Gender-Affirming EMDR Therapy

The current cultural and political climate is causing significant trauma for many transgender and gender-diverse (TGD) individuals. As of June 2024, 586 anti-transgender bills have been proposed in the United States, surpassing the total for the entirety of 2023 (Reed, 2024). Substantial research demonstrates that a trans-hostile environment adversely affects the mental health of transgender individuals (Price et al., 2021; Abreu et al., 2023; DuBois et al., 2023; DuBois et al., 2024; Hughto et al., 2022; Puckett et al., 2022). These detrimental effects occur irrespective of whether the proposed bills become law (Price et al., 2021).

The Minority Stress Model, as articulated by Hendricks and Testa (2012), posits that transgender and gender-diverse individuals develop heightened vigilance to cope with anticipated discrimination. This marginalization of stress leads to the internalization of negative societal messages, impacting mental health (Price et al., 2021). Price et al. (2021) explore how marginalization stress gives us a framework for understanding how minority stressors impact the mental health of TGD people.

Understanding this dynamic is essential for providing affirming care to transgender and gender-diverse clients. It is insufficient to believe oneself to be free of prejudice against these TGD individuals; therapists must actively cultivate cultural competency.

Puckett et al. (2023) conducted a study examining the experiences of TGD clients in therapy over a year, focusing on their responses to sociopolitical events. The study identified effective therapeutic practices and common missteps. Clients reported positive outcomes when therapists demonstrated essential presence and validation. Conversely, ruptures occurred when clients perceived therapists as disconnected or misunderstanding their concerns. Negative experiences included instances of therapists misgendering or deadnaming clients.

Clients also appreciated therapists who contextualized current events in relation to other behaviors, such as eating disorders and acknowledged events relevant to the TGD community, such as the Trans Day of Remembrance or public figures coming out. They valued therapists who shared personal perspectives aligning with the clients’ views (Puckett et al., 2023).

Adhering to guidelines such as those issued by the American Psychological Association (APA) in 2015 for psychological practice with transgender and gender-nonconforming people is crucial for providing affirming care within a gender-affirming EMDR practice. These guidelines and their additional 2024 statement emphasize the necessity of affirming, evidence-based, inclusive care.

There is limited literature on EMDR therapy for TGD clients. Dr. Sand Chang’s chapter in Mark Nickerson’s book, “Cultural Competence and Healing Culturally Based Trauma with EMDR Therapy,” discusses EMDR therapy as affirmative care for transgender and nonbinary clients. Dr. Chang illustrates using an internalized affirmed gender as a positive resource (Chang, 2017).

Here Are a Few Tips on Providing Affirming Care

Follow Gender-Affirming Therapy Procedures: Adhere to the APA’s 2015 guidelines and stay current on the literature regarding affirming care.
Move Beyond Absence of Prejudice: Affirming care requires more than a lack of prejudice. It requires actively addressing internal bias and reaching cultural competency.
Recognize the Profound Sociopolitical Impacts: It is crucial to understand how the sociopolitical environment affects the mental health of TGD individuals. Dismissing their experiences as overreactions to current political or cultural climates is dismissive and harmful. Acknowledging these impacts allows therapists to better empathize with their clients and provide more effective care.
Respect Client Concerns: Address the specific issues clients seek therapy for, which may not always relate to their gender identity.
Avoid Negative Responses: As Chang (2017) notes, avoid paternalism, saviorism, performative allyship, and pathologization.

Some Tips on Affirming Care Specific to EMDR

Targeting the Sociopolitical Environment: While targeting the current political/cultural environment can be beneficial, therapists should only do so if the client suggests it. Clients may be able to shift to adaptive beliefs such as “I have some power,” “I have resources,” or “I have support.” It is important not to invalidate their experiences. Focus on choice as an empowered response (Chang, 2017).
Mindfulness in Resourcing and Parts Work: Be mindful when resourcing or doing parts or inner child work. Ask the client if that works for them and if these parts or inner children have a gender, and honor that. TGD clients may have parts that identify as a variety of genders or have no gender, and the therapist must use the correct pronouns in their work.
Use Caution with Body-Based Interventions: Clients with gender dysphoria may dissociate from their bodies, and forced presence could cause distress.
Intersectionality with Neurodiversity: Be aware of the high prevalence of neurodiversity, particularly autism, among TGD individuals. Warrier et al. (2020) found that TGD individuals are significantly more likely to be autistic than cisgender individuals. Provide Neurodiversity Affirming Treatment.

By implementing these guidelines, therapists can offer more effective and affirming care to transgender and gender-diverse clients.

Cathy Hanville, LCSW, They/She is an EMDR Consultant practicing in Pennsylvania and California. They have been in practice for over 20 years and often teach about issues relating to providing gender-affirming care.

References

Abreu, R. L., Sostre, J. P., Gonzalez, K. A., Lockett, G. M., Matsuno, E., & Mosley, D. V. (2022, March 24). Impact of Gender-Affirming Care Bans on Transgender and Gender Diverse Youth: Parental Figures’ Perspective. Journal of Family Psychology, 36(5), 643-652. https://psycnet.apa.org/doi/10.1037/fam0000987

American Psychological Association. (2015). Guidelines for Psychological Practice with Transgender and Gender Nonconforming People. American Psychologist, 70(9), 832–864. https://psycnet.apa.org/doi/10.1037/a0039906

American Psychological Association. (2024, February). APA Policy statement on evidence-based inclusive care for transgender, gender diverse, and nonbinary individuals. American Psychological Association. www.apa.org/about/policy/transgender-nonbinary-inclusive-care

Ashley F., & Domínguez, S. Jr. (2021). Transgender Healthcare Does Not Stop at the Doorstep of the Clinic. The American Journal of Medicine, 134(2):158-160. https://doi.org/10.1016/j.amjmed.2020.09.030

Chang, S. C. (2017). EMDR therapy as affirmative care for transgender and gender nonconforming clients. In M. Nickerson (Ed.), Cultural competence and healing culturally based trauma with EMDR therapy (pp. 177–194). Springer Publishing Company.

