Counseling in a Gender-Expansive World

Resources to Support Therapeutic Practice

Douglas Knutson; Chloë Goldbach and Julie M. Koch

A 2023 Choice Reviews Outstanding Academic Title

Transgender and gender-expansive people are increasingly becoming the focus of media, politics, and of public conversation. With this increased attention comes greater visibility and counselors are now, more than ever, likely to clinically engage with openly transgender or gender-expansive clients during their careers. This is in spite of the fact that many counselors have not received specific training in skills, knowledge, and awareness necessary to provide affirming, informed care for these populations. In this book, the authors provide practical, real-life suggestions and interventions to help therapists, supervisors, and trainees increase in their competence and confidence in working with transgender and gender-expansive clients. The resources provided here are informed by evidence-based practice, scholarship on intersectionality, and by social justice and advocacy movements. This book is a useful supplement to clinical work with transgender and gender-expansive people, especially for the many clinicians who work in regions with limited transgender-specific resources.

Rowman & Littlefield Publishers

Pages: 252 • Trim: 6⅜ x 9

978-1-5381-2941-8 • Hardback • October 2022 • $126.00 • (£97.00)

978-1-5381-2942-5 • Paperback • October 2022 • $37.00 • (£30.00)

Subjects: Psychology / Psychotherapy / Counseling, Social Science / Women's Studies

Courses: Psychology; Clinical; Counseling and Therapy; Skills, Techniques, Interviewing, Interpersonal Process, Documentation, and Termination, Psychology; Clinical; Counseling and Therapy; Gender Identity, Sexuality, LGBTQIA++, Non-Binary, Gender Expansive and Intersectional Counseling

Counseling in a Gender-Expansive World

Resources to Support Therapeutic Practice

Hardback

Paperback

Summary

A 2023 Choice Reviews Outstanding Academic Title
Transgender and gender-expansive people are increasingly becoming the focus of media, politics, and of public conversation. With this increased attention comes greater visibility and counselors are now, more than ever, likely to clinically engage with openly transgender or gender-expansive clients during their careers. This is in spite of the fact that many counselors have not received specific training in skills, knowledge, and awareness necessary to provide affirming, informed care for these populations. In this book, the authors provide practical, real-life suggestions and interventions to help therapists, supervisors, and trainees increase in their competence and confidence in working with transgender and gender-expansive clients. The resources provided here are informed by evidence-based practice, scholarship on intersectionality, and by social justice and advocacy movements. This book is a useful supplement to clinical work with transgender and gender-expansive people, especially for the many clinicians who work in regions with limited transgender-specific resources.

Details

Rowman & Littlefield Publishers

Pages: 252 • Trim: 6⅜ x 9

978-1-5381-2941-8 • Hardback • October 2022 • $126.00 • (£97.00)

978-1-5381-2942-5 • Paperback • October 2022 • $37.00 • (£30.00)

Subjects: Psychology / Psychotherapy / Counseling, Social Science / Women's Studies

Courses: Psychology; Clinical; Counseling and Therapy; Skills, Techniques, Interviewing, Interpersonal Process, Documentation, and Termination, Psychology; Clinical; Counseling and Therapy; Gender Identity, Sexuality, LGBTQIA++, Non-Binary, Gender Expansive and Intersectional Counseling

Author

Douglas Knutson (he, him), PhD, LHSP, is an assistant professor in the School of Community Health Sciences, Counseling and Counseling Psychology at Oklahoma State University. He serves as director of the Diversity and Rural Advocacy Group (DRAG), a consortium of international researchers and advocates who focus on health and resilience in LGBTQ+ populations. Dr. Knutson has published 38 peer-reviewed articles, book chapters, professional papers, and encyclopedia entries. He has coauthored 74 presentations delivered at international, national, and local conferences and professional meetings. His work has been referenced in USA Today, Stateline, and NPR News. He currently serves on the editorial boards of The Counseling Psychologist and Psychology of Sexual Orientation and Gender Diversity. Dr. Knutson’s work is focused on the development and implementation of transgender- and nonbinary-affirming interventions with an emphasis on rural populations.
Chloë Goldbach (she/her/hers), MS, MA, is a White, lesbian, transgender woman and PhD candidate in counseling psychology at Southern Illinois University Carbondale (SIUC). She organizes community-wide events on transgender and nonbinary issues as an officer of the SIUC Women, Gender, and Sexuality Studies organization, serves as an associate researcher of the Diversity and Rural Advocacy Group (DRAG) at Oklahoma State University, teaches courses on LGBTQ+ and workplace diversity issues, leads a YouTube channel on transgender and nonbinary topics, and is a therapist-in-training with a focus on serving LGBTQ+ clients and clients with eating and body image concerns. Chloë has published 10 peer-reviewed articles, encyclopedia entries, and professional papers, all related to issues impacting LGBTQ+ individuals. She has delivered more than 40 presentations at international, national, and local conferences, training workshops, and professional meetings. She is currently conducting research on barriers to healthcare access for transgender and nonbinary people, experiences of LGBTQ+ people during the COVID-19 pandemic, and centering the voices and experiences of transgender and nonbinary people in the treatment and conceptualization of gender dysphoria.
Julie M. Koch (she/they), PhD, is professor of counseling psychology in the College of Education at the University of Iowa. She/they has extensive experience with clinical practice with LGBTQ+ rural populations. Dr. Koch is a former high school teacher and school counselor. Dr. Koch enjoys working with schools and international collaborations. She/they was a Monbusho Scholar at University of Hokkaido and received a Fulbright Specialist Grant to work with the LGBT Centre in Mongolia.

