the gender quest workbook supplemental guide for clinicians

supplemental guide for clinicians

(additional contributing author: Peter Goldblum, PhD)

Hello from the authors!

We’d like to first thank all of you wonderful clinicians who are doing inspiring work daily to sup-
port clients of all gender identities!

aims of the gender quest workbook

In working with teenage and young adult clients whose gender identities and gender expressions didn’t
fit comfortably into the standard boxes of male and female assigned to them at birth, we became aware
of just how many young people out there do fall into this broad category, and how there is a dearth of
resources for these individuals and their clinicians. We developed this workbook to begin to address
that need.
Teens, young adults, and society at large all seem to be thinking in more nuanced ways about
gender. Many people now identify as genders other than the two options of “boy/man” and “girl/
woman” we have traditionally seen portrayed in mainstream Western cultures. Some common identi-
ties and labels used among these youth include transgender, trans, genderqueer, and gender diverse
or gender expansive. Even among youth who do identify as boys/men and girls/women, their gender
expressions (ways of behaving that are interpreted as related to gender, including dress, movement,
hobbies, voice, and other expressions) may be significantly different than what is traditionally expected
or valued for their assigned sex at birth. For example, there are boys who want to wear skirts or aren’t
into sports or have more feminine mannerisms, and girls who want to date women or play football or
become construction workers.
These youth with expansive gender identities (identities outside of the boxes) and gender expressions
are not so unique—almost no one is 100 percent masculine or feminine in all aspects of their identity,
genetics, body shape, hair patterns, personality, interests, dress, mannerisms, hobbies, careers, family
roles, or other parts of their life. Yet, for some people, gender identity and expression is significantly
different from what their environment expects of them. For these gender expansive people, and par-
ticularly for the youth among them, certain common developmental and clinical challenges can arise.

Copyright © 2015 Rylan Jay Testa, Deborah Coolhart, and Jayme Peta / New Harbinger Publications.
Permission is granted to the reader to reproduce this form for personal use. 1
the gender quest workbook supplemental guide for clinicians

Our research and clinical work has highlighted three common challenges that gender expansive
youth (as well as adults) may bring to treatment, for which we felt there was a lack of resources. These
include:

• Confusion or conflict about one’s gender identity or gender expression. This ambivalence or
uncertainty within one’s self may be a result of not yet having examined one’s gender identity
(sense of self) or gender expression (aspects of appearance and behavior that convey gender). It
can also result from difficulty aligning one’s gender with the beliefs, values, and expectations
one has learned about gender.

• Distress related to gender minority stressors. This includes stressors faced from the external
world, such as gender-related violence or bullying, gender-related rejection, and gender-related
discrimination. It also includes the internal stressors experienced as a result: internalized
transphobia (internalization of negative beliefs about gender diverse people), negative
expectations about one’s future due to one’s gender identity or expression, and the real or
perceived need to conceal one’s gender identity, experience, or history.

• Barriers to rapport with mental health providers. Because of vicarious or personal experiences
of minority stress, clients may be guarded around health care providers. The history of
diagnosis of nontraditional gender identities as mental disorder (ongoing in some contexts)
and role of psychologists as “gatekeepers” for access to transition-related medical interventions
(such as hormones and surgeries) add to the reluctance by many to engage with mental health
professionals.

This workbook therefore aims to address these issues. Chapters 1, 2, and 7 largely address confusion
and conflict regarding gender identity and expression by providing both psychoeducation and oppor-
tunities for individuals to explore and experiment with gender. Chapters 3, 4, 5, 6, and 8 focus more
on how to navigate gender in different contexts, cope with associated stress, and develop resources for
resilience.
Because many gender expansive youth do not have access to clinicians who are prepared to provide
a knowledgeable, safe, and affirming context to work through these issues (either because of lack of
providers in their communities, financial concerns that leave them unable to access care, or reluctance
to disclose gender-related issues), we designed this workbook such that many people could use it as a
self-help tool. However, for those who can access a provider who either has prior knowledge and expe-
rience in working with these youth, or who is willing to develop competency in this area, we believe
there will be advantages in using both the workbook and the therapeutic relationship. Clinicians can
expand upon workbook materials and exercises to support the workbook’s aims, and the workbook can
assist in addressing any presenting issues of clinical rapport discussed above.

