'They' Need More From Us

Cape Town, South Africa
Cape Town, South Africa

This post has been updated by the author to protect the identities of those receiving counseling.

As a graduate social work intern working with college students, I regularly check in with my colleagues to discuss cases and get feedback. I was recently discussing with a colleague the case of an 18-year-old undergraduate student, who I'll call "Sam." Sam self-identified as gender non-binary and preferred the gender pronouns "they" and "them."

While reading through the demographic information, I was stopped by my colleague, who looked at me incredulously and asked, "Wait... gender non-binary? Does that mean they don't want to pick one?" Ultimately, Sam's pronouns -- rather than their long mental health history including suicide attempts and self harm -- became the focus of the conversation.

As mental health professionals, it is our job to be ahead of the curve when it comes to evolving cultural norms and respecting our clients' rights to define who they are without pathologizing them. The social work code of ethics defines our mission as meeting "the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty." But we are not only first responders for individuals who experience trauma, discrimination and hardship, it is also our responsibility to be allies and advocates for the vulnerable and silenced communities with whom we work.

The mental health community hasn't always been the best ally to vulnerable populations. Our profession has a dark history of getting it dangerously wrong when it comes to understanding and accepting those who do not fit into a narrow, white, heteronormative box. Take for example the mental disorder once known as Drapetomania, "the disease causing negroes to run away [from their masters]." Or consider the Diagnostic and Statistical Manual of Mental Disorders (DSM), which included homosexuality among its diagnoses until 1973. It was only in 2014 that New Jersey passed a law prohibiting "conversion therapy," or the practice of attempting to change someone's sexual orientation, as an intervention for homosexual clients; many states still allow this practice. And it wasn't until 2012, with its most recent iteration, that the DSM-5 removed Gender Identity Disorder from its list of recognized diagnoses.

As a nation, the trans community is gaining more visibility in mainstream culture with shows like Transparent and I Am Cait, and the growing visibility of stars like Laverne Cox and Chaz Bono. But as with any cultural shift, there is resistance, backlash and awkward transition. The New York Times, which has a long-standing editorial rule that prohibits the use of the singular "they," is struggling to figure out how to write about people who use gender neutral pronouns, while the Washington Post has updated their bylaws to include it as permissible when referring to gender non-conforming subjects. But pronoun usage is only one component of a much deeper and more dangerous societal resistance to accepting the trans community.

Both South Dakota and North Carolina have passed bills barring transgender students from using bathrooms in schools that don't correspond to their gender assigned at birth, citing unfounded stereotypes of trans people as sexual predators. These are only a few of the many targeted pieces of legislation that marginalize and discriminate against the trans community.

The consequences of this discrimination are not benign. According to Human Rights Campaign, nearly half of all people identifying as transgender will experience sexual assault in their lifetime. The same report showed that 90 percent of transgender people have experienced harassment in the workplace, and 26 percent have lost a job because they were trans or gender non-conforming. The LGBTQ community, and those identifying as trans or gender non-conforming in particular, have some of the highest suicide rates in the nation.

According to the American Foundation for Suicide Prevention, 41 percent of trans and gender non-conforming adults have attempted suicide, compared with only 4.6 percent of the general population. These individuals are also significantly more likely to experience homelessness, depression, harassment, sexual abuse and a whole host of other traumatic events. This is a population that needs improved access to supportive and affirming mental health services.

But this is not only a structural issue. The ability to respect and understand a client's identity is a vital clinical skill that facilitates engagement and fosters a positive therapeutic alliance. When I first sat down with Sam, they were so nervous that they were afraid they might vomit. After asking them what pronouns they use, there was a palpable shift in their demeanor: one of relief. They then told me to use their preferred name of Sam, which they hadn't shared because they "never know how people will react."

This is why it is important to check in as professionals to examine our own biases and how they are playing out in the room with our clients. As mental health practitioners, it is essential to our practice that we recognize and affirm all identities, as well as challenge our own assumptions and biases. Our clients, and our practice, depend on it.