Lost in Trans-Lation

Trauma as a Conceptual Framework

In 2002, the World Health Organization (WHO) released the World Health Report on Violence and Health (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). The report highlighted many different types of violence documented by global health care systems and identified three specific types of violence—interpersonal, self-directed, and collective. To organize the many violent acts that surface in the transgender literature, we have decided to follow the precedent of the World Health Report and cluster violence into three organizing themes: interpersonal (violence that occurs between, at least, two people), self-directed (violence that is self-inflicted), and collective (violence that is inflicted by larger groups of people/institutions). Transgender clients who experience any of these types of violence are at a higher risk for developing psychiatric symptoms that may require the attention of a mental health care provider (Mizock & Lewis, 2008).

PTSD is the most widely acknowledged trauma-related disorder (American Psychiatric Association [APA], 2000). According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM-IV-TR]; APA, 2000), a diagnosis of PTSD can be given when there is a history of exposure to a traumatic event in which the person “has experienced witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others (Criterion A1)” and “the person’s response involved intense fear, helplessness, or horror (Criterion A2)” (p. 463). In addition, for a diagnosis of PTSD, there must also be symptoms from each of the following three symptom clusters: intrusive recollections, avoidant/numbing symptoms, and hyperarousal symptoms.

Unlike previous versions, the workgroup for the DSM-IV-TR elected to expand the qualifying conditions of PTSD for a traumatic event (Breslau & Kessler, 2001). In addition to physical traumatic stressors, the DSM-IV-TR explicitly listed several nonphysical events as meeting criterion A1 (e.g., learning about traumatic events experienced by a friend or close relative, being diagnosed with a life-threatening illness). Thus, many of the violent acts characterized under the three organizing themes of violence—interpersonal, self-directed, and collective—will, in fact, meet the A1 requirement. If a transgender client also reports intense fear, helplessness, and horror following a trauma and also presents with symptoms from the three symptom clusters, then a PTSD diagnosis is warranted.

As some traumatic stress is rooted in psychosocial context (Root, 1992), Herman (1992) suggested that the original conceptualization of PTSD, based heavily on the one- episode traumatic stressor, did not adequately describe the full range of responses. Herman advised that alternative classification systems may be necessary to fully depict the distinct symptoms reported by survivors who experience ongoing and prolonged interpersonal violence (that also often resulted in additional self-directed violence). She proposed that symptoms were better accounted for, and thus more effectively treated, when using a spectrum of trauma reactions, ranging from acute stress reaction and “simple” or “classic” PTSD to “complex” PTSD (which was later classified as Disorders of Extreme Stress Not Otherwise Specified [DESNOS]; Van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005).

In support of Herman’s (1992) conceptualization, acute stress reactions often do resolve on their own with little to no therapeutic interventions (Hegadoren, Lasiuk, & Coupland, 2006). Furthermore, “simple” PTSD, which is characterized by the current DSM-IV-TR diagnostic criteria, can be successfully addressed by using short-term cognitive behavioral techniques; however, such techniques tend not to be effective in alleviating “complex” PTSD because clients often drop out of treatment (Foa, Keane, & Friedman, 2000; Spinazzola, Blaustein, & Van der Kolk, 2005). The therapeutic relationship has emerged as a variable in lessening symptoms associated with “complex” PTSD (Pearlman & Courtois, 2005). These findings suggest that a critical component of complex PTSD is interpersonal functioning (Spinazzola et al., 2005).

Although it is still unclear as to whether “complex” PTSD is a discrete syndrome or a related feature of PTSD, health care providers should note that the conceptualization of “complex” PTSD does not include the intrusive recollections, avoidant/numbing symptoms, and hyperarousal symptoms that are a requirement of “simple” PTSD (Briere & Spinazzola, 2005; Herman, 1992). Instead, symptoms of “complex” PTSD include (a) difficulties in identity, (b) inability to foster stable relationships, (c) stress-related somatization, (d) inability to modulate emotional states, (e) alterations in consciousness and dissociation, (f) difficulty maintaining boundaries and personal safety, and (g) alterations in meaning making and spirituality (Pearlman & Courtois, 2005). As the literature suggests that transgender clients are likely to encounter multiple types of stress related to their transidentity, it is likely that they may present with symptoms associated with PTSD, complex PTSD, or both (Brown, 2008; Lev, 2004).

