How well does bereavement counselling provide for the particular needs of trans people

A note on terminology

This literature review seeks to use the language that is currently most commonly accepted by the trans community and the terms they choose to use to self-define and describe their gender experiences. However, a diversity of terms is used within the community and this reflects the complexity of the issue of identity and the ongoing struggle for self-definition. 

This review acknowledges that gender does not exist on a binary system but on a continuum. For a discussion of gender identity see Kate Bornstein (1994) and Lyndsey Myskow (2007). The novelist Leslie Feinberg (1998), an activist from this community, said that ‘our lives are proof that sex and gender are much more complex than a delivery room doctor’s glance at genitals can determine, more variegated than pink of blue birth caps’ (p 5).

There is a glossary at appendix 1 and terms included in this glossary are highlighted in italics in the text when being used on the first occasion.

Abstract

Several developments over the last 10 years have brought profound changes for trans people in the UK and for their families and friends. Whilst these changes are welcome, there is still much to be done and not all of society, including the therapeutic community, will have caught up with these changes. The trans community has faced, and is still facing, transphobia, discrimination, prejudice and social exclusion.  

The trans community is part of an increasingly aging population in the UK. This paper seeks to review the literature that identifies the particular needs of trans people and their friends and families as they cope with the challenges of aging including the death of a loved one or of friends and family. 

The paper explores how social exclusion, estrangement and isolation may make contact with bereavement counselling services all the more important for this community. However, a history of rejection and prejudice may create a barrier as potential trans clients remain defensive and wary of these services. Although there is little research on the subject, it is likely that the barriers to counselling will not be overcome unless therapists take action to reach out to this community and reassure them with their trans-affirmative practices.

Introduction and background

There is now a cohort of 'first generation' trans people in the UK who transitioned to their acquired gender in the 1960s and 1970s. These individuals, and those who transitioned more recently but later in life, will be getting older now and experiencing a range of common age-related issues such as ill-health, financial hardship, loneliness and bereavement. 

At the same time society is constantly changing and, although there is much more work still to be done, the last decade has seen some significant advances for the trans community. New statutory rights, to privacy and protection from discrimination in employment and service provision, have been fought for and won. There have been developments in medicine and surgery and the use of social media has opened up new opportunities for communication and social networking. It is true that, for many trans people, friends successfully replace family when family ties are weak.

However, whilst these advances are important, the impact of transphobia, stigma, prejudice and family and social exclusion may mean that trans elders are more isolated and with fewer means of support than other people of their age who are not trans. These factors may mean that trans clients have particular needs during the ill-health and death of a life partner, a parent, a friend or other loved one and they may turn to bereavement therapy for support. Similarly, family, friends and partners may seek support following the death of a trans person. The provision of culturally sensitive and appropriate services should be a fundamental ethical concern for all counsellors[1].

Purpose

Through a review of the relevant literature, this paper seeks to assess the extent to which the providers of 'generalist' bereavement counselling in the UK understand and are equipped to meet the particular needs of the trans community and their relatives and friends. The paper contains a broad overview of the issues that may be encountered by this community and what they may need from therapy. As a follow-on question, the paper also seeks to identify areas where therapists could remove barriers and develop a more trans-affirmative practice to better understand, attract and serve this community.

Scope

The literature selected for inclusion in this review was limited to contemporary works, with a focus on mainstream psychotherapy and bereavement counselling in the UK.

Contemporary works

There were two main reasons for selecting only contemporary sources and they were:

• That the issues are ‘live’ now for the first generation trans people aging in the UK [2]

• That legislative changes enacted in the last decade mean that any documents on trans issues, published much before 2004, will be largely out of date. Recent legislative changes include the Gender Recognition Act (2004), the Goods and Services Directive (2004/113/EC, the Civil Partnership Act (2004) and the Equality Act 2010. Collectively, these changes have created new statutory rights designed to protect trans people from discrimination in employment and in the provision of goods, facilities and services and they have provided new rights to privacy[3]

Mainstream therapy

It is important that trans people should not be seen exclusively in terms of their gender identity history and that the therapist sees the client with a holistic perspective. As a number of commentators have said: ‘trans people get colds too’ GIRES (2008). This review focuses on the services offered by ‘mainstream’ therapists offering bereavement counselling. 

