By Laura Kacere, reprinted with permission from Cathartic Space Counseling

When non-binary clients seek out therapy, it may be that they’re seeking out a safe space to explore their gender identity and expression. They may already understand their gender identity and seek support in coming out to friends and family, or they may be seeking therapy for something else entirely, like for anxiety and depression. Regardless of what is bringing them to your office, it is imperative that therapists create a space that feels safe and affirming, and this requires a level of knowledge and comfort on the part the therapist.

While we often think of clients as teachers, and it’s important to trust that clients know their own experiences better than clinicians do, we also have to take responsibility for educating ourselves on the common experiences, and common mistakes, that clinicians and others often make when working with non-binary clients. Although there is more research and training in the mental health field today than in previous years around working with transgender clients, it is still very limited, and there is far less understanding in the mental health field around non-binary and other gender non-conforming identities.

When we have a better sense of the issues affecting our clients, we are more effective in helping individuals further explore their sense of self to build greater authenticity and congruency in their lives. Through my own work with non-binary clients, as well as with all clients (gender experiences and expressions pertain to all of us!) I’ve found the following 5 principles to be useful considerations.

Educate yourself: terms and experiences

The term non-binary usually refers to people who identify their gender outside of the binary, as neither man nor woman, or both, or somewhere in between. While I use the term non-binary here, the term genderqueer is often used in the same way – generally as a catch-all category to refer to individuals identifying outside of the gender binary. Under the “non-binary umbrella,” there are many more terms that may more accurately describe a person’s gender, such as bigender, gender fluid, gender neutral, agender, and more. Use this list to explore other terms and definitions. Learning about pronouns (and asking every client what their pronouns is!) can also help you feel more comfortable using language that creates a safer, more affirmative environment.

It’s also important to learn about experiences of marginalization that your non-binary client may experience, both through interpersonal interactions – including street harassment, microaggressions, and bullying, as well as on a systemic level – including higher incarceration rates, discrimination in housing and employment, and a general lack of protections for gender non-conforming individuals. As with any marginalized community, we cannot consider mental health concerns as separate from the environmental context of distress and systemic oppression.

Be open to seeing gender as a spectrum, not a binary

Our understanding of gender has continued to expand over recent decades, thanks to gender theorists like Judith Butler, who have questioned the limitations and innateness of gender. It’s worth digging a little deeper into feminist and queer theory to explore these ideas further, but I think the most important thing to acknowledge is that limiting gender to a compulsive binary categorization can be inaccurate, and even harmful. Gender, both in identity and expression, exists on a spectrum, from masculine to feminine, and framing it this way allows all of us more room for self-inquiry and exploration.

You can use this Gender Unicorn activity to help clients explore their gender on a spectrum that also differentiates gender identities from presentation/expression, as well as from their sexual and emotional desires. By making space for clients to explore their gender in their broad and open way, you make space for clients to explore their gender based on their own needs and desires, within the context of their environment, relationships, and history, rather than on your own. If these concepts seem confusing to you, there are plenty of resources out there to learn more about it – here are two that I find helpful:

Gender Spectrum: Understanding Gender

Nat’l Geographic, How Science is Helping Us Understand Gender

Explore your own experiences of and views on gender

Regardless of your views on gender, as well as your personal gender identity, it will be extremely useful for you to do your own work exploring your internalization of societal expectations and norms when it comes to gender. Be careful about how you bring your assumptions around gender into the room, and acknowledge and unpack your own biases before seeing non-binary clients, so as not to further stigmatize or invalidate their experiences. Understanding your own ideas about gender will help make sure your therapy room is supportive and validating for gender exploration.

For more support in exploring your gender, check out therapist Dara Hoffman-Fox’s book You and Your Gender Identity: A Guide To Discovery

Don’t pathologize: Gender exploration/fluidity does not equal dysphoria

This is pretty simple, but a necessary rule to make clear for working with any gender non-conforming client. Don’t assume that because a client does not always feel like they fit into categories of “woman” or “man”, that this is symptomatic of a pathological nature within them, and that their distress will be relieved when they “choose a category.” This only further stigmatizes your client, and will likely set up a dynamic in which they don’t feel there is space to truly explore who they are with you.

