How To Get What You Need From Your Therapist
Self-advocacy, identity, and the therapeutic relationship
The waiting room outside my therapist’s office is what some part of my mind will conjure up whenever I think of a therapist’s office for the rest of my life, and I kind of hate leaving my sessions with him. It’s hopelessly beige, with comfortable couches and a brass-and-glass coffee table that’s unspeakably tacky in the way only the 1990’s ever managed to be—all glitz and glam, without ounce of class, meant to showcase wealth that nobody who walks through the room will ever have. Conspicuous consumption and aspirational displays of imaginary wealth. The 90’s in a nutshell.
My therapist is a kind guy, older, with a well-trimmed grey-and-white beard and a matching full head of hair. If you’d opened a dictionary to find an illustration of the Platonic ideal of what a therapist ought to look like, his portrait would be there, smiling and inoffensive.
I’m thirteen. I don’t recognize any of these things.
My parents rise from the comfy couches, and Steve The Therapist turns his attention to them. I wander away, uncomfortable for reasons I can’t really articulate.
“Well, he’s still working through a lot,” Steve The Therapist tells my parents in his kindly and gentle voice. An understatement, given the rage and pain I’d described only minutes before, and I try to not listen in, but I can’t help it. He’s talking about me. “Be gentle with him. He needs support right now.”
My parents have a few questions for Steve The Therapist. They always do. He’s therapist number six since the disaster of my birthday. Therapists one through five hadn’t made it more than two sessions with me before I’d rejected them. A couple of bible-thumpers, one jerk who clearly hadn’t been actually interested in my situation, someone who’d wanted to just pump me full of pills and send me on my way, and a lady who’d just felt creepy for reasons I couldn’t explain. My parents are frustrated with me, I know, but I’ve made it four sessions with Steve The Therapist, and things are still going all right.
“One more thing,” I hear Steve The Therapist say. “From what I’ve seen so far, he’s pretty much a poster child for an LGBT youth. Big problems all of a sudden come puberty, trouble with his peers, so be aware of that possibility and support him if he turns out to like other boys,” Steve The Therapist says. My estimation of him drops. I like girls, and now I know that I absolutely should not tell Steve The Therapist about the Victoria’s Secret magazines I’ve secreted away from my mom’s mail, and hidden underneath my mattress. How I’ll spend hours looking longingly at Tyra Banks, feeling something I can’t really quite explain.
For a moment, I think about telling my parents that I want another new therapist. There’d been a fight last time I said that, though.
I decide to stick it out. Years go by
Steve The Therapist helps. More or less. When the Victoria’s Secret catalogues are eventually discovered, he forgets about his own advice about keeping an eye on me in case I’m queer. It’s not really his fault that he’s incompetent, that he thinks LGBT ends at the G.
It’s the 90’s. Transgender means Buffalo Bill.
Eighteen years and two other therapists later, I plop down on M—’s couch for the first time. My dad’s dying from cancer, I’m overwhelmed, grieving, terrified, and I’m pretty sure this building is made of asbestos. M— is wearing a cozy sweater against the fall chill and the dankness of the fourth-story office.
“Hey,” I say. So, I guess just background up front? I’ve been diagnosed with treatment-resistant depression since I was thirteen, I’ve seen eight other therapists in my life, been in therapy more or less constantly my whole life. I’m married, a professor, little kids creep me out for some reason, and my dad’s dying from cancer.” I feel like I’m vibrating from all the different emotions I’m feeling at once, and while the bland inoffensiveness of therapists is sometimes tiring to me, they’ve always helped me put my ducks in a row so I can keep going.
M— gives me a long, calculating, thoughtful look. The silence between us stretches.
“Sounds like you’re really going through it, huh?” she asks, and her tone has a combination of compassion, wryness, and an acerbic wit I’ve never heard from a therapist before.
“Yeah,” I say with an overwhelmed, half-hearted chuckle.
“Fuck,” she says. “That sucks.”
I burst into hysterical laughter, which quickly turns into the tears I’ve been unable to cry ever since my father’s diagnosis.