According to feminist conceptualizations, trauma response symptoms are thought to serve as a communicative function and reflect learned strategies to cope with environmental stresses (Brown, 1994). In extreme cases where individuals routinely employ coping strategies to deal with oppressive environments, learned helplessness, a feature associated with complex PTSD, may develop (Herman, 1992; Root, 1992). Clients who experience learned helplessness tend to interpret events in internal, stable, and global ways and tend to minimize or ignore the ways in which oppressive systems contribute to distress (Peterson & Seligman, 1983). For example, it is not atypical for survivors who have been assaulted by someone of the same gender to want to stop “being trans.” Survivors then may seek conversion therapy or religious cults to find a “way out” (Lev & Lev, 1999, p. 55). In such situations, clients have interpreted “the problem” to be a stable characteristic situated in themselves, which they then interpret as an inevitable problem for all future relationships. The trauma and internalized transoppression are not acknowledged by the survivor and therefore are minimized or ignored. Thus, the therapist should encourage the client to see how external stressors contribute to current distress.

There is additional evidence that the cumulative effect of hegemonic norms can shape worldviews and increase the likelihood of developing symptoms associated with PTSD and complex PTSD (Espin & Gawelek, 1992). Insidious trauma, also referred to as microaggressions (Sue et al., 2007), consists of repetitive and enduring exposure to racism, classism, transphobia, sexism, and other forms of oppression (Espin & Gawelek, 1992). For transgender clients, an insidious traumatic experience may include having a doctor ask inappropriate or invasive questions during a routine check-up or hearing a talk show host discuss transissues in pathological or demeaning ways. In isolation, a single insidious event may not be considered traumatic; however, over the course of repetitive exposure, a transgender client may suddenly develop symptoms linked to PTSD and/or complex PTSD following an apparently minor stressor (Brown, 2008; Root, 1992).

Insidious trauma has a self-fulfilling influence, which significantly shapes the development of personality, and in the case of transgender clients, these aspects are subsumed into their narrative about gender (Lev, 2004). Often these personality styles are not conceptualized as responding to insidious trauma, and, as a result, the underlying stressors are never acknowledged or discussed in therapy (Espin & Gawelek, 1992). As insidious traumatic events are subtle, clients may not even identify such incidents as problematic. However, when mental health providers translate these events as insidious traumas, they not only raise the client’s understanding of the nature of their distress but also may decrease the likelihood that the client will develop full-blown PTSD or “complex” PTSD (Brown, 2008; Root, 1992).

In assessing and conceptualizing trauma, Lamble (2008) warned against deracialing accounts of transgender traumatic events. Lamble argued that identifying transphobia as the sole root of violence may eclipse other systemic causes and overshadow hierarchies of race, class, and sexuality. Indeed, the type of trauma an individual experiences, the type of support an individual receives, and the ways in which trauma is understood, encoded, and later recalled are all related to variables such as age, race, class, sexual orientation, disability, and gender (Brown, 2008; Stewart, Ouimette, & Brown, 2002). By acknowledging that the causes behind violent crimes are multifaceted, it is imperative for the clinicians to recognize and understand intersecting identities. This is especially true when examining the influence of insidious trauma; an event may be motivated by multiple biases. Perceived control about traumatic experience has been shown to aid in adjustment in a variety of traumatic situations, and therefore it is crucial that the therapist examine the many ways intersecting oppressions inform perception of a predictable and safe environment (O’Neill & Kerig, 2000; Root, 1992; Van der Kolk et al., 1996).

Clients who identify as transgender may come to therapy to address a variety of concerns (Lev, 2004). Given the extensive literature documenting multiple types of violence in the lives of transgender people, it is crucial that mental health providers assess and attend to both subtle and overt forms of stressors (Lombardi, Wilchins, Priesing, & Malouf, 2001; Mizock & Lewis, 2008). Initial assessments should include questions that evaluate the presence of both PTSD symptoms and “complex” PTSD. Furthermore, we suggest that mental health providers ask questions pertaining to interpersonal violence, self-directed violence, and collective violence—keeping in mind that clients may not recognize the presence of the more subtle insidious traumas in their lives. In the following section, we have highlighted the most common forms of violence that have emerged in the transgender literature. We recommend that mental health providers ask transgender clients explicit questions about exposure to these types of violence.

