What to Look for in a Therapist:
A Trans Perspective

by Reid Vanderburgh, MA

Making the decision about whether or not to physically transition is probably the most crucial choice any trans person ever faces. It can be helpful to have a therapist ally to facilitate this decision-making process. However, it can be counterproductive when the trans person encounters a therapist who is ill-informed about trans issues, and is unwilling to learn. A trans person with such a therapist ends up paying the therapist while also trying to educate them, and may not receive the very guidance they were seeking to begin with. You may be fortunate enough to have trans friends who have already educated a local therapist for you, who can provide you with a referral to someone who did good work with them. If not, however, you may end up shopping for a therapist and not knowing how to find a good one. Further, a therapist who works well with one person may not be a good match for someone else. You can’t always expect to resonate with someone else’s therapist, however well they’ve come to understand gender issues.

It has been my experience that clients in the beginning stages of exploring transition options often find it difficult to put their feelings into words and may not be able to express what they need from a therapist. For many, talking to me openly about their deepest feelings concerning gender and how it has played out in their lives marks a milestone, the first time anyone (other than trans friends) has ever taken them seriously or been encouraging in their inner exploration. While they look to me for guidance as a therapist, more than one has also remarked at the end of our first session how relieved they are that they don’t have to explain as much to me as they felt they would to a non-trans therapist. “You already get it,” one FTM client said, with a great deal of relief in his voice.

This client is fortunate enough to live in Portland, Oregon, as do I. But what about the budding FTM who finds himself living in Tulsa, Oklahoma? Or the MTF coming of age in Butte, Montana? How different might Brandon Teena’s life have been had there been an openly trans therapist in Lincoln, Nebraska? Most trans people end up seeing therapists who are not trans and don’t have a great deal of knowledge about trans issues. This doesn’t have to be a discouraging situation, however, if the client knows what questions to ask when looking for a therapist to help them process their way through these life-transforming decisions.

The first thing to pay attention to is how comfortable you feel with the therapist. If the energy feels wrong, if you feel uncomfortable with the therapist as a person (regardless of how well they understand gender issues), you are probably going to have difficulty establishing what’s called a therapeutic alliance. Therapy is a joint venture – the therapist is the guide, but the client must be able to fully trust the therapist as a person in order to take full advantage of the guidance. Be honest with yourself: It may be that you are going into the room expecting to distrust this person, which can end up becoming a self-fulfilling prophecy. There is a fine line between trusting your gut instinct and stacking the deck against the therapist in advance by expecting the worst.

If you feel good about your prospective therapist as a person, they’ve passed the first test. The next thing to explore with the therapist goes beyond their level of knowledge about trans issues. Most will not know much beyond the textbook distinction between gender identity and sexual orientation. (Some older therapists may not even know this much, as such distinctions have only made it into human sexuality texts in the last decade or so.) What you really need to know about this person is how willing they are to learn about your issues on their own time. Are they willing to do internet research, to find resources to help them learn the issues? Are they willing to contact people like me to consult? Are they willing to rethink the paradigm they most likely learned in school, that being trans is a psychological disorder known as GID (Gender Identity Disorder)? Are they willing to consider instead that gender identity is just that, an aspect of core identity, and that psychological problems arising in clients are often a result of growing up in a trans-hostile culture, not an automatic by-product of being trans? These are specific questions you can ask of a prospective therapist, to learn more of their philosophy and flexibility in the face of challenging new knowledge.

Ask questions about how they view homosexuality. It is common that a therapist who reveals prejudices and blatant misunderstandings about gays and lesbians will also have a negative bias about trans people. What you are looking for is a therapist who says something like, “I don’t think there’s anything wrong with any particular sexual orientation. When I work with a gay or lesbian client, I don’t try to change their sexuality, but help them accept that this is part of who they are.” This is a therapist who views sexuality as a fundamental aspect of core identity, not as an issue of psychological pathology. More than likely, a therapist holding this point of view can also come to see that gender is likewise an aspect of core identity and not an issue of psychological pathology. This therapist has passed the second test.

The third test involves interpretation of the Harry Benjamin Standards of Care (SOC). I saw three therapists early in my own transition process. The first two saw their role as determining whether or not I was trans. This is how they interpreted the SOC: They were supposed to ask me questions, based on the “symptoms” of GID, and then make a diagnosis. I didn’t trust either of them, and did not do good work with them as a result.

The third therapist I saw asked me questions, also, but she was not going down a list of symptoms in order to make a diagnosis. She wanted to know how well I knew myself, and how well I knew what the various physical options were. She wanted to know whether my expectations of hormones and surgery were realistic. When she saw that I had good self-knowledge, and that I knew that hormones and surgery would not, for instance, make me capable of fathering children, she gave me a letter of referral for surgery, to use as I saw fit. The crucial difference is this: The first two therapists saw their role as determining my gender for me, while the third therapist saw her role as making sure I knew who I really was, on a deep level. It didn’t take her long to make that determination – I only saw her for three or four hours. She is a therapist who would pass the third test.

In the long run, it doesn’t matter much what theoretical orientation a therapist has, or what their favorite techniques or methods are. What matters most is that you feel comfortable with them, that they are willing to do their homework on their own time and not on your nickel, and that they realize that you are the only one who should be making decisions about your gender identity. In all likelihood, you will not be working with a trans therapist. But that doesn’t mean you can’t find a therapist with whom you can do good work.