Know thyself
One of the most persistent problems in the entire galaxy of transgender healthcare is the curious gatekeeping/stewardship(as in: the opposite of gatekeeping, where someone welcomes you in rather than trying to keep you out) job that therapists have. On one hand, therapists have an ethical responsibility to their patients which begin with an obligation to protect their patients from harm and to trust them to know and speak the truth of their own hearts (APA Code of Ethics, Principles A and B). On the other, WPATH, insurance companies, and national health services require providers to make sure that trans people understand the consequences of our medical transitions, and to make sure that we’re physically and emotionally ready for the challenges we’ll face in things like surgical recovery.
Frankly, I think it puts even the most well-meaning therapists in a real bind.
Worse, it gives bad therapists a lot of cover to discriminate against us.
And, worst of all, we need to self-advocate the most forcefully for ourselves, as patients, when we’re at our least certain: when we’re coming out to ourselves, and when we’re trying to resolve ourselves for the surgeries many of us need, despite how terrifying all of those things are. It requires us to know ourselves, know our deepest needs, through all of the internalized transphobia, childhood trauma, and the instinctive fawn reflex many of us have drilled into us at a bone-deep level.
That’s an impossible task. And it’s counter to the whole principle that therapy even, ostensibly, exists for: to help us learn our own truths, heal the hurts we’ve normalized, and find a way out of the painful places that bring us to therapy in the first place. For better or worse, nobody starts therapy when they’re feeling great. Maybe the world would be a better place if they did.
There’s a damn good reason why you hear mixed messages from trans folks about the support they receive—or don’t—in therapy. It’s a place we need to be vulnerable and soft to make emotional progress, but where we’ve always, always had to be at our strongest and most guarded.
It’s a vicious catch-22.
Those who harm us, thinking they’re helping
I’ve been through a lot of therapy. Like, a lot a lot. If you except the first thirteen years of my life, I’ve been in therapy for longer than I’ve been out of therapy. In many ways, I’m the poster child for what therapy can, and can’t, accomplish. I’ve been on antidepressants, seen by an array of different therapists with different therapeutic techniques and approaches—pretty much, if there’s a legal way to work on depression, trauma, and gender in a state where I’ve lived, I’ve tried it.
Mostly, I’ve found a lot of stuff that hasn’t worked for me. Like, at all.
One of the biggest problems in therapy is that consciousness and emotions are incredibly complex, so what works for one person will not work for another. Every single therapeutic approach needs customization to work best with each unique patient. I’ve said any number of times here that biology is messy, but consciousness? Consciousness is messier by an order of magnitude at least.
Unfortunately, this means that your starting expectation when you try out a new therapist is that they will probably not be a good match for you.
Yeah. That sucks.
But it gets worse.
Biology and medicine, messy as they are, are based on verifiable, testable truths about the human body. Hormone levels are such-and-so—that sort of thing. Even a mediocre doctor who’s a raging jackass can give you decent care. That’s not the case in psychology. Let’s take an example not connected to trans stuff just for illustration.
Say a woman thinks that they might be autistic. It happens; we’re learning lately that autism has been massively underdiagnosed, especially among women and BIPoC folks, so a lot of people got missed when they were young. Our hypothetical woman goes in to see her therapist and asks to be assessed. That therapist doesn’t have specific experience diagnosing autism, so she sends our patient out for evaluation with an expert. Even this starting point is in the best half of cases—lots of non-expert therapists would simply tell her that she isn’t autistic because of their passing familiarity with more traditional understandings of autism, rather than as the modern model of autism as a spectrum. She pays the thousands of dollars the tests cost after waiting a long time to see that specialist.
And then? The tests only care about what she was like as a child.
And they rely on the adults who were in her life at the time to make the assessment.
In the year 2024, we still only have tests built to test for autism in children. And they’re heavily skewed towards catching the types of autism that show up in little white boys, rather than in little girls, BIPoC folks, and gender-expansive people.
And those tests assume an allistic adult observer, which is a problem because autism is genetically heritable. If the person’s parent is also an undiagnosed autistic person, who normalized the autistic behaviors both they and their daughter have? The test will come back negative unless our curious woman shows overwhelming in-person evidence. This is why self-diagnosis is so common, and so widely accepted, in the autistic community.