Despite the fact that gender dysphoria exists as a diagnosis in the DSM-V, we have to be incredibly careful about using this as a general framework for understanding clients who seek therapy due to questioning their gender. There may certainly be moments of dysphoria or distress as clients uncover parts of themselves and shift toward more authentic expressions, changing aspects of their presentation/bodies, and coming out to friends and family, but in this process, it is often the environment within which a client exists that causes the stress, and less reflective of intrapsychic conflict or pathology. We live in the world that often feels unsafe for gender non-conforming individuals because it is unsafe, and there is a lot of vulnerability involved in coming out as/presenting as non-binary.

Feeling overwhelmed, confused, anxious, or sad can accompany this gender exploration for a variety of reasons; but this doesn’t mean that exploring gender is a problem, or that it is the cause of the hurt. In fact, it is often through the process of gender exploration and change that these symptoms of distress decrease.

Uncertainty is okay

Make space in your sessions for doubt, for uncertainty and insecurity, for the discomfort that comes with this often scary inner exploration alongside a pushing of societal categories. In “What’s My Gender,” author Micah writes about “certain uncertainty,” saying:

You are not only diving deep into what it means to be you, but having a non-binary gender (or just considering the possibility) means coloring way outside the lines of what exists in society, sometimes even coloring off the page entirely! So of course it can be both a very scary, though exhilarating, experience.

Help your client to be okay in that uncertainty by normalizing it, and allowing yourself to sit in that uncomfortable uncertainty as well. Remind them that it’s okay to not know right away, and even for your identity to change over time. Helping a client let go of the expectations or urgency of “needing to know” can open up a whole new space for clients to try out new things, access more inner creativity and playfulness, and pay more attention to what they notice inside around what they like and don’t like.

Don’t push for linear transition or an “end” goal

When we talk about gender non-conformity, we often talk about a transition with an end goal, as if there is one final true expression of one’s gender. This is more likely to be the framework of therapy with a transgender client, but often, with clients who identify as non-binary or gender fluid, the changes may be more subtle, sometimes only internal, or may constantly be in shift. Be careful about asserting that a linear process must take place before they can consider themselves to be the gender identity they associate with. Being non-binary does not require any particular expression or presentation, it simply requires a person to find it authentic and true to who they are.

Trust your client

Lastly, but most importantly, as with any client, it is so important to trust our clients’ own understanding of themselves over your ideas about who they should be. Respect their choices – they may ask that you use different pronouns from one session to the next, or they may express their gender in ways you don’t understand, and that’s okay. You don’t need to always understand why, and maybe they don’t need to either. Just be respectful, honor their choices, and make it clear that you recognize them as the expert on their gender identity. Validate your client, every step of the way. This can be a scary process, and your client may be faced with a lot of external pressure to conform to gender expectations. Make your therapy room at least one space where your client can safely express themselves.

To learn more about what non-binary clients may experience, or if you think you may want to explore your own gender, consider these resources, or contact me at laura@evergreencounselingwellness.com.

Help! I Think I Might Be Non-Binary, But How Can I Know?

The Gender Playbook: A Guide to Figuring Out Your Non-Binary Gender Identity

This Is What Gender Non-Binary People Look Like

Gender Unicorn (I truly love this – print these off and color in where you feel you are at any given moment)

GenderSpectrum.org

By Laura Kacere, reprinted with permission from Cathartic Space Counseling

Did you know that women are nearly twice as likely to be affected by depression and anxiety disorders as men? Women who are unemployed, less educated, and have less access to wealth are at even higher risk, as are women of Color and immigrant women. Post-traumatic stress disorder, which affects approximately 7.7 million adults in the U.S., is also more likely to occur in women than men. Why are women more likely to be affected by these largely diagnosed disorders of depression, anxiety, and PTSD? What’s the relationship of gender and mental health? And what role can feminism play in all of this?