Interpersonal Violence

A review of the literature on violence against transgender individuals suggests that many transgender clients are exposed to interpersonal traumatic experiences (Lombardi et al., 2001; Mizock & Lewis, 2008). Interpersonal violence refers to violence that occurs between at least two individuals (Krug et al., 2002) and can include physical assault, sexual assault, harassment, street violence (e.g., muggings, threats, etc.), domestic partner abuse, and/or random searches by police and medical professionals (Lev & Lev, 1999). Various needs assessment studies document a heightened risk of experiencing physical or verbal harassment for transgender adults (Xavier et al., 2004).

Researchers estimate that more than half of transgender populations experience violence at one time in their life (Kenagy, 2005; Lombardi et al., 2001). There is a high likelihood of sexual assault; reports range from 14% (Lombardi et al., 2001) to 53.8% (Kenagy, 2005). It is interesting to note that Lombardi’s lower percentage emerged from a predominantly White sample whereas Kenagy’s study was more ethnically diverse. Transgender survivors of violence are disproportionately Black when compared with overall population statistics (Stotzer, 2008). The probability of experiencing an attack may be related to age and socioeconomic status as well; older, employed individuals with higher income had a lower probability of experiencing violence (Lombardi et al., 2001).

An analysis of incident reports in Los Angeles County from 2002 to 2006 determined that the majority of crimes based on a person’s gender identity were violent actions (Stotzer, 2008). ¹ Out of 49 documented crimes that were related to gender identity, nearly three quarters were some form of assault (Stotzer, 2008). More than half of these crimes involved a perpetrator of a different racial or ethnic group than the survivor. Violence trends in prison populations may mirror those of the general population: transgender inmates experience disproportionate rates of violence in comparison with the general incarcerated population (Dean et al., 2000). The prison scenario is further complicated by placement procedures—the current system of sex-segregation fails to address transgender needs.

Compared to a group of psychiatric inpatients, transgender clients reported a higher prevalence of emotional maltreatment in childhood, which, in adulthood, was associated with higher levels of dissociative systems (Kersting et al., 2003). In addition, more than half of transgender adults reported an unwanted sexual event before the age of 18, which Gehring and Knudson (2005) attributed to peers’ curiosity about the sex of the transgender person. In this sample, transgender participants also reported experiencing verbal abuse (77%), social embarrassment (55%), and guilt from parents (58%) before their 15th birthday. These results are notably higher than the reports of bullying in the general adolescent population, which is estimated to be around 30% (Nansel et al., 2001).

The degree in which an individual is able to “pass” as a chosen gender is also related to risk of interpersonal violence (Mizock & Lewis, 2008). Roen (2001) discussed two distinct approaches and possibly political stances: passing (“either/or”) and crossing (both/neither). According to Roen, passing is the attempt to convince others by your appearance and demeanor that you are in fact “a man” or “a woman.” Roen explained crossing as a refusal to present exclusively as a man or woman; crossing is a “refusal to fit within categories” (p. 505). Male-to-female persons have the highest risk of experiencing a crime based on gender presentation (Dean et al., 2000). This is probably related to the physical effects of testosterone (e.g., hair growth) which makes passing difficult (Devor, 2004).

Furthermore, social support appears to be related to the extent to which transgender clients develop resiliency and buffer the effects of trauma (Rachlin, 2001). Social support can be defined both personally (through friends and family) or organizationally (through employment, churches, and/or financial institutions; Mathews, Stansfeld, & Power, 1999). Informing partners, children, siblings, and parents about one’s transidentity has been shown to increase interpersonal stress and has often resulted of loss or change in relationship intimacy (Bolin, 1988; Parker & Barr, 1984; Sapora & Brzek, 1983). Additional interpersonal and financial strain may exist within the context of employment, where revealing one’s transgender identity frequently results in loss of employment status (Bolin, 1988). Since social support is critical in combating the negative effects of trauma, the interpersonal strain related to transidentity is a large barrier in minimizing traumatic stress.

Self-Directed Violence

Self-directed violence refers to violence that is self-inflicted, including self-abuse and suicide (Krug et al., 2002). Experiencing discrimination may increase the risk of self-directed violence (Clements-Nolle, Marx, & Katz, 2006). Among transgender clients, high-risk behaviors, also known as tension-reduction behaviors, may emerge as a means to reduce and cope with activated abuse-related distress (Briere, 2006). These high-risk behaviors include suicide attempts (Clements-Nolle, Marx, Guzman, & Katz, 2001; Clements-Nolle et al., 2006), unsafe sex practices (Bockting, Robinson, & Rosser, 1998; Nemoto, Operario, Keatley, & Villegas, 2004), and substance abuse (Nemoto et al., 2004; Xavier, 2000). High rates of HIV are found in transgender populations, which may be a possible consequence of high-risk behaviors (Clements-Nolle et al., 2001; Xavier, 2000).