Our understandings of both autism and what it means to be trans have advanced rapidly in the last decade or two, but that means that there are a lot of therapists out there—therapists like Steve The Therapist—who are kind, well-meaning, but trapped in outdated understandings of either, leaving them incompetent.
They don’t mean to cause harm. But they do.
And then, of course, there are those therapists who don’t believe in modern understandings of autism, or modern understandings of what it means to be trans—the sorts of people who endorse Applied Behavioral Therapy, which is profoundly abusive to autistic kids and which is structurally no different from conversion therapy.
There are a number of therapists out there today who think that nonsense like autogynephilia is real. That being trans is a fetish. They testify before governments, and prey on trans people terrified of their own transness and desperate for a way out.
And they practice therapy, claiming to be specialists in trans issues.
Meeting your match
The grim reality that trans people face almost everywhere on Earth is that, whether it’s a called for by a national government, a national healthcare service, or health insurance, trans people generally require the help of therapists to transition in the ways we need. Some places, it’s for basic things like identity documents, but even in the most open and affirming places on Earth, the gateway to some of the most essential surgeries we might need are very firmly kept by the decree of WPATH itself. While language exists in Standards of Care 8 to allow the surgeon’s team itself to provide those endorsements, in practice one or more independent letters are required by insurance, a national health system, or whoever your local gatekeepers are.
So, how can you find a therapist who will act as a steward, not a gatekeeper, so you don’t waste your time, energy, and money on someone you won’t work well with?
To start at the beginning, Psychology Today offers the most comprehensive listing of therapists out there, and works in more places than any other single resource. While there are countries where PT doesn’t have a listing of local therapists, those places are more the exception than the rule.
To use it effectively:
Enter your location in the website.
When you get your first listing of local therapists, go straight to the bar on the top of the screen with bubbles. You’re going to want to set a few things to shorten things down, and be efficient.
First, hover over Issues, then click Transgender.
Second, if you’re in the US, hover over Insurance and choose your insurance.
Third, hover over Age and click Adults, unless you’re in your late teens.
Fourth, you may want to hover over More and choose a therapist with experience working with members of your minoritized status, if appropriate to you, and you may also want to click Secular and Non-Religious.
Choosing non-religious therapists/therapeutic approaches weeds out almost all Christian conversion therapists who lurk in these listings. If you’re faithful, finding a supportive therapist of your faith may be important—but it may also take more attempts.
Read the bios of the therapists who appear in your results. Pay attention to the way they talk about themselves—and, where possible, work with members of the trans community itself.
Pick two or three bios that sound promising, and like people you might be able to work well with, and send them inquiry emails to see when they might have availability to work with you.
Here are a few examples of bios that have the sort of thing you want to see in an affirming gender therapist. I’ve removed identifiable information about them, to protect the privacy of the therapists involved.
A few things stand out as green flags in these sorts of listings:
Therapists who list their pronouns in their bios, and who self-identify as members of the queer, and especially trans, community.
“Queer-affirming,” “Trans-affirming,” “Culturally-sensitive,” and “trauma-informed,” are all terms that a therapist uses to show they they do not see themselves as a gatekeeper, and that their job is to affirm and help their patients, not to hurt or change them.
An emphasis on authenticity.
Clear and specific statements of their areas of specialization. Mental health is a big field, and nobody can be an expert at everything.
When you have your first meeting with a new therapist, or when you want to check and see whether a therapist you’ve already been working with is serious about practicing these things, here are a few simple screening questions you can ask them (and the types of answers you want to see):
What do you require before you’d be willing to write a WPATH letter for a patient seeking gender-affirming surgery?
Them to ask me to write it. Nothing more.
That you know what recovery is going to look like, and that you have the things and support you’ll need for a successful recovery.
This is a good answer particularly where bottom surgery or masculizing top surgery, either of which have major recoveries which require time off work in a physically safe environment and physical support from other people, is concerned. While it might seem like minor gatekeeping at a glance, a recovery with complications can cause a lot of trauma, and it’s a therapist’s job to not send people out to face challenges before they have the tools they need to succeed.
I don’t see it as my job to gatekeep this sort of thing.
In what circumstances whould you make a diagnosis of autogynephilia?
None.
Autogynephilia is a legacy diagnosis that’s not supported by research anymore, and I don’t use it.