Whilst bereavement is an experience that is common to all, irrespective of their gender identity, the focus here is on how far therapists are aware of and able to reach out, attract and respond to the particular needs of trans clients and their friends and families in dealing with the loss of a loved one.  

As part of this research, contact was made with the main services offering bereavement services and counselling in the UK, such as Marie Curie and Cruse Bereavement Care. Cruse responded to the contact with a statement of their vision:‘that everyone should have somewhere to turn to when someone dies, and this of course includes members of the trans community.’This was fine; as far as it goes. On the other hand, it could be described as passive or even complacent. Most of the websites of these organisations have separate sections for young people, old people, suicide and the experience of military families for example, but there is nothing that would suggest a trans-affirmative approach. 

When searching for material relating to bereavement and the experience of trans individuals, the use of the acronym’ LGBT’ as a search term was often unproductive. The experience was similar to that highlighted by Michele Bridgeman[4] when she wrote to Therapy Today[5] in 2008 in response to a feature article on ‘Working with Difference’. This article, she said, purported to ‘challenge the heterosexual models of thinking which can inadvertently lead therapists to overlook or marginalise issues specific to lesbian, gay and trans clients’. However, despite its stated intent, the article, she said, made no reference to the particular needs of trans clients.

Transitioning

Much of the trans literature is, of course, about transitioning and gender reassignment. This covers hormone therapy, cosmetic procedures and gender reassignment surgery, as well as the psychosocial aspects of transitioning. These are specialist areas often dealt with through a Gender Reassignment Clinic where the trans person will be seeking to satisfy the criteria for a Gender Recognition Certificate to obtain legal recognition for their acquired gender. There is also a growing affirmative strand of therapists offering services for the LGBT community[6]

Psychotherapy

Of the 6[7] documents selected for review, only the BACP review of research on counselling and psychotherapy for Lesbian, Gay, Bisexual and Transgender (LGBT) People, is aimed specifically at therapists. The NHS and Age UK booklets are aimed at the providers of professional services more generally, as well as the trans community and their loved ones. The 3 EHRC documents are addressed mainly to those seeking to contribute to the formation of policy.

UK focus

Whilst the 6 documents that are included in this literature review all have the UK as their focus, reference is also made to three sources from the USA.[8]

Qualitative themes

All 6 are largely concerned with qualitative themes and issues.  Several of the authors comment on the dearth of even the very basic data about the size and composition of the trans community. [9] This lack of data will not be rectified soon as the 2011 census did not include a question on whether people identified as trans. 

As a result, much of the literature relies on individual case studies or small sample surveys in the areas of employment, housing or health care, for example[10]. There is a fascinating piece of local research on the experiences of the LGBT community in Brighton and Hove. [11] However, there is little on bereavement and the experiences of counselling support within the trans community. Not only is there a paucity of data but often the trans community itself is described as elusive and difficult to reach for those outside of that community. 

Findings

In their research for the BACP, King et al (2007) looked for evidence of outcomes from the use of counselling by the wider LGBT community. They set the scene with a bold and important statement about the historical background:

‘Prejudice against homosexuality amongst therapists and the rest of society is similar to prejudice against transgenderism, as, in contrast to discrimination against characteristics such as race or sex, both have been regarded as unnatural and morally perverse’. 

However, despite an extensive search they report that they found few papers containing quantitative evidence of the effectiveness of therapy for LGBT people. They did find a number of early qualitative studies, for example Gambrill, Stein and Brown (1984), indicating that potential LGBT clients may have been socialised to be defensive and wary of the attitudes of others including therapists. They argue that unconditional acceptance by the therapist of the client’s sexual orientation or gender identity would enable the potential client to approach mainstream therapy with a greater perception of safety and confidence. This is true providing therapists can find ways of demonstrating that this acceptance is genuine and that commitment is heard by the trans community.