Transgender populations report remarkably high rates of suicide. Studies that have asked directly about suicide ideation and suicide attempts predicted that approximately one third of transgender people have attempted suicide (Clements-Nolle et al., 2001; Kenagy, 2005). Nearly two thirds (67.3%) of Kenagy’s (2005) participants reported that the suicide attempt was related to their gender identity. Suicide ideation statistics are even higher than suicide attempts, with reports of thoughts about suicide as high as 64% (Xavier, 2000).

Unsafe sexual behaviors are also documented in transgender research. Sex work was reportedly common among transgender individuals, which stemmed from stressors such as financial hardship and high rates of unemployment (Nemoto et al., 2004; Xavier, 2000). Focus groups with male-to-female transgender people of color revealed problematic norms associated with sex work (Nemoto et al., 2004). For example, participants reported that condom use was dependent on degree of intimacy—sex with primary partners negated condom use (intimate act) while sex with customers involved more consistent condom use (lack of intimacy). The interviews did reveal, however, that risk behaviors among transgender sex workers increased with financial need. As financial need increased, the weight of safety in decision making decreased.

Current research also lists substance abuse as a major concern for transgender populations (Bockting et al., 1998; Clements-Nolle et al., 2001; Nemoto et al., 2004; Xavier et al., 2004). Focus groups revealed that substance abuse is often directly related to sex work as a coping mechanism (Nemoto et al., 2004). The participants referred to drug use in their intimate relationships as a means of intensifying feelings. Transgender persons may abuse substances to shield the self from relationship stress, transphobia, and discrimination (Mizock & Lewis, 2008; Xavier, 2000). The day-to-day stresses of living in a transphobic world may overwhelm a transgender person to the point of preferring drug use for its numbing effects and as a distraction. One focus group participant described the experience as such: “It was like every day there was always a bunch of trauma going on . . . and I got out of the trauma, I still . . . had thoughts of all the stuff that transpired, and all of the things I’d seen, and in order to get rid of that . . . I needed to get high in order to deal with it” (Nemoto et al., 2004, p. 731).

Rates of HIV are disproportionately high among transgender populations. Substance abuse may be related to these findings as nonhormonal injection drug use is significantly associated with HIV status (Clements-Nolle et al., 2001). Unsafe sex practices, another form of self-directed violence, may also be connected to the high rates of HIV. Male-to-female transgender sex workers are at particularly high risk of HIV if their financial desperation leads to unprotected sex. Although some researchers are now calling for a topic expansion beyond HIV/AIDS in transgender health research, the current evidence demonstrates a need for both preventative measures and coping resources to be put into place (Harcourt, 2006). Xavier et al. (2004) report findings from numerous studies that suggest a prevalence among transgender women ranging anywhere from 14% (Rodriquez-Madera & Toro-Alfonso, 2000) to 47% (Nemoto, Luke, Mamo, Ching, & Patri, 1999).

Comparably lower rates of HIV are found in female- to-male transgender populations, ranging from 2% to 3%; however, HIV prevalence in female-to-male transgender individuals has been insufficiently researched (Xavier et al., 2004). In addition, transgender youth may be disproportionately affected by HIV (Sausa, 2003). The current body of research on HIV prevalence among transgender populations is limited by a strong bias toward male-to-female participants; more research is needed among female-to-male and other identifications. Regardless, the initial evidence does indicate high percentages of HIV-positive individuals among transgender populations (Clements-Nolle et al., 2001; Kenagy, 2005).

Collective Violence

Collective violence refers to violence that is perpetrated by larger groups of people/institutions (Krug et al., 2002). If a transgender person who has experienced a traumatic event decides to seek treatment, the individual may face unique barriers to care. A transgender person may avoid medical treatments and/or police investigations for fear of the possibility of insensitive treatment (Lombardi, 2001). In addition, the individual may not have access to affordable health care coverage for a variety of reasons, including joblessness and poverty (Xavier, 2000; Xavier et al., 2004). Discrimination is another barrier to care. Anecdotal evidence indicates health care insurers may refuse to cover any service once a patient is identified as transgender (Feinberg, 2001; Hong, 2002). Twenty-six percent of participants responded affirmatively when Kenagy (2005) asked them, “Have you ever been denied health care because you are transgender?” These barriers make transgender patients less likely to seek care (Xavier, 2000) and most likely to exacerbate distress. Furthermore, transgender clients may be concerned about outing themselves to a health care provider because of the stigma associated with being transidentified (Munson, 2008).

