What is gender-affirming mental health care?
Reviewed by Susan Radzilowski, MSW, LMSW, ACSW
Written byAmye Archer, MFA
Last updated: 09/27/2023
“I’ve known since I was 12 that I wanted to change my name,” says Hope Krashnak, LCSW. A social worker who specializes in gender exploration and identity issues, Krashnak only recently took legal steps to change their first name to Hope as part of their transition to nonbinary.
This experience of longing, waiting, and moving forward has informed Krashnak’s own practice, and they keep it in mind when meeting new clients, many of whom are young adults. “I listen and I affirm,” Krashnak says—two of the core tenets of gender-affirming mental health care for transgender people.
Gender-affirming care helps a person understand, explore, and realize their gender identity.1 It includes age-appropriate education about gender and sexuality, family and social support, and gender-affirming medical interventions. Major medical and psychological organizations, including the American Psychiatric Association, the American Medical Association, and the American Academy of Pediatrics, support these practices for working with the transgender community.2
Meeting people right where they are
“Sometimes I’m working with clients who are experiencing gender dysphoria, and they’ve just started to question their gender,” Krashnak says. “Then I’m working with someone who’s considering the step of changing their legal name. It varies, but the important thing is that I validate where they are in that moment.”
A person may be transitioning socially, meaning they’ve changed their pronouns, their name, the way they dress, or any combination of external factors. Then there are people considering a medical transition, which may or may not include hormone therapy or surgical intervention. A gender-affirming therapist supports a client no matter where they are in their process.
Gender-affirming therapy does not mean encouraging someone to take steps they’re not ready for—in fact, it’s just the opposite. “I’ve worked with someone for about a year now, and they’re just starting to take medical steps,” Krashnak says. “When they first came in, that was their biggest goal. There was still a lot they had to work through, including that they didn’t have the support they would need going forward.”
A social or medical transition can be complicated, explains Krashnak: “You might need a letter for hormone replacement therapy (HRT). You might need a lot of documentation for legal name changes. You might need documentation and a lot of assistance for surgical intervention, if that’s what is needed—and a lot of people don’t have the support system to be able to put these things in place.”
When someone does feel ready for a medical transition, Krashnak stays involved as an advocate and a source of support. “There are so many barriers, we need to take an extra step with trans and nonbinary people to make sure they get the right services and don’t have to jump through all these hoops just to get basic health care,” says Krashnak. Mental health clinicians who work with trans and nonbinary clients tend to get much more involved in the medical system than those who don’t.
The difference between gender dysphoria and body dysmorphia
When someone is in the early stages of questioning their gender, no matter their age, they may be experiencing gender dysphoria. This means feeling uncomfortable or dissatisfied with the gender you were assigned at birth, and it may be focused on specific body parts, such as an Adam’s apple or breasts.
Body dysmorphic disorder (BDD), or body dysmorphia, is a mental health condition where a person fixates on their own physical flaws. These flaws may be real but minor, or they may be entirely imagined. Sometimes body dysmorphia accompanies gender dysphoria, but not always.
Krashnak says body dysmorphia is like looking at one of those carnival mirrors that distorts your appearance: You see yourself in a way that others don’t. Gender dysphoria is when you know what you look like, but it doesn’t match how you feel inside.
The majority of Krashnak’s clients experience gender dysphoria, but not all. “It doesn’t make someone invalid if they don’t have dysphoria. They could still be trans and/or nonbinary,” Krashnak says.
Mental health support for medical transitions
It’s difficult to know when the time is right for a medical transition, especially for younger people. It’s not the therapist’s role to encourage or discourage this very personal decision. Instead, a gender-affirming therapist will support the client’s choice while tending to their mental health.
“There’s a tightrope we have to walk to not be a barrier or another person who disappoints, but also make sure the client is sure before doing something irreversible,” says Krashnak.
Although each person is different and there’s no one-size-fits-all checklist, Krashnak says there are some general questions therapists should ask themselves when a client says they’re ready to pursue a medical transition.
Have they been questioning for a steady amount of time? Krashnak’s clients have often been thinking about transitioning for a long time before stepping foot in their office. “Many of my clients come to me and say they’ve been questioning their gender for years, sometimes even decades,” Krashnak says. To receive a diagnosis of gender dysphoria, a person must have been experiencing these feelings for at least six months.3
Has there been a sudden change in behavior? Clinicians like to see consistency, says Krashnak. “For example, if somebody has had body dysmorphia or even an eating disorder their whole life, and then all of a sudden they have gender dysphoria, I’m going to make sure there’s nothing more happening before they move forward. Is the dysphoria caused by the body dysmorphia? And if so, can we untangle those first?”