Given the lack of any significant body of evidence, they go on to make some generic recommendations that:

• All psychotherapy training institutes should regard knowledge of LGBT development and lifestyles as part of core training

• Therapists should seek to inform themselves of the culture and lifestyles of LGBT clients rather than expecting their clients to educate them

• More services are provided for transgender people that focus on general psychotherapeutic issues rather than exclusively on the pathway to or from gender change

• Whittle and Turner (2007) have written a practical booklet to assist trans people and/or their family and friends to deal with the particular needs that arise in the circumstances of a death. It covers the particular issues that may occur that are additional to those associated with what Worden (2010) calls ‘uncomplicated’ bereavement. They are:

• Estrangement – that trans people and their families may have become estranged because their acquired gender  was never accepted and this may have led to distress or feelings of regret, anger, betrayal and loss. Trans people may have developed new social networks but members of those networks will not necessarily have known the deceased and will not ‘share’ the grief

• Privacy – friends and family may be unaware of the gender identity issues before the death of the trans person, disclosure may be an issue after death. Tact and sensitivity will be required when describing the deceased and there will be particular concerns for the relatives or partner of a deceased trans person regarding the treatment of the body by the funeral directors and mortuary staff. Loree Cook-Daniels (2002) says that:  ‘Although the trans person’s struggle with ‘stealth vs.out’ ends at death, the question lives on for the transperson’s survivors'. She gives an account of her own experience of the post mortem following the suicide of her trans partner and her struggle to maintain their dignity  

• The relationship may not be recognised by friends and family so the bereaved partner is left to grieve alone. This may lead to issues of ‘disenfranchised’ grief described by Doka (2002) when the ‘right’ to grieve is invalidated because the loss is discounted or dismissed. A trans relationship may not be recognised or a trans person might not be informed that a loved one is ill or dying and may not be welcome at the funeral. In the Trans Mental Health Study by McNeil et al (2012) a trans individual says:

‘I missed out on attending my aunt’s funeral as I was not allowed to enter either the women’s or men’s sections of the synagogue. It was upsetting and humiliating to turn up and not be allowed in.’

• Friends and family may feel angry towards the trans family member or they may experience regret for not having been more supportive or accepting during their lifetime. 

• For some trans people, the event of a death provides an opportunity to re-establish contact as the shared loss enables people to gain a new sense of perspective. 

• In some circumstances, the change of circumstances for a trans person may give them the freedom to consider transitioning to their acquired gender. A transition which they did not consider possible when their spouse was alive.[12] 

• The Age UK booklet (2011) is a good source of information on trans issues in later life. There is advice on residential services on dementia and the trans person is advised to write down clear instructions - an ‘Advance Directive’ - on who has access and can make decisions, what clothing they should be given and so on. 

• In their Trans Gender Review, Mitchell and Howarth (2009) recognise the successful campaigning work of trans groups such as ‘Press for Change’. They map the range and type of issues that trans people face including bullying, discrimination, harassment, physical/sexual assault, transphobia and rejection by families, colleagues and friends. They point the way for future research and policy development. They say that:

‘Some trans people may experience a lack of family and social support as a result of transphobic reactions to their gender identity. They may also experience compromises to their right to a family life. Yet, there was virtually no research on the family lives, households and relationships of trans people.’ Mitchell and Howarth (2009)

The other 2 documents included in this literature review are both from the EHRC. The first is entitled ‘Not Just another Statistic: Life in Wales for Transgender People’. It is based on nine case studies and reveals that trans people find dealing with discrimination and isolation from family and friends is one of the one of the most difficult challenges and often leads to the breakdown of family relationships. The report makes it clear how, even though this amounts to discrimination, seeking redress through a legal challenge is not an option when the situation is within the family and fraught with emotion and feelings. The Trans Mental Health Study (McNeil et al 2012) indicates that 65% of the trans people included in that study were worried about growing old alone because they were trans.

The final paper is called ‘Gender Identity’ and is an information booklet for trans people in Scotland and their families and friends. This includes options for surgery, information on rights and privacy, use of pronouns and valuable tips for friends and families when responding to the news that somebody close is trans. The tips are realistic and sensible and it is acknowledged that adjusting to the new information may take time. 

Conclusion

The BACP report suggests that trans-affirmative therapy is likely to be helpful in counteracting the impact of transphobia and calls for ‘more services to be provided that focus on general psychotherapeutic issues rather than exclusively on the pathway to or from gender change’. It is clear that, although bereavement can be challenging for all clients in different ways, the needs of the trans community and their loved ones may be accentuated by social exclusion and estrangement. This is an area of work that would warrant further research on:

• Trans elders coping with bereavement
• When and how they access bereavement counselling
• Their experience of and outcomes from bereavement counselling

• Reicherzer et al (2011) use case studies to discuss the experiences of transgender clients and counsellors in America. They observe that many counsellors will not see transgender clients and that, when they do, despite good intentions, they are not sure how to proceed. The advice for counsellors working with trans clients is to offer a ‘person-centered approach’ that offers unconditional positive regard, is non-judgmental, empathetic and fully open to the narrative of the client. Therapy, Carroll argues, should be offering an affirmative and safe zone for trans clients. The emphasis, as ever, is on listening and allowing the story to be told in the context of whatever has been brought to therapy - depression, loneliness or bereavement for example. 