Table of Contents

Introduction
Section I: Laying the Foundation for Affirmative Work
Chapter 1: Building an Understanding of Gender
Bill
Molly
Rowan
Gender Terminology
Gender Binary
Gender Identity
Gender Expression
Gender Continuum
Gender Identities
Cisgender
Transgender
Nonbinary
Intersex
Transsexual
Pronouns
Summary and Recommendations
Reflection Questions
References and Suggested Readings
Chapter 2: Exploring your Gender Identity
Bill
Molly
Rowan
The Unexplored Life
Cisnormativity
Misgendering/Mispronouning
Deadnaming
Gender Identity and Your Environment
Family and Friends
Workplace
Community
Privilege
The Binary and Me Exercise
Summary and Recommendations
Reflection Questions
References and Suggested Readings
Chapter 3: Gender Identity and the Intersectional Self
Bill
Molly
Rowan
Client Intersectionality
Privilege and Power
Race and Ethnicity
Sexual Orientation
(Dis)ability Status
Socioeconomic Status
Human Service Professional Intersectionality
Gender Identity
Exploring Intersectional Gender Identity
Connecting with Others
Client-Professional Interactions
Points of Interaction
- Socioeconomic Status
- Sexual Orientation
- Minoritized Racial Status
- Social Support
- Age
Summary and Recommendations
Reflection Questions
References and Suggested Readings
Chapter 4: Gender Identity and Lifespan Development
Bill
Molly
Rowan
Early Awareness
Gender Assumptions
Childhood and Adolescence
Childhood
Adolescence
Puberty
School
Early Adulthood
Work
Middle to Late Adulthood
Summary and Recommendations
Reflection Questions
References and Suggested Readings
Chapter 5: Gender Identity and Geographic Location
Bill
Molly
Rowan
Cultural Nuance
Teletherapy
Urban Areas
Transportation
Violence and Safety
Fees for Service
Discretion
Family, Partners, and Friends
Positive Aspects of Rural Areas
Proximity to Family
Faith, Friends, and Church
The Beauty of Nature
Access to Services
Limiting Aspects of Rural Areas
Proximity to Family
Faith, Friends, and Church
Seclusion
Internet Access and Remote Connections
Travel and Resource Access
Access to Competent Providers
Semi-Rural and Semi-Urban Areas
People Who Immigrate
General Guidelines
Explore the Geographic Culture of Origin
Access Distance and Physical Access to Resources
Explore Spatial Connections to Community and Religion
Address Family Businesses, Ties, and Expectations
Explore the Impact of Local Laws and Policies
Access Availability, Longevity, and Commitment
Summary and Recommendations
Reflection Questions
References and Suggested Readings
Section II: Elements of Affirmative Practice
Chapter 6: Relationship Building
Bill
Molly
Rowan
Prior to Meeting a Client
First Appointment
Early Stages of Relationship
Strengthening the Relationship
Termination and Beyond
Summary and Recommendations
Reflection Questions
References and Suggested Readings
Chapter 7: Assessment and Diagnosis Frameworks
Bill
Molly
Rowan
A Brief History of Mental Health Diagnostic Categories
Assessment
Formal Measures
Informal or Interview-Based Assessment
Intake Protocols
Diagnosis
Default Diagnosis
Differential Diagnoses
Stabilization
Diagnoses as Permission or Endorsement for Treatment
Ethics and Diagnoses
Common Pitfalls
Refusing to Write a Letter
Ignoring Gender Expansive Identities and Intersections
Homogenizing the Population
Being Unprepared to Provide Affirming Services
Summary and Recommendations
Reflection Questions
References and Suggested Readings
Chapter 8: Ethics and Professional Standards
Bill
Molly
Rowan
Positive Ethics
Taking a Positive Ethics Approach
Positive Ethics and Decision-Making
Nonmaleficence and Positive Ethics
Ethics and Legal Issues
Conversion Therapy
Ethics and Practice Concerns
Multiple Relationships with a Single Client
Relationships with Client Families
Rural Considerations
Informed Consent
Competence
Multicultural and Social Justice Practice
Summary and Recommendations
Reflection Questions
References and Suggested Readings
Chapter 9: Transition, Care Teams, and Clinical Process
Bill
Molly
Rowan
Transitions
Social Transition
Medical Transition
Gender Dysphoria
- Diagnosis and Access to Care
Gender Euphoria
Passing
Diverse Pathways
Care Teams
Clinical Processes
Summary and Recommendations
Reflection Questions
References and Suggested Readings
Chapter 10: Resources and Letter Writing
Bill
Molly
Rowan
Resources
Letters
Affirming Hormone Therapy
Affirming Surgeries
Carry Letters
Other Resources
Competence Building Resources
Transition Care Resource
Web-Based Resources
Summary and Recommendations
Reflection Questions
References and Suggested Readings
Section III: Affirmative Care in Context
Chapter 11: Affirmative Work in Various Settings
Bill
Molly
Rowan
General Considerations
Leadership
Support Staff
Operating Systems
Location Specifics
Schools
College or University Counseling Centers
Private Practitioners
Corporate and Large Companies
Conclusion
Summary and Recommendations
Reflection Questions
References and Suggested Readings
Chapter 12: Partners and Families
Bill
Molly
Rowan
Foundations and Key Concepts
Deconstructing Negative Biases
The Power of Acceptance
Gender in Family Dynamics
Gender Fixation in Families
Components of the Family System
Supporting Gender Expansive Children
Supporting Gender Expansive Parents
Gender Transition and Romantic Relationships
Partners and Relationship Dynamics
Transitioning in Close Relationships
Polyamorous Relationships
Summary and Recommendations
Reflection Questions
References and Suggested Readings
Chapter 13: Groups
Bill
Molly
Rowan
Group Stages
Group Formation
Group Member Selection
Forming
Storming
Norming
Performing
Termination
General Suggestions
Summary and Recommendations
Reflection Questions
References and Suggested Readings
Chapter 14: Sex, Sexuality, and Romantic Attraction (Dannie Klooster)
Bill
Molly
Rowan
Historical Perspectives on Sexual Health
Gender-Affirming Approaches
Gender Expansive Clients and Sex Education Myths
Towards a Sex-Positive Framework
Body Positivity
Eroto-Positivity
Kink Positivity
Relationship Positivity
Additional Considerations
Conclusion
Summary and Recommendations
Reflection Questions
References and Suggested Readings
Chapter 15: Supervision
Bill
Molly
Rowan
Lisa, LPC, and Austin, Master’s Trainee
Supervision and Contextual Factors
Group Supervision
Identity Differences
Power Dynamics
Constructive Feedback
Supportive Feedback
The Supervisory Relationship
Self-Disclosure
Boundaries
Parallel Process
Ruptures and Conflicts
Supervision as a Professional Role
Qualification Compatibility
Consultation
Continuing Education
Future Developments
Summary and Recommendations
Reflection Questions
References and Suggested Readings
Conclusion
Appendix A: Resources Table
Figure 1
Appendix B: Letter of Recommendation for Hormone Replacement Therapy
Appendix C: Letter of Recommendation for Surgery
Appendix D: “Carry Letter”
Appendix E: Clinician Action Steps
Table 1
Index
About the Authors