DuBois, L. Zachary, Puckett, Jae A., Price, Sarah F., Kuehn, Kelsi, Lash, Brenna, Walker, Tian, Holt, Natalie R., Allura L., Ralston, Huit, T. Zachary, Miles, Makinna, Volk, Sage, Capannola, A., Tipton, Clover, Hope, Debra A., Mocarski, Richard, Juster, Robert-Paul. (2023). The Impact of Sociopolitical Events on Transgender People in the US.” Bulletin of Applied Transgender Studies 2 (1-2): pp. 1–26. https://doi.org/10.57814/sdx3-7y41

DuBois, L. Z., Puckett, J. A., SturtzSreetharan, C., Jolly, D., Lash, B. R., Huit, T. Z., Holt, N., Ralston, A., Hope, D. A., Mocarski, R., Walker, T., Miles, M., Volk, S., Capannola, A., Tipton, C., & Juster, R.-P. (2024). Mental health, coping, and resilience among transgender and gender diverse people during the 2020 U.S. presidential election. Psychology of Sexual Orientation and Gender Diversity. https://doi.org/10.1037/sgd0000700

Hendricks, M. L., & Testa, R. J. (2012). A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the Minority Stress Model. Professional Psychology: Research and Practice, 43(5), 460–467. https://doi.org/10.1037/a0029597

Holt, N.R., Ralston, A.L., Hope, D.A., Mocarski, R., & Woodruff, N. (2021). A Systematic Review of Recommendations for Behavioral Health Services for Transgender and Gender Diverse Adults: The Three-Legged Stool of Evidence-Based Practice is Unbalanced. Clin Psychol (New York), 28(2):186-201. PMID: 34456519; PMCID: PMC8386449. www.ncbi.nlm.nih.gov/pmc/articles/PMC8386449/

Hughto, J. M. W., Meyers, D. J., Mimiaga, M. J., Reisner, S. L., & Cahill, S. (2022). Uncertainty and Confusion Regarding Transgender Non-discrimination Policies: Implications for the Mental Health of Transgender Americans. Sexuality Research and Social Policy, 19(3):1069-1079. https://doi.org/10.1007/s13178-021-00602-w

James, S.E., Herman, J.L., Durso, L.E., & Heng-Lehtinen, R. (2024). Early Insights: A Report of the 2022 U.S. Transgender Survey. National Center for Transgender Equality, Washington, DC. https://ustranssurvey.org/download-reports/

Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychological Bulletin, 129(5):674-697. https://psycnet.apa.org/doi/10.1037/0033-2909.129.5.674

Price, S. F., Puckett, J., & Mocarski, R. (2020). The impact of the 2016 US Presidential Elections on transgender and gender diverse people. Sexuality Research and Social Policy, 18:1094–103. https://doi.org/10.1007/s13178-020-00513-2.

Puckett, J. A., Huit, T. Z., Hope, D. A., Mocarski, R., Lash, B. R., Walker, T., Holt, N., Ralston, A., Miles, M., Capannola, A., & Tipton, C. (2022). Transgender and gender-diverse people’s experiences of minority stress, mental health, and resilience in relation to perceptions of sociopolitical contexts. Transgender Health, 9(1). https://doi.org/10.1089/trgh.2022.0047.

Puckett, J. A., Kimball, D., Glozier, W. K., Wertz, M., Dunn, T., Lash, B. R., Ralston, A. L., Holt, N. R., Huit, T. Z., Volk, S. A., Hope, D., Mocarski, R., & DuBois, L. Z. (2023). Transgender and gender diverse clients’ experiences in therapy: Responses to sociopolitical events and helpful and unhelpful experiences. Professional Psychology: Research and Practice, 54(4), 265–274. https://doi.org/10.1037/pro0000513

Reed, E. (2024, July 11). Anti-Trans Legislative Risk Assessment Map: July 2024 edition. Anti-Trans Legislative Risk Assessment Map: July 2024 Edition. www.erininthemorning.com/p/anti-trans-legislative-risk-assessment-3dc

Rosati, F., Lorusso, M. M., Pistella, J., Giovanardi, G., Di Giannantonio, B., Mirabella, M., Williams, R., Lingiardi, V., & Baiocco, R. (2022). Non-Binary Clients’ Experiences of Psychotherapy: Uncomfortable and Affirmative Approaches. International Journal of Environmental Research and Public Health, 19(22):15339. https://doi.org/10.3390/ijerph192215339

Warrier, V., Greenberg, D. M., Weir, E., Buckingham, C., Smith, P., Lai, M. C., Allison, C., & Baron-Cohen, S. (2020). Elevated rates of autism, other neurodevelopmental and psychiatric diagnoses, and autistic traits in transgender and gender-diverse individuals. Nature Communications, 11(1): 3959. https://doi.org/10.1038%2Fs41467-020-17794-1

Wesp, L. M., Malcoe, L. H., Elliott, A., & Poteat, T. (2019). Intersectionality Research for Transgender Health Justice: A Theory-Driven Conceptual Framework for Structural Analysis of Transgender Health Inequities. Transgender Health, 4(1):287-296. https://doi.org/10.1089/trgh.2019.0039

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Gender-Affirming EMDR Therapy