Would you support a trans teen seeking puberty blockers and/or HRT?
Yes.
I currently am, for another patient/patients.
If a patient were to ask you where they might find HRT/gender affirming surgery/trans support resources locally, would you be able to point them in the right direction without having to do extra research?
I’ve got a packet of that sort of information, if you’d like it.
Sure, no problem.
When was your last continuing education session on trans issues, and what organization was it with?
Any time within the last five years, but ideally within the last 6-12 months.
Any organization which is not one of the following organizations or people, as they are organizations which push anti-trans pseudoscience, conversion therapy, or the thinly-masked rebranding of it known as “gender-exploratory therapy”:
4thWaveNow
The Alliance for Therapeutic Choice and Scientific Integrity
The American College of Pediatrics
David Pickup
Erica Anderson
The Family Research Council
The Gender Exploratory Therapy Association
Genspect
J. Michael Bailey
James Cantor
Kenneth Zucker
Laura Edwards-Leeper
Lisa Bell
Lisa Littman
Lisa Marchiano
Michael Laidlaw
The National Association of Scholars
The National Task Force for Therapy Equality
The Pediatric and Adolescent Gender Dysphoria Working Group
Ray Blanchard
Rethink Identity Medicine Ethics
Roberto D’Angelo
Sasha Ayad
Susan J. Bradley
Stephanie Davies-Arai
Stella O’Malley
Transgender Trend
Youth Trans-Critical professionals
Apologies for the laundry list. There are so many people and organizations here because, for the organizations, they are often quickly formed and then abandoned, created to sign a few political push letters and then identified as bad actors by the wider psychological community. Almost every organization on this list was founded by the same group of people, also on this list, and all of the people and organizations identified here have been identified by the Southern Poverty Law Center as a hate organization, a pusher of anti-trans pseudoscience, or both. Even several of the names on this list are actually pseudonyms for others on the list, minted to hide bad reputations.
None of the answers to those questions is controversial in the psychological literature at all, and should be easy answers for any competent gender therapist. Moreover, they’re foundational parts of practicing patient self-advocacy and establishing a strong relationship with your therapist.
Beyond that? Talk with them. See if you fit well with the person. Be ready to try someone else if things don’t click quickly. M— has been a life-changing therapist to work with. I’ve seen her for six and a half years now, but her wry wit and readiness to challenge me when I try to intellectualize or dismiss my emotions—a defense mechanism which, believe it or not, is pretty bone deep for me—has been an absolutely indispensable part of my journey.
It’s really, really worth it to find someone who will affirm, support, and empower you, because there’s a lot in transition that can be damn tough. Working with your therapist should never be one of them.
This is a great resource that I may refer to if I have to end up moving away from Indiana at some point in the future (preferably Illinois as that's still close enough to visit my supportive family on holidays). Although it'll be made harder by the fact that I've been having an insurance predicament (simply put: neither informed consent HRT location is covering the insurance provider I switched to in November--even though the insurance marketplace said THAT insurance plan would cover THAT specific location; and that insurance company is not even listed on the Psychology website listed in this article) that means I may have to go back on DIY HRT until I have a job that can pay for HRT out-of-pocket.
So I got a lot of things terrifying me right now. Particularly insurance, anti-trans legislature, and not feeling sure if I can handle living alone in a new environment.
Great article, I've got a huge amount from reading your writing here and I really appreciate you taking the time to address this one. I'm a therapist myself and have been on the receiving end of a lot of bad and mediocre and a small amount of very good therapy.
Unfortunately you're right about the complexity of psychological issues which means that even a very good therapist might take some time to find the right place to work with a client or the right angle to take, and similarly even the most committed client might find it difficult to find the right way to articulate and explore the right topics. When all goes well this becomes an effective and collaborative process between both parties, but damn it can be hard to get there.
It's further complicated by the fact that you can have a very good rapport with a therapist but still not make any progress if their approach or way of working just doesn't reach the areas that need to be addressed. I unfortunately wasted quite a bit of time with therapists who were genuinely doing their best and who I felt understood and supported by, but were not pushing me into the areas of myself that actually needed work.
I desperately wish that therapy was more readily available and that more therapists better understood their blind spots and endeavoured to address them.