Reviews

This book is an essential reference for counselors, therapists, educators, and human services staff. As the authors point out, "gender-expansive" clients typically have faced traumatizing rejections, betrayal, disenfranchisement, and violence. They need an affirmative counseling environment. Understanding the foundations of their experience, gender terminology and identities, pronouns and pitfalls (e.g., so-called deadnaming) is critical. Counselors need to explore and understand the assumptions, biases, theoretical knowledge, and values surrounding gender-expansive clients and issues. Building a therapeutic relationship requires understanding how gender identity intersects with life span development, geographic location, privilege, race, ethnicity, disability, sexual orientation, the intersectional self, and socioeconomic realities. Counselors need to provide affirming professional interactions. One consequence of geographic location is that clients may confront safety, transportation, or service fee issues, and may find teletherapy more practical. Building a trusting relationship is vital, as are goodness-of-fit of assessment and diagnostic frameworks. Common pitfalls include ignoring gender-expansive identities and interactions, deadnaming, and homogenizing the population. Positive ethics, legal issues, and practice concerns require consideration, as well as attention to transitions and providing an affirming environment. This is an excellent book that includes poignant vignettes, powerful examples, thoughtful "reflection questions," references, and suggested readings. Practical recommendations are also described. The "Binary and Me" exercises and "Pitfalls" sections are especially useful. Highly recommended. All readers.

