understanding (MOU) now includes trans and asexual people, whereas previously it focused on same-sex attraction. If you belong to a professional body, you are expected not to practise conversion therapy, which is defined by BACP as follows:

Why is conversion therapy banned by professional bodies?

The research on conversion therapy for trans people suggests that they are even more likely than sexual minorities to have experienced conversion therapy (Higbee et al., 2020). Research also evidences the significant psychological harm conversion therapy does to trans people (Government Equalities Office, 2021; Hipp et al., 2019; Tran et al., 2024; Turban et al., 2020). This includes increasing suicidality (Turban et al., 2020; Campbell and and van der Meulen Rodgers, 2023): in general individuals who have undergone conversion therapy are twice as likely to have suicidal thoughts (Government Equalities Office, 2021; see also Blosnich et al., 2020; Meanley et al., 2020).

Additionally, conversion therapy does not ‘work’ as a government report stated: ‘There is no robust evidence to support claims that conversion therapy is effective at changing sexual orientation or gender identity’ (Equalities Office, 2021). In short, conversion therapy is proven to be both harmful and ineffective. However, that does not mean that in a prevailing culture that is doubting and undermining, it is not possible to (either deliberately or unconsciously) help a client suppress or doubt a trans identity.

Affirmative practice is the opposite of conversion therapy – where conversion therapy holds that some identities are inferior – as affirmative practice gives all LGBTQA+ identities an equal value. To offer affirmative practice, all practitioners, including those who are LGBTQA+ themselves, are likely to need to have worked on ideas and biases they have internalised from the culture around them that say that some identities are more correct or authentic, valid or valuable than others.

Affirmative practice can also be understood as the opposite of poor practice. Research studies examining trans clients’ experiences of psychological therapies suggest that they are likely to have poor/negative experiences (e.g. Compton et al., 2022; Mezzalira et al., 2025). A 2019 systematic review of this research concluded that: ‘the incompetence of MHPs [mental health professionals] appears to be a common theme across time and space, and that should not be the case’ (Snow et al., 2019, pp. 154). To understand more about what the existing literature suggests contributes to poor experience of psychological therapy for trans clients, try the next exercise, derived from the findings of Mizock and Lundquist (2016).

Trans broken arm syndrome

What ICTA participants said about their experiences of psychological therapies is discussed below, but the ‘missteps’ identified by Mizock and Lunquist are also present in the ICTA data. There were additional themes, too. ‘Trans broken arm syndrome’ is a phrase used by trans people to describe the phenomenon whereby everything is inappropriately related back to them being trans. As one participant said:

When a trans person accesses therapy for something entirely unrelated, it is very important professionals do not inappropriately reference a client’s trans identity or, worse, tie something unrelated into a trans identity.

In the following video, experienced trans-affirmative therapist Ellis Johnson explains some of the elements he feels are essential in an affirmative therapist:

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ELLIS JOHNSON:

So, I'd say it's really important to meet your client where they're at in their transition. There is sometimes an idea that transitioning is a terrible thing, a scary thing, is a worst-case scenario, it's something that's ruining a client's life. And actually, for lots of clients, perhaps they don't even really need to talk about being trans. Perhaps that's a part of their identity that isn't causing them distress.

For some people, they might want to take it cautiously. They might feel that it's just something to be celebrated and they actually don't really need to sit with the worries and the fears about it. Perhaps that's not their greatest concern.

So, be careful about your assumptions with regard to how the client is going to feel about their transition, whether they're going to be super cautious about it. Or perhaps maybe they're ready. They've been thinking about it for a very long time, and they're ready to get going and they just need you alongside them. So, be careful about what assumptions you're making about your client's relationship with their gender, with their transness.

Be careful about your own assumptions in terms of what you imagine a client wants to move towards in terms of their gender. Be careful that you're not reinforcing the gender binary in the space and in your interactions in your mind. It's really important to leave space for a client to explore their understanding of gender and how their expression might want to come to the forefront – how they might change, how they feel in themselves.

Be careful that you're not reinforcing the idea that they have to move from one box to another box. We want to actually be moving towards an explosion of gender identity, an embracing of movement and change and diversity and expression, and that isn't just about moving from one box to another box. So, be careful about what you expect your clients to want from their transition.

I think in the therapeutic community there's an idea that we should be able to treat everybody the same and that we'll give everybody an equal experience, equally good experience of therapy. I think it's really important to move away from that and recognise that there are aspects of trans lives that people who aren't trans just don't have an idea about. And to that end, it is important for us to educate ourselves as therapists.

There is a vast body of knowledge out there that we can tap into that will inform the way that we work and make it safe and possible to create a safe therapeutic relationship with trans clients. It is on us as therapists to educate ourselves outside of the sessions and not expect trans clients to educate us with everything they know about things that perhaps they don't even need to talk about in that space. So, be aware of the known unknowns, we could call it – the things that we know we don't know and the space for us to know them and to get to know them.

It is important to educate yourself about the lived realities of trans lives, and part of the reason for that is to make sure that you're not casting doubt on the reality of the things that trans clients are bringing to you. One example might be talking about hate crime or racism. It's important for you to have an understanding of the impact of those things and the fact that they are a reality for lots of trans people.

It's not just that trans people live in fear because they're thinking about things in the wrong way. Actually, their concerns about hate crime – for example, violence – are really valid, and they're based on real experiences and real data that we can see around us. So, be careful about questioning too deeply people's fear of walking down the street, for example, when actually, that fear is based in reality – their lived reality.

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In the rest of this section, you will be considering challenges to affirmative practice and how to work with them. First however, consider the following example of how to work affirmatively by watching this extract from Jake and Patrick’s fifth session.

In order to work ethically and effectively with trans clients, it is important to avoid some potential types of unconscious bias: cissexism and transnormativity.