• Carroll et al (2002) endorse this and observe that a discussion of transgender issues is rare in professional journals and texts and so counsellors are ill-prepared to meet the needs of transgender clients, to positively validate their experiences and affirm their identity. Their article is intended to help bridge this gap and inform counsellors of the salient issues. They say that:

‘the focus has shifted from using surgical and hormonal interventions and thereby enabling transgendered persons to ‘pass’ within the traditional binary society to affirming the unique identities of transgengered persons’.

This has implications for those counsellors who have an unyielding ‘either- or’ attitude to gender identity. This rigid mind-set would need to shift in order to support clients with a unique trans identity who wish to challenge the binary gender system. Carroll and her colleagues also argue that counsellors need to become familiar with the evolving terminology and develop their understanding of the issues by, for example, reading biographical texts. They say that, for themselves as counsellors, their lives have been enriched by their trans clients and that counsellors should contribute to the learning of others by bringing the stories of their clients to their professional literature[13]

Reicherzer et al (2011) recommend that counsellors consider that a history of trans-phobia, severe marginalisation, rejection and social exclusion may lead trans people to withdraw and to struggle to establish a social network of contacts. They conclude that, like most clients: 

‘transgender persons have expressed that their greatest desire in seeking counselling is simply to feel listened to and supported.’ 

However, simply being ‘person-centered ‘is unlikely to be enough if the therapist is not able to attract trans clients in the first place. The Galop publication, ‘Shining the Light ‘, is a useful toolkit and includes 10 keys to becoming a trans positive organisation such as, engaging with a broad range of trans people and speaking out against prejudice. Some of the strategies for attracting trans clients, creating a trans friendly environment and becoming a ‘trans ally’ are useful for all service organisations including those offering therapy. Quoting Desmond Tutu they make it clear that it is not enough to be passive:

‘If you are neutral in situations of injustice, you have chosen the side of the oppressor. If an elephant has its foot on the tail of a mouse and you say that you are neutral, the mouse will not appreciate your neutrality.’ Desmond Tutu.

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Article 97

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Glossary                                                                                                                      Appendix 1

Acquired gender – the new gender of a person who has had their gender reassigned and/or legally recognised. 

BACP – British Association of Counselling and Psychotherapy

Binary – or gender binary is the classification of sex and gender into two distinct and disconnected forms of masculine and feminine

EHRC – Equality and Human Rights Commission

Gender Dysphoria – is the medical term for the condition and it is recognised by the Chief Medical Officer.  

Gender Indentify Disorder – or GID first appeared in the Diagnostic Statistical Manual, Third Edition (DSM – III) published in the 1980s.  A person has GID if there is incongruence between her or his internal sense of gender and the expectation society has for her or his gender.  Since 1980, there have been three more editions of the DSM.  The current edition, (DSM –IV-TR) establishes four criteria that must be met before a diagnosis of GID can be given. 

• The individual must have a strong and persistent cross-gender identification
• The cross-gender identification must not merely be a desire for any perceived cultural advantages and the individual must experience persistent discomfort with her or his given gender
• The person must not have an intersexed condition
• The disturbance the individual experiences must cause significant clinical distress or other impairment

There is an expectation that, with the publication of DSM-V, transgender identity will no longer be classified as a mental disorder. This will be a significant change that, it is hoped, will remove stigma, reduce anti-trans prejudice, and it will mean that a trans individual will not have to be recorded as having a mental illness before they can receive Surgical Reassignment Surgery. 

Many in the trans community go further and have rejected the idea of GID as it seems to suggest that difference or non-conformity is a pathology or a disease. They argue that uniqueness is not an illness and they do not feel the need to fit into the social norms determined for them by society and the current cultural context. 