Access to health care continues to be a crippling problem for many citizens in the United States. According to the most recent 2007 Census report, 15.3% of the population does not receive any form of health insurance (DeNavas, Proctor, & Smith, 2007). This figure is further complicated with a glance over the racial breakdown of health coverage: 10.4% of White, 16.1% of Asian, 19.2% of Black, and 32.1% of Hispanic populations are uninsured. In observing that uninsured rates for Black and Hispanic populations nearly double and triple those of Whites, a hierarchical system becomes apparent. Kenagy (2005) discovered that transgender respondents of color were less likely than White transgender respondents to have a primary care provider.

The combination of prohibitive costs with high rates of unemployment results in a major institutional barrier to care for transgender populations. In a Philadelphia transgender needs assessment, nearly one quarter of the sample (24.8%) was unable to obtain health services because of cost (Kenagy, 2005). Approximately, 32.7% of the sample was unable to access mental health care due to cost of services. Considering the high risks that the transgender population faces, it is alarming to find such inadequate coverage. Similarly, a need assessment in Washington, D.C. reported that 47% of transgender respondents lacked coverage and 39% did not have a doctor for regular care (Xavier, 2000).

Current U.S. legislation and policy contribute to hampered access to care. The health care system relies heavily on the gender binary, and virtually any form one encounters will require identification as “male” or “female.” There are legal implications to the current system of gender identification for those patients who are living as a gender different from their gender assigned at birth (Burdge, 2007). Some insurers or service providers have turned patients away because of such a disparity (Feinberg, 2001). Health care policies often have loopholes that open the door to discrimination against transgender patients, regardless of whether the care is routine or related to sex reassignment surgery. Hong (2002) criticized insurers for inappropriately applying sex reassignment surgery (SRS) exclusion clauses to deny coverage to transpatients for care not related to transitioning. A pamphlet from the Transgender Law Center (2004) cited the example of an insurer that might refuse to cover treatment for liver damage because it may have resulted from hormone therapy. The Transgender Law Center argues that this is a policy violation and encourages an appeal of similar decisions.

Sadly, blatant legislative discrimination occurs in the antidiscrimination Americans With Disabilities Act (ADA; Hong, 2002). According to Hong, the ADA “protects privately insured individuals by prohibiting private employers, insurers and health care providers from targeting a particular medical condition for discriminatory treatment” (p. 89). The act was designed to prevent employers from denying coverage to employees under discrimination against specific medical conditions. However, the ADA has a specific clause excluding protection for any medical condition related to gender dysphoria. The clause states that “the term ‘disability’ shall not include transvestism, transsexualism, pedophilia, exhibitionism, voyeurism, gender identity disorders not resulting from physical impairments, or other sexual behavior disorders” (ADA, 1990). Regardless of the categorization of gender dysphoria as a mental illness, it is contradictory to classify transgender identity as a mental illness (gender identity disorder) while excluding it from legislation that promotes antidiscrimination of medical conditions.

Confidentiality concerns are heightened with transgender clients based on their degree of outness (Bockting, Robinson, Benner, & Scheltema, 2004; Feinberg, 2001). Bockting et al. (2004) give the example of knowing which name or pronoun to use when speaking to third parties, as the patient may go by another name with family members. Health care facilities create another minefield for the transgender client. Sex segregation by rooms, wings, or buildings is common practice in hospitals and treatment centers across the country (Feinberg, 2001; Transgender Law Center, 2004). This system’s adherence to the gender binary renders it ill equipped to serve a transgender patient. Denying access to restrooms or misplacement in sex segregated facilities are discriminatory practices. Feinberg (2001) described a hospital visit that occurred during the mid-1990s that illustrates many of the harmful interactions that may cause treatment to result in further harm. After being admitted to the hospital with a temperature above 104 °F, Feinberg claims to have awoken midnight to ridicule from the staff for being a “Martian.” The staff continued to harass Feinberg and refer to her as “it” until she felt compelled by their treatment to leave. Not surprisingly, provider insensitivity can affect a transgender individual’s decision to seek or stay in treatment (Lombardi, 2001).