Cissexism is the word for the way cis understandings of the world dictate how society is ordered, an ordering which is based on an un-examined assumption that only cis people exist or – sometimes – matter (Arayasirikul and Wilson, 2019). In our practices, there may be subtle and less subtle ways cissexism shows up. For example, an intake form might ask if a client is male or female and give no other option, not considering whether this question is necessary (outside of monitoring purposes, when there are good practice ways to ask it) and how complicated and jarring it might be for many trans people to answer.

Doubting or invalidating trans experiences is part of the cissexist assumption, as the following quote from one ICTA participant suggests:

Transnormativity describes the existence of pre-conceptions of what a trans person is, with the consequence that trans people who do not fit these assumptions/stereotypes are seen as invalid (Riggs et al., 2019). ICTA participants reported, for example, having their trans identity being challenged because their dress, hair style or name was deemed inappropriate for their gender.

Like Patrick, trans clients may consider whether they should adapt their presentation in order to better be accepted by society. However, we as therapists might want to consider our position on this – is a person, cis or trans, only valid or acceptable if they conform to rigid ideas of how gender should be expressed and presented?

To further explore how cissexism and transnormativity might impact your attitudes to trans clients, try the following activity.

This quote comes from an ICTA participant talking about her experience of being persistently misgendered while accessing psychological therapy through a third-sector voluntary organisation. In this account, misgendering led to significant emotional distress and to termination of therapy. Given the context – a professional relationship that was supposed to support this person’s mental health – the therapist’s misgendering seems particularly damaging.

It is therefore vital that you get into the habit of checking what the correct pronouns are for all the people you work with and introducing your own pronouns. It is also essential to practise getting these right, both when you talk to the client and when you talk about the client, for example, in your notes or supervision.

To further consider the potential impact of misgendering in the context of therapy, try the next activity.

As a therapist you are likely to have an approach to working with clients. One question might be how affirmative practice sits alongside your modality. Our own view is that it makes sense to think of affirmative practice as a meta-theory or over-arching framework that sits beyond particular schools of therapy in terms of how they work with clients. This is similar to the notion of cultural competence as something overarching that should inform therapeutic work with clients, however we practise.

Trans-affirmative practice approaches can be considered as a specific type of cultural competence. Importantly, the research on therapist cultural competence clearly finds that therapists are not good at rating whether they are in fact culturally competent – only client-rated cultural competence is shown to be positively related to clients’ therapy outcomes (Soto et al., 2018). This underlines the importance of therapists taking on board the idea that they may not be – from their trans client’s perspective – practising affirmatively. We therefore need to be aware how our language, approaches and assumptions about the world may not be supportive to clients. It also suggests the value of giving clients space to provide feedback on how they are experiencing the therapy. To consider this more, try the next activity.

There is research evidence of the benefits of affirmative practice. A 2023 systematic review found that affirmative therapy was associated with reduced distress, depression, anxiety, suicidality and substance use as well as better coping and emotion regulation, self-esteem and self-acceptance (Expósito-Campos et al., 2023). A survey of trans (including non-binary) clients found that affirmative practice was associated with better therapy outcomes and client satisfaction (Pepping, Cronin and Davis, 2025) while a trans-affirmative approach, a nurturing therapeutic bond and recognition of both authentic gender and client experiences of cisnormative stigma were all associated with better therapy outcomes in another systematic review (Mezzalira et al., 2025).

Trans people will come to therapy with a range of issues that may require and respond to different approaches. Practising affirmatively is about being non-discriminatory in the way we practise our individual modalities, i.e., making sure a range of therapeutic modalities are accessible to trans clients by ensuring they are affirmative. Practising affirmative therapy is not a separate approach and it is not just for trans people – it is just as important to be trans affirmative in our stance with clients presenting as cis, because they or a loved one may at some point come out as trans, or they may have transitioned historically and not be out to us.

There is a small but growing body of literature on modality-specific trans-affirmative practice, such as:

• Pachankis et al.’s (2020) evidence for affirmative, minority-stress-focused CBT interventions for anxiety and depression.

• Haziza and Pehkonen’s (2025) proposal of the value of psychodynamic group psychotherapy for trans people.

• Crowter’s (2022) argument for the radical value of a person-centred approach – especially unconditional positive regard – for working with trans clients.

Pachankis (2018) presents existing quantitative evidence for affirmative practice and argues for creating a further evidence base for its effectiveness. Examples of such a growing evidence base include Pachankis et al.’s (2020) evidence for affirmative, minority stress focused CBT interventions for anxiety and depression.

Austin and Craig (2015) discuss adapting CBT for trans clients with depression and anxiety, while Livingstone (2011) outlines the benefits of a phenomenological, affirmative, person-centred approach to counter experiences of pathologisation and shame.

The ICTA project suggests that further research is needed to inform and improve practice, in particular:

• Which kinds of services/approaches are a priority for developing and evidencing affirmative practices – for example, our data suggests a high need of domestic and sexual violence services, services for neurodiversity (autism, ADHD, dyslexia, etc.)
• Quantitative evidence to back up the qualitative evidence of the benefits of a non-directive, trans-affirmative approach in which clients can explore gender identity without being steered or suppressed, or fearful that expressions of uncertainty will undermine them.

The ICTA study found very mixed experiences of psychological therapies within the NHS, third-sector organisations and in private practice. Try the activity below to find out what ICTA participants discussed as helpful for creating safe therapeutic spaces for trans people.

This section has focused on how to create a safe space for trans clients and argued that this means adopting an affirmative practice approach, avoiding behaviours and assumptions that are stigmatising or undermining of trans clients and reflecting on whether our typical approach to working with clients might need to be adapted to work with trans clients.

Now, continue to 5 Working with the diversity of the trans community.