— Choice Reviews

In these times when the gender affirmative model is ascending and the gender-expansive world will be a better one for it, Knutson, Goldbach, and Koch offer the invaluable gift of a GPS to guide us in the care and support of transgender and gender-expansive people of all ages. A must-read for anyone who wants to learn or expand their knowledge about the concepts, theory, context, practice and resources that will ensure effective therapeutic practice for transgender and gender-expansive people of all ages.

— Diane Ehrensaft, author of The Gender Creative Child and director of Mental Health, Child and Adolescent Gender Center, Benioff Children’s Hospital, University of California, San Francisco

Counseling in a Gender-Expansive World is an excellent in-depth look at the world of gender outside of the binary. The authors help readers understand their own concepts of gender with reflection questions for class discussions and to help students understand their own perceptions of gender, gender identity, etc. The authors challenge students to grow in their understanding of gender in our society. This book will be a helpful tool for furthering the development of mental health professionals in understanding affirmative practices for all gender identities.

— Beck A. Munsey, Tarleton State University, Fort Worth

This book offers both students and clinicians an overview of gender expansive people, their identity development over the lifespan, and how clinicians and mental health professionals can benefit from adopting affirmative counseling with LGBTQIA+ clients.

— Mari Alschuler, Youngstown State University

This is a timely, comprehensive textbook for learners in the health professions seeking to understand gender-expansive identities and issues of providing affirming, competent care. It is nuanced in its discussion of intersectionality, social justice, oppression, and privilege. This is a great resource for educators, learners, and professionals, especially those new to providing gender-expansive care.

— Lara Stepleman, Augusta University

Counseling in a Gender-Expansive World is a great introduction to terminology used within and to describe transgender communities. This book encourages current and future mental health practitioners to think about their own relationship to gender and how their own gendered biases may impact their ability to work with and support trans clients. This isn't just a textbook—it's a toolkit. Each chapter has self-reflection questions at the end that are thought-provoking and push you to reflect on who you are and want to be as a provider. This is an important read for cisgender providers generally, but especially those who want to work with trans and gender-expansive clients.

— Brendon T. Holloway, MSW, doctoral student and graduate research assistant, University of Denver, Graduate School of Social Work

Douglas Knutson, Chloë Goldbach, and Julie M. Koch’s book Counseling in a Gender-Expansive World: Resources to Support Therapeutic Practice presents the most comprehensive offering on working with gender-expansive clients to date. Therapists will come away feeling more confident and culturally competent in their work with TGNCNB (transgender and gender non-conforming non-binary) folx and be better equipped to build stronger therapeutic alliances with these marginalized clients.

— Ivan Diller, LCSW-R, Founder and Clinical Director, Omni Psychotherapy

Counseling in a Gender-Expansive World provides a fresh and empathic perspective for service professionals working with gender-expansive people. Each chapter also provides a blueprint for self-reflection on the clinician’s own lived experiences of gender and developed biases, and their impact on our identities and interpersonal interactions. Honest, approachable, and thought-provoking, this resource respectfully challenges the current social construct of and beliefs on gender.

— Nick Santo, DSW, LCSW-R, psychotherapist and adjunct lecturer at New York University

This book is a through, detailed, and helpful exploration of gender identity and its impacts on people. It provides a great overall picture of the experiences and needs of gender-expansive clients, and guides students and clinicians alike in developing their ability to be supportive and culturally sensitive professionals working with this community. Case examples, self-as-therapist exploration, clinical recommendations, and summaries for each chapter contribute to this excellent resource for counselors interested in working with the gender-expansive community.
Beyond assisting those in traditional helping professions, the authors have taken care to demonstrate an inclusive definition of human service professions. This air of inclusivity is present throughout the text and provides an important reminder that we are all human beings with the ability to help create a better world—and that much of this involves accepting and supporting one another. I fully recommend this book to anyone wanting to better support the gender-expansive community.

— Alicia A. Bosley, assistant professor of counseling and mental health professions, Hofstra University

Features

In this book, readers can expect to find resources for:
- Exploration of gender identities (for personal growth, with clients, and in supervision)
- Understanding how privilege and oppression relate to gender identity and expression
- Providing supervision to counselors working with transgender and gender expansive (TGE) clients
- Understanding diverse and intersectional TGE identities
- Ethical issues when working with TGE people
- Worksheets and interventions that can be used to support TGE clients
- Finding regional resources to support TGE clients through diverse social and medical transition processes
- How finances affect transition for some transgender clients
- Developing a plan to work with TGE clients in both rural and urban regions
- Examples of letters of recommendation, carry letters, and how to develop a “resource list”
- How practitioners can market their practice to TGE clients
- Recommendations for those working with TGE clients in schools, college counseling centers, and other settings