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if, when, and how to utilize the workbook

in clinical settings
Each provider must ultimately use their clinical judgment to decide whether and when to utilize any
workbook materials and exercises with a given client. However, we designed the materials to be uti-
lized when the following is true:

• The individual is in their teen years or older (while writing is focused on “teens and young
adults,” we think most of the content will also be useful for adults).

• The client is able and willing to read and complete such materials, either inside or outside of
session.

• The person is able to experience negative emotions that may arise as a result of completing
workbook materials without engaging in behavior that poses a serious risk of harm to self or
others.

• The clinician’s assessment and resulting conceptualization reveals that one of the three
challenges discussed above is an important aspect of the clinical picture. Suggestions on
assessing whether these challenges are present for a client are below:
• To assess distress regarding confusion or conflict about gender identity or expression, we
recommend utilizing appropriate questions from the full gender assessment table you can
find in the following publication:

Bockting, W. O., Knudson, G., & Goldberg, J. M. (2006). Counseling and mental health care for
transgender adults and loved ones. International Journal of Transgenderism, 9, 35–82.
• To assess distress related to gender minority stress, we recommend utilizing the
appropriate scales from the Gender Minority Stress and Resilience Measure you can find in
the following publication:

Testa, R. J., Habarth, J., Peta, J., Balsam, K., & Bockting, W. (2015). Development of the Gender
Minority Stress and Resilience Measure. Psychology of Sexual Orientation and Gender Diversity,
2(1), 65-77.

Generally, clinicians will have been trained to recognize guardedness or other indicators of barri-
ers to rapport. Further indication that challenges to rapport are at least partially related to gender can
be overt (comments about provider not understanding) or more subtle, such as a client who mentions
others whose gender isn’t binary or who dress or groom themselves in a gender-nonconforming way to
assess the clinician’s “friendliness” to gender expansiveness.
If a provider decides that the workbook could be of clinical use, they must then decide how to utilize
the materials and exercises. These decisions will be made by the provider based on several factors.

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Clinician factors: Material can be incorporated into many treatment orientations. In particular, many
exercises and much of the language will fit particularly well with CBT and ACT approaches, but can
also complement a wide range of other perspectives.

Client factors: Depending on the client’s needs, and on their ability and willingness to read and
complete exercises independently outside of session—including their ability to tolerate negative
emotions without engaging in harmful behaviors—options include the following:

• Content options:
• Utilize the whole book
• Choose certain chapters
• Choose particular exercises

• Method options:
• Provide as book recommendation for clients to complete independent of your work with
them
• Have clients read material and complete exercises outside of session and then explore
reactions in session
• Read material and complete exercises in session and subsequently process reactions

expanding upon the workbook in

clinical settings
In this supplement, we wanted to share some suggestions about how clinicians may expand upon the
workbook materials to further address the challenges we discussed above that gender expansive clients
may face and bring to treatment.

expanding upon rapport

In order to provide effective services for gender expansive individuals, a clinician must (1) have a knowl-
edge and understanding of what it means to be gender expansive. This allows for the genuineness and
accurate empathy recognized by many clinical orientations to be important aspects of the therapist’s
stance. Once knowledge and understanding have been established, the clinician must (2) take steps to
clearly convey to clients that therapy is a safe space for them to share, explore, and process their gender-
related thoughts, feelings, and experiences.