Based on the nature of their trauma experience, some transgender clients may have required emergency medical care or mental health services. For many transgender trauma survivors, discriminatory emergency response care may increase the severity of psychological distress following the initial trauma. Wolff and Cokely (2007) analyzed 1,896 incident reports from a GLBT advocacy group in Minnesota collected during the 1990s. The study found that police conduct improved throughout the decade, but on the whole, negative responses and behaviors from officials occurred more often than positive responses. Examples of negative behaviors include mocking, blaming, or harassing the victims and failing to file reports. Tyra Hunter’s well-publicized death in 1995 is a realization of the worst-case scenario. At the scene of her car accident, rescue medics stopped administering care and began to mock and insult her on discovering her male genitals; Tyra later died in the emergency room.

In addition to emergency room situations, many transgender survivors of trauma will also seek mental health counseling that can also be further traumatizing to them. Scholinski (1998) articulated how mental health service providers further exacerbated his distress by arguing that he should wear make-up to “keep her safe” when he decided to seek counseling after a series of harassing events. Such comments that imply “victim blaming” can often deter transgender clients from seeking further mental health services that might be critical to their recovery process.

Clinical Recommendations and Models for Working With Transgender Survivors of Trauma

Much of the existing literature on mental health services with transgender individuals does not provide adequate recommendations for intervention with transgender survivors of trauma. Guidelines for therapy with transgender clients (e.g., Standards of Care; Israel & Tarver, 1997; Meyer et al., 2001) have been developed for therapy with transgender clients. Although the Standards of Care (SOC) do not discuss psychotherapeutic techniques for use with transgender clients, these guidelines do describe the potential for psychologists to have a number of roles within their professional identity and as a function of the transgender client’s overall experience. In addition to these guidelines, we uncovered a number of writings that proposed theoretical models of psychological service provision with transgender clients that differed in terms of social and developmental perspectives (e.g., Mallon, 1999; Nuttbrock, Rosenblum, & Blumenstein, 2002), in terms of therapeutic theoretical orientation (e.g., Juran, 1999; Vitale, 1996), in terms of the therapeutic process of assisting a client in the psychological processes related to gender transition (e.g., Bockting & Coleman, 1992; Lev, 2003, 2004; Rachlin, 1997), and in terms of evaluation of developing sensitivity and cultural competence in the effective counseling of transgender clients (Raj, 2002). Much of these writings depict specific ways in which therapists can work with transgender clients during the gender-transition process; however, again, there is a noticeable absence about how to work with transgender survivors of trauma and specific interventions or recommendations to aid in clinical practice.

To assist clinicians who may work with transgender survivors, we provide recommendations for clinicians on interpersonal, self-directed, and collective levels so that clinicians can engage with their clients on multiple levels of advocacy and practice. We recognize that clients who identify as transgender may come to therapy for a variety of reasons. For some transgender clients, the focus will be on identity issues; for other clients, the focus will be primarily or exclusively on something separate (such as an assault); and for the remaining clients, the focus may be on the intersection of gender identity and trauma. In some cases, therapists will need to balance the need for treatment related to trauma with a client’s request for a supportive letter for sex reassignment surgery, and in these cases, it will be important for therapists to clarify that transitioning alone may not eradicate stresses related to past traumas. Though it is not necessary (or even appropriate) to process identity before proceeding with therapy in all cases, we do recommend that therapists take a transpositive therapeutic stance. A transpositive therapeutic stance “positively values, affirms, supports, encourages and empowers transgender clients” (Raj, 2002, p. 3).

Initial Groundwork for Working With Transgender Survivors of Trauma

Interpersonal Implications and Therapeutic Strategies

Therapeutic Strategies for Self-Directed Violence

Therapeutic Strategies for Dealing With Collective Violence

Conclusion

As clinicians and researchers, we have found our work in the transgender community to be exceptionally rewarding and complex. Overall, our recommendations for clinical practice with transgender clients are a combination of both idiographic and nomothetic approaches to clinical practice. We believe that it is important to have some general clinical strategies for working with transgender clients that address self-directed, interpersonal, and collective types of trauma experiences. These objective strategies are grounded in an advocacy-focused framework that respect and explicitly affirm clients’ various identities. They also help clients work through issues of trauma and concurrently strive for optimal areas of functioning in their own life. However, we also believe that clients are unique individuals and that more client-specific, nomothetic approaches are appropriate so that interventions match clients’ symptoms, needs, and overall outcome goals for therapy.