It is common to try to understand mental health through the framework of the medical model, the way we tend to view physical ailments, viewing mental health concerns as disorders of the individual, and therefore treating them as such. Psychologists like Alfred Adler have identified the significance of viewing “the individual in context,” noting not just the impact our social and cultural environment has in shaping us, but on the role our connection to community can play in our development and in healing.

Limiting our understanding of disorders to the individual “out of context” disregards the larger systemic and cultural factors that play a role in such a disparity in mental health. Perhaps it can be seen most clearly when it comes to PTSD, for example. According to the National Center for PTSD, women are more than twice as likely to experience PTSD in part because sexual assault is the most common traumatic incident leading to traumatic stress, and women make up 90% of adult victims of sexual assault, with about 1 in 3 women experiencing a sexual assault. These numbers reflect a serious cultural and societal problem around gender and power.

The issue of sexual violence has become a more frequent topic of discussion in media recently, as women are increasingly feeling empowered to speak out about their traumatic experiences. There seems to be a bit more safety at the moment in a culture that otherwise lends itself to victim-blame (though there is certainly still a lot of this happening); we’re seeing that when women speak out in large numbers, a culture of support can be created, which often means survivors are less likely to carry the burden alone, and less likely to blame themselves for the violence they’ve experienced. Receiving social support – from family, friends, and the wider community – is a significant protective mechanism in preventing the development of PTSD. Our cultural response to women about their traumatic experiences can play a huge role in how they view what happened to them, and how they heal.

As with PTSD, we cannot view depression and anxiety as separate from the sexist oppression that women experience in our country, and worldwide. Women’s economic disadvantage, connected to such issues as inequality in wages and the lack of accessible reproductive healthcare, lends itself to higher rates of stress, and fewer resources to manage mental health challenges.

There is much research still needed on the adverse psychosocial experiences of women, but research does show that 3 important protective factors against depression include autonomy/ability to exercise some control in response to events, access to material resources that allow for that autonomy, and social support. When we simply look at the feminization of poverty in the U.S., as well as limitations in bodily autonomy that stem from limited access to reproductive care and the large prevalence of gender-based violence, we can see how these protections do not exist for many women. Along with the violence (or threat of violence) of devastating policies and interpersonal harm that affect our mental health, it is also the daily microaggressions and “benevolent sexism” that can lead to chronic stress, as well as symptoms of anxiety and depression.

According to the World Health Organization, “Depression, anxiety, somatic symptoms and high rates of comorbidity are significantly related to interconnected and co-occurrent risk factors such as gender based roles, stressors and negative life experiences and events. Gender specific risk factors for common mental disorders that disproportionately affect women include gender based violence, socioeconomic disadvantage, low income and income inequality, low or subordinate social status and rank and unremitting responsibility for the care of others." And as one might guess, racism similarly increases adverse mental health reactions, including increased anxiety, depression, and stress.

In short, sexism, like all forms of oppression, is bad for your mental health. So how does feminism fit in with all of this?

Feminism can be understood broadly as the advocacy for women’s political, social, and economic equality. I want to clarify here, that when I speak about women, I am including transgender women, who face painfully high (and rising) rates of both systemic and interpersonal violence and discrimination. The kind of feminism that I believe in will lead us in the direction of progress and support for our mental health centralizes the needs of transgender women, as well as those of women of Color. This is an anti-oppressive or intersectional feminism that challenges a historical legacy of White feminism and understands the fight for gender equality must include fighting the overlapping systems of racism, heterosexism, wealth inequality, and other forms of oppression.

Experiences of trauma on a systemic level, such as poverty and incarceration, and interpersonal/individual, such as sexual abuse and intimate partner violence, as well as the less overtly traumatic yet insidious harm of compulsory gender roles and objectification of women’s bodies are all rooted in these systems of oppression. Feminist therapists have helped radically shift our understanding of these kinds of distress as fundamentally connected to social context, arguing that how we think about healing from trauma and other mental health concerns can be rooted in feminist awareness, and that feminist identification and activism can be healing for trauma survivors, as well as for those struggling with depression and anxiety. But how does feminism actually help us recover and heal?

Check back next month for Part 2 of this piece: Feminism & Mental Health: Prevention and Healing