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(1) developing knowledge and understanding

No matter what our gender identities and expressions are as clinicians, we all must undo strong soci-
etally imposed understandings of the gender binary and of preferred gender expressions, transphobia,
and our own expectations of negative events for gender expansive people. Further, many gender expan-
sive youth and adults have experiences and identities that are significantly different from other popu-
lations, including lesbian, gay, and bisexual populations. Therefore, in order for clinicians to further
develop knowledge and understanding of gender diversity, we recommend the following:

• Complete your own Gender Quest, utilizing the workbook materials and exercises

• Explore the websites and books, included in the list of resources that accompanies The Gender
Quest Workbook

• Obtain consultation with someone experienced in working with transgender and gender-
expansive youth or adults

• Access the following resources, designed specifically for providers working with gender
diverse youth:
• American Psychological Association’s Answers to Your Questions About Transgender
People, Gender Identity, and Gender Expression webpage: http://www.apa.org/topics/lgbt
/transgender.aspx
• Gender Spectrum’s Mental Health webpage: https://www.genderspectrum.org/resources
/mental-health-2/

(2) conveying knowledge and understanding

Having a knowledge base is not sufficient if the client is not aware of it. Therefore, it is also crucial
that the clinician give cues to assure clients that they will provide a safe space for their gender-related
thoughts, feelings, and experiences. In order to communicate this, we suggest that clinicians do the fol-
lowing:

• Be conscious of how friendly your clinic environment is for transgender and gender expansive
clients. For example, clinic staff that the client will interact with in addition to the clinicians
should be educated to refer to the client by the client’s affirmed name and gender. Depending
on clinic documentation, special efforts may be made to clarify this on charts that will inform
clinic staff. Intake and assessment paperwork at your clinic should have appropriate response
options for gender expansive clients with regard to gender (you may include “Transgender,”
“Genderqueer,” and “Other,” or simply a blank to fill in if possible). If clients are asked to
identify their sex, it should be in addition to gender and not be conflated with gender, and
would be best labeled as “Sex assigned at birth” (response options may be “Male,” “Female,”
and “Intersex”). In addition, bathrooms should be provided that are either gender-neutral or
“all gender” bathrooms. Having only male and female restrooms puts many gender expansive

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clients in an uncomfortable and potentially dangerous position. Finally, safe space stickers
or posters, as well as positive images of gender expansive people in an office space in art or
magazines, can signal safety. If any of this is impossible for your location, it is advised that the
clinician open space for a conversation about this.

• Be conscious of the language, questions, and assumptions you bring to your interactions with
a client. Since it is impossible to tell based on appearance what a person’s gender identity
is, interactions with all clients should allow for the possibility that they identify as gender
expansive in some way. Similar to the changes advised to clinical paperwork above, a clinician
should ensure that their language and questions reflect an understanding of gender diversity.
For example, even a question aimed at being inclusive of sexual minorities, such as “Are you
primarily attracted to men or women?”, communicates to the client that you believe gender has
two options. Instead, you might ask, “Do you find yourself primarily attracted of people of a
certain gender?” Since binary assumptions are so pervasive in our language and culture, it can
take practice and cautiousness to use language that truly conveys a sense of understanding and
knowledge about gender diversity.

• Be conscious of your reactions to clients’ statements and behaviors related to gender. Clients
who are unsure of your competence in this area may test the waters in a variety of ways.
For instance, a client might make a comment about another person’s gender identity or
expression, or slowly share some of their thoughts or experiences. They may also dress or
groom themselves to adjust their gender presentation. In these instances, the clinician must
find a balance, such that they are not overreacting and showing excessive interest, but also not
avoiding or showing hesitancy. They must also discern how to provide affirmation of clients’
experiences, thoughts, and feelings, while allowing space for continued exploration of their
identity and expression. As with the preceding tasks, consultation may also be extremely
useful to developing these skills.

expanding upon exploration regarding gender

identity and expression
Exploration is a theme of the workbook. We believe therapy can add significant value to the workbook
material and exercises, as clinicians provide space and questions to help clients reflect on and learn
about themselves from these experiences. In this section is a list of additional exploratory exercises and
follow-up questions a clinician may offer within sessions as the client progresses through the work-
book.
Options for additional exploratory exercises include:

• Wearing different clothing, makeup, jewelry, or hairstyle within session

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• Using different pronouns or names within session

• Role-playing gender-related conversations with adults or peers within session

To process the client’s reactions to workbook material and exercises, the following questions might
be utilized:

• How did you feel before/during/after that experience?