Does the client have mental health or substance abuse issues? According to the Standards of Care put forth by the World Professional Association for Transgender Health (WPATH), mental health providers should screen and treat clients for conditions like anxiety, depression, or addiction before gender-affirmation surgery.4 Untreated mental health concerns or substance use disorders may mean a client can’t participate in perioperative care, which includes follow-up appointments, wound care, and other steps to ensure physical healing.
Keeping track of the latest training, especially the guidance recommended by WPATH, is critical for knowing which steps to take. “This is a rapidly changing field, and there’s new guidance all the time,” Krashnak says. “It’s important we stay up on the latest science and research.”
Guidance for parents and caretakers of young kids
Caring for a child who expresses discomfort with their assigned gender can be challenging, especially for parents who have little experience with gender dysphoria or gender diversity—but parental support is vital and is associated with improved mental health, as well as other positive outcomes.5 You might start by considering some of the challenges trans children face.
When gender-diverse people encounter ongoing discrimination, stigma, or rejection based on who they are, it harms their mental health. According to research, 82% of transgender people have considered suicide and 40% have attempted it, with suicidality highest among transgender youth.6 Other studies show that adolescents and adults who identify as transgender have high rates of depression, anxiety, eating disorders, and self-harm.7
If you or someone you love in the trans community is struggling, contact the Trevor Project by calling 1-866-488-7386 or texting START to 678-678. Help is available 24/7.
With these risk factors in mind, it’s important to work on building up what therapists call protective factors around your child.8 You can do this by:
Encouraging your child’s exploration: It’s normal for kids to explore their identity in various ways, including gender. “If your child suddenly starts voicing thoughts like ‘I don’t want to be a boy’ or ‘I’m not a boy,’ then allowing that kid to do whatever that kid feels they need to do, within normal age-appropriate limits, is a good way to support them,” says Krashnak.
For younger kids, exploration might include dressing as a different gender or using different pronouns. For older children, it may also mean working with a gender-affirming therapist or finding a gender-affirming health care provider. Browse our directory to look for a licensed mental health professional near you.
Being an advocate for your child at school: Schools play a huge role in the lives of transgender kids.9 If your child has shown a consistent desire to change their name or pronouns, consider working with their school to encourage teachers and peers to be gender affirming—for example, asking staff to use kids’ chosen pronouns and take steps to reduce bullying.
If your child goes to public school, there are laws to help them get the support they need. In 2016, the Obama administration released guidance to ensure that the rights of transgender students are protected under Title IX of the Education Amendments of 1972.10 The guidance makes it clear that schools receiving federal money aren’t allowed to discriminate based on a student’s gender identity or transgender status.
Helping educate your community: There are many communities where transgender and nonbinary people feel unwelcome and unsafe. Much of this discrimination stems from a lack of knowledge about the trans experience. If you’re the parent of a trans child, you may feel frustrated and scared for your family. But if it feels like a safe option, you can work to educate your community with help from the Human Rights Campaign (HRC). Their Welcoming Schools campaign aims to prevent bullying through education, and there are a number of other online and local resources listed on their website.11, 12
Krashnak understands that not all parents will know the best ways to support their child, but believes there’s too much at stake not to try. “At the end of the day, the consequences of supporting your child’s exploration are much less harmful than the consequences of not supporting them,” Krashnak says.
When in doubt, be an ally
The transgender community is facing an enormous uphill battle in their fight for equal rights and representation. Supporting this community and anyone in your orbit who identifies as trans is critical right now. This could mean writing to local politicians, joining organizations that advocate for trans people, or simply offering support to a person you know.
The best way to support a friend or loved one who’s questioning their gender identity or considering transitioning is to ask what they need, Krashnak says: “You can ask helpful questions like ‘How can I support you?’ If you’re close with someone, you can ask about chosen pronouns or a chosen name.”
Despite the current climate, Krashnak feels hopeful that as the number of trans allies grows, the world will become a safer place. They point to the number of people coming out as evidence of progress.
“Gender identity is sometimes understood by the age of four, but you still have 40-year-olds coming out as trans,” Krashnak says. “That’s not because they didn’t know the whole time—it’s because they never had the chance to explore it. Thankfully, now they feel safer being their true selves.”
About the author
Amye Archer, MFA, is a senior writer at therapist.com. She is the author of “Fat Girl, Skinny” and the coeditor of “If I Don’t Make It, I Love You: Survivors in the Aftermath of School Shootings,” and her work has appeared in Creative Nonfiction magazine, Longreads, Brevity, and more. Her podcast, “Gen X, This Is Why,” reexamines media from the ’70s and ’80s. She holds a Master of Fine Arts in creative nonfiction and lives with her husband, twin daughters, and various pets in Pennsylvania.
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