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Transgender and Non-binary Individuals’ Experiences in Healthcare

Transgender and gender non-conforming (TGNC) individuals utilize mental health services at a high rate relative to the general population (Grant et al., 2011; Green et al., 2013; Wang et al., 2005); however, studies have found that the quality of care that they receive is often lacking (Benson, 2013; Whitman & Han, 2017). Clinicians are often uninformed about TGNC issues (Benson, 2013; Whitman & Han, 2017) resulting in clients needing to educate their therapist (Benson, 2013; Elder, 2016). Additionally, a lack of information may lead otherwise well-meaning clinicians to perpetuate microaggressions against their TGNC clients. Microaggressions are subtle, often implicit forms of discrimination that convey a negative attitude towards a minority person’s identity (Sue et al., 2007). While microaggressions against TGNC individuals have not yet been examined in a therapeutic context, previous work has examined TGNC microaggressions in everyday life (Nadal, Skolnik, & Wong, 2012) and in the context of friendship (Galupo, Henise, & Davis, 2014). Additionally, one study examined the microaggressions faced by sexual minority clients in therapy (Shelton & Delgado-Romero, 2013); due to the close relationship between these communities (sexual and gender minorities), these microaggressions may extend to TGNC clients as well. Microaggressions can impact the relationship between the aggressor and target (Galupo et al., 2014), a concern given the importance of the therapeutic alliance on therapy outcomes (Baldwin, Wampold, & Imel, 2007; Martin, Garske, & Davis, 2000). With racial minority clients, the presence of microaggressions in therapy has been linked with weaker therapeutic alliance (Constantine, 2007; Macdonald, 2013; Neville, Spanierman, & Doan, 2006; Owen et al., 2011), poorer therapeutic outcomes (Constantine, 2007; Owen et al., 2011), and may lead to early termination (Owen et al., 2017). Understanding what constitutes a microaggression in this context may be a necessary step for therapists to engage in fewer microaggressions and resolve those that do occur (Owen et al., 2018; Owen, Tao, Imel, Wampold, & Rodolfa, 2014).

Although there has been growing interest in ensuring that TGNC clients receive culturally competent mental health services (American Psychological Association, 2015; Boroughs et al., 2015; Elder, 2016; Hendricks & Testa, 2012; Singh, 2016), many clinicians fall short of providing this (Benson, 2013; Elder, 2016; Whitman & Han, 2017). In order to provide a more affirming and effective therapy experience for TGNC clients, more needs to be known about their experiences in psychotherapy. Much of the research that exists on the topic has focused on general experiences and relied on small sample sizes (Benson, 2013; Elder, 2016).The present study aims to begin to fill this gap by qualitatively exploring the experiences of TGNC clients with microaggressions in therapy. Thus, analysis of the data collected from this study will aim to investigate the following research questions:
1) What types of microaggressions do TGNC clients face in therapy and how do these microaggressions manifest?
2) How do TGNC clients react to or cope with microaggressions in this context?
3) What factors do TGNC clients value when working with mental health professionals?

This research has significant practical implications for transgender and gender non-conforming individuals with mental health issues. There is currently little empirical literature regarding the experience of trans individuals in psychotherapy, yet in order to access some forms of medical transition it is required to use these services. It is my hope that by better understanding the current failings of mental health professionals' interactions with this population, the quality of care received will improve. The results from this study will hopefully lead to the development of training for clinicians such that they are able to provide better care to the transgender and gender non-conforming individuals.


In order to be eligible to participate in this project, individuals must be 17 years of age or older, be Canadian or living in Canada, and identify as transgender, non-binary, or otherwise identify as a gender other than the one you were assigned at birth (i.e. not be cisgender).


All participants have the option of entering into a draw to win one of eight $25 amazon gift cards.

Mitigation measures

The study uses branching logic to minimize the time that participants spend taking the study. The final questions in the study focus on positive and affirming therapy experiences to have the participants finish the survey in a positive mood. The debriefing form will contain information on microaggressions to validate individual’s experiences of distress. Participants may learn about resources that are available online or over the phone across Canada if they are experiencing distress either from participation in the study or prior to participating.

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