• What parts did you like/dislike?

• What parts did you feel connected to?

• What did that experience or those feelings tell you about your gender identity?

• How did you feel about yourself during/after the experience?

• How would your experience have been different if you weren’t concerned with others’
reactions?

• What/who did you find yourself drawn to or admiring of?

• How did you deal with any discomfort that arose?

• Do you feel that you want to do this again? Why or why not?

expanding intervention to address gender minority

stress and build resilience
While chapter 8, Dealing with the Hard Stuff, provides psychoeducation about minority stressors and
facilitates building coping skills, this workbook does not attempt to directly address significant minor-
ity stress experiences clients may have faced. Because working through personal experiences of minor-
ity stress, like working through any trauma, may temporarily significantly increase levels of distress,
we felt that this type of intervention would be more appropriate for a clinical context.
While treatment protocols for addressing minority stress have not been validated, we would like
to offer a protocol developed by Dr. Peter Goldblum and utilized at the Sexual and Gender Identities
Clinic at Palo Alto University. This protocol suggests that, similar to evidence-based treatments for
helping people overcome experiences of trauma, experiences of minority stress can be approached by
helping people to fully experience and integrate their thoughts and emotions related to the event and
reconstructing meaning from the event. In order to achieve this, the following techniques can be imple-
mented:

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(1) Uncover significant experiences.

• Have the client describe distressing scenes in detail, reexperiencing the associated emotions
and thoughts.

• Assist the client in labelling the affect and locating it within the body.

• Ask the client to identify the meaning of the experience, using questions such as:

1. What did this event say to you about you (self-concept)?

2. What did this event say to you about others?

3. What did this event say to you about being your gender?

4. What did this event say to you about your future?

5. What conclusions about yourself or others did you draw from this experience?

6. What decisions did you make based on these conclusions?

7. What impact have these decisions had on you (positive or negative)?

(2) Reduce impact and future occurrence of minority stressors.

• Prompt the client to question or evaluate resulting internalized transphobic beliefs and
negative expectations about future events.

• Assist the client in evaluating what is safe and unsafe.

• Encourage increased exposure to safe but avoided situations.

• Assist in developing and utilizing personal coping skills.

• Support the client in increasing engagement with a supportive community of people who share
their minority status(es).

• Assist the client in developing pride in their identity with exposure to positive messages,
portrayals, and role models who share their minority status(es).

• Support the client in advocating for changes that will reduce risk for future minority stressors.

• Intervene yourself in different contexts (such as school policy or state legislation) to advocate
for changes that will reduce the occurrence of minority stressors.

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success in partnership
As a final note, we thought it would be crucial to state that as a mental health provider doing work with
gender expansive people, one often needs to work in partnership. The issues we address in this book—
confusion and conflict about gender identity and expression, and experiences of minority stress—are
all a result of the contexts that gender expansive people exist within. These contexts send confusing
or conflicting messages about who and how they should be and damaging messages about what their
future holds. Thus, to provide treatment for an individual dealing with any of these issues, one must
also consider and often involve oneself in the different contexts of the client’s life. For example, clini-
cians may be called upon to provide family therapy or supportive counseling for parents, caregivers,
or siblings as they adjust to a family member’s different gender experiences. Clinicians may need to
assist school teachers and administrators in understanding how to address the needs of their gender
expansive youth. For clients who seek medical interventions to affirm their sense of self, clinicians are
often asked to collaborate with medical providers in assessing readiness for the intervention. We hope
that this book empowers you to take on this role.

continuing progress
A wonderful aspect of doing this work is realizing just how many amazing and generous people are
working to make progress in providing quality care to gender expansive youth. There are materials in
our online list of resources that have been extremely helpful for us and may be of assistance to you as
well. Thank you for all of your contributions to this progress.