Gender Recognition Certificate – a certificate provided to those who have been successful in their application for gender recognition

Gender Recognition/Reassignment – altering one’s gender assigned at birth. This is often a complex process including cultural, legal and medical adjustments.  The person’s preferred acquired gender becomes recognised in law.

LGBT – Lesbian, Gay, Bisexual and Trans (or Transgender).  LG & B refer to sexual orientation (who we are attracted to) and Trans refers to gender identity (who we are).

Pass - the act of being seen as the gender(s) you know yourself to be.

Stealth - the act of ‘passing’ in your ‘target gender’ without disclosing one’s transsexual history, usually because it is irrelevant, e.g. ‘living in stealth mode’.

Trans - an umbrella term to describe people whose gender identity is different from the sex they were assumed to be at birth.  Trans identities are complex, involving the particularities of individuals’ experiences and practices. Such complexity needs to be recognised rather than seeking to place all trans people into particular ‘boxes’. Trans identities can also be transient …I was trans woman but now I have transitioned I am just a woman.

Trans-affirmative – attitudes/services/practices that are positively welcoming, supportive and understanding of the trans people. 

Transgender - is also an umbrella term that is used to describe people whose lifestyles appear to conflict with the current gender norms of society. Often used interchangeably with trans. 

Transition and Transitioning - The process of becoming the gendered person you know yourself to be. This may or may not involve surgical intervention

Transphobia - irrational fear, dislike, hatred of, and/or hostility towards, people who are trans or who otherwise do not confirm to traditional gender norms

Transsexual - usually a person who intends to undergo, is undergoing or has undergone gender reassignment (which may or may not involve hormone therapy or surgery)

Transvestite people – term used to describe a person who dresses in the clothing of the opposite sex. Generally transvestites do not wish to alter their gender

People with a transsexual history - when a transsexual person who wants to live fully and permanently in the gender opposite to the gender they were assigned with at birth completes their transition they may not see themselves as being under the trans umbrella. They may see their transsexual history as a medical issue which has now been resolved and so is no longer relevant to their lives. As such, it is disrespectful to insist on calling them trans, or transsexual. They should be treated as the men or women they know themselves to be.

[1] Taken from the British Association of Counselling and Psychotherapy Ethical Framework for Good Practice (2009)

[2] ‘Generational replacement’ is probably taking place.  This theory of social change assumes that people are less likely to adopt changes as they age. Therefore, social changes become more widespread as younger people who grew up with the changes become a larger proportion of society

[3] For a full record of the legislative developments, and to anticipate further changes to come, see the guidance published by the Equality and Human Rights Commission (EHRC) www.equalityhumanrights.comand theGender Identity Research and Education Society (GIRES).

[4] UK Registered Psychotherapist, Consultant & Speaker on Gender Identity

[5] The journal of the British Association for Counselling and Psychotherapy (BACP). 

[6] A directory of counsellors is provided at http://www.pinktherapy.com/en-us/findatherapist.aspx

[7] Details of all 6 documents are listed at appendix 2

[8] The first is the work of FORGE, set up in Wisconsin in 1994.  FORGE is unique, because it includes the only Transgender Aging Network (TAN), and it is an important source of pioneering thought and action in the field led by Loree Cook-Daniels. The second is the very recent work of Reicherzer, S. L. et al (2011) on Counselling transgender trauma survivors.The third US article is by Carrol, L. et al (2002) and is perhaps the most challenging for counsellors as it requires them to shift their thinking about gender identity from the traditional binary model to something far more fluid

[9] In 2000, after informal consultations with the Passport Section of the Home Office, ‘Press for Change’ estimated there were around 5,000 transsexual people in the UK, based upon numbers of those who had changed their passports (Home Office 2000). As of November 2006, 1,660 people had already been awarded a Gender Recognition Certificate (GRC).

[10] See also the headline findings from the Home Office transgender surveys in 2011 and the ‘Advancing Transgender Equality ‘Action Plan published in December 2011 http://www.homeoffice.gov.uk/publications/equalities/lgbt-equalitypublications/transgender-action-plan

[11] Count me in Too. Brown, K. and Lim, J. (2009) Count me in too:  LGBT lives in Brighton and Hove www.countmeintoo.co.uk

[12] This is also called ‘post traumatic growth’: where a significant loss is sometimes a spur to personal growth

[13] with the usual safeguards to protect the confidentiality and anonymity of clients