Unpacking Femininity: Supporting Trans Feminine Clients and Inhibiting Clinical Bias

As just a brief illustration, in June of 2020, the Trump administration attempted to roll back nondiscrimination healthcare and health insurance protections for transgender people. The Human Rights Campaign (2020) reported that in 2019, 25 transgender or gender non-conforming people were murdered, and by the fall of 2020, 34 transgender or gender non-conforming people were killed by violent means, many of them people of color. Marginalization and transphobia also frequently result in negative mental health outcomes (Giammattei, 2015; Gamarel, Reisner, Laurenceau, Nemoto, & Operario, 2014; Hendricks & Testa, 2012).

In 2016, the National Transgender Discrimination Survey reported that of the 27,715 respondents, 39% reported serious psychological distress within the last month, 40% had attempted suicide in their lifetime, and 7% attempted in the last year (James et al., 2016). These numbers are staggering when compared to the general U.S. population, with about 21% reporting any mental illness (National Institute of Mental Health, 2019) and 0.6% attempting suicide (Centers for Disease Control and Prevention, 2019).

Within the gender diverse and expansive communities, not all experiences are the same. While there are certainly commonalities to the discrimination many face, there are more complicated localized experiences related to specific gender identity. This brings to light the unique considerations needed for trans feminine individuals regarding their mental health and safety.

Trans feminine individuals

Trans feminine (sometimes written as transfeminine or trans femme) is used as an umbrella term for someone assigned male at birth who either expresses or identifies as feminine or with femininity more than masculinity. Various labels can be used, such as transgender woman, trans woman, trans feminine/femme, female, woman/women, girl(s), trans female, non-binary/nonbinary, genderqueer, and an individual may use one or more labels to identify themselves. Trans feminine individuals, particularly those of color, are considered greatly marginalized populations, facing a host of daunting issues (Cornelius & Whitaker-Brown, 2017; Koken et al., 2009). Within these groups, there is a higher prevalence of mental health issues, financial hardship, rejection, abuse, and sexual stigmatization (Gamarel et al., 2014; Koken et al., 2009). According to a recent meta-analysis by the Centers for Disease Control and Prevention (CDC, 2016), transgender women, especially those of color, are most at risk for HIV infection. Another study suggested a high prevalence of psychiatric diagnoses, substance dependence and comorbid disorders (Reisner et al., 2016). Trans feminine individuals, like the rest of the larger transgender community, also experience rejection within the medical community. Many report delaying preventative care due to prospective discrimination within the healthcare field and are more likely to delay care if they have experienced previous harassment or denial of services (Glick et al., 2018).

While these statistics paint a grim picture of what trans feminine folks fear and encounter regularly, these are overt, often visible occurrences that speak to the emotionally and physically violent treatment our society has imparted on them. Still, there are perhaps less visible, sometimes internal struggles for trans feminine individuals related to the acceptance and experiences of femininity.

Unpacking femininity

My clinical practice and research focus on supporting the experiences of LGBTQIA+ clients. Therapeutic work concentrates on relational dynamics within their communities, their romantic partners, families of origin, and how minority stress and marginalization influence these systems. I have witnessed trans feminine clients of all ages, racial and ethnic identities, class, and religious backgrounds, experiencing specific and marked distress related to cis normative feminism (i.e., the norms put forth by the cisgender community) and social ideals that surround the constructs of femininity and feminism. Cisgender therapists must consider and reflect upon how deep and painful this issue runs for trans feminine folks. For cisgender therapists who identify as women, there are privileges to gender and expression that present responsibilities for acknowledgment, and these privileges have the potential to cause harm if not discussed. Trans feminine encounters with cis normative feminism are complex and may be easily overlooked if not purposefully introduced and utilized as a tool to help them in therapy. Self-work relative to these privileges can be a tool to unlock a new level of client/therapist alliance and can be helpful to honoring unique struggles, journeys, and strengths built amidst marginalization.

The idea of femininity (just like masculinity) is embedded in our social and cultural networks from the time of our birth. It also shifts with the sociopolitical climate, sometimes positively, other times negatively. For those who believe in a fluid, socially constructed and expansive idea of femininity, “feminine” and “femininity” can really be broadly defined with a wide array of identities, expressions, and performances. This also underscores that femininity is always intersectional with other identities. To some, however, the idea behind femininity is not that flexible. In essence, some believe that only cisgender women can be included within the models of feminism and femininity.

Since the 1970s, trans feminine people and non-binary women and people have been excluded from feminist movements. Sally Hines (2019) writes about the long, complicated history of feminist theory, feminist politics and queer theory, and the fact that the validation of trans feminine people has long been contested: “Central to these conflicts is the notion of authenticity—of who is, or can be, considered to be a ‘woman.’” (p. 146). Trans feminine people have been erased, challenged, and outright rejected by more traditional feminist communities (many of them white) because they conceptualize gender as a binary based on assigned sex of a body at birth; asserting that assigned sex is an unchangeable characteristic conflated with gender identity; and that gender cannot be self-determined (Pearce, Erikainen, & Vincent, 2020).

Trans feminine encounters with cis normative feminism are complex and may be easily overlooked if not purposefully introduced and utilized as a tool to help them in therapy. 

There is a lengthy and pained discourse around these ideologies that has been a battleground since the 1970s. It has also been a war that has been waging most recently in online and social media spaces such as Reddit, Twitter, Facebook, YouTube, etc., as well as journalism outlets where trans activists are speaking out against the scourge of discrimination propagated by anti-trans feminists (a recent example being responses to J. K. Rowling’s comments). For years, trans feminine individuals have been rejected for their feminine identities, essentially denied “admittance” into femininity by predominantly white cisgender women. They have been vilified and their identities have been weaponized by patriarchal feminist rhetoric that attempts to convince others that femininity is only for people assigned female at birth, that the self-definition of gender identity cannot exist, and that trans feminine people are a “risk” for oppression and violence against cisgender women. Katelyn Burns (2019), a freelance journalist, reveals on Vox.com the irony of the arguments of these “gender-critical” feminists (also referred to as “TERFs” for Trans-Exclusionary Radical Feminist). She references that while these gender-critical feminists restrict access to femininity by arguing “biology” (a term often offensive to the trans community) and view trans women as threats to their safety, they are promoting more oppression and letting misogynistic men have a free pass. In another article, Pearce et al. (2020) discuss the positioning of trans women as “dangerous” or “violent” as an insinuation that cisgender women are fragile or inherently vulnerable. These authors point out the implicit whiteness of these gender-critical arguments in that white cisgender women have the power or racial privilege to claim needing protection. One can also argue that the comparison between trans feminine and cisgender women and the implication of cisgender white women as vulnerable simply promotes racism and sexism.

For many of us, our therapists are the first people we come out to, so having our identities validated in multiple ways and being appropriately gendered at all times provides a base from which we can begin to confront internalized negative messages.

The intrinsic messages received by trans feminine individuals surrounding acceptance, reification, validation, and recognition of their womanhood or femininity are of the utmost importance in our clinical work. We must consider how our clients cope with this marginalization. In some cases, it may be overt for them, while for others, silent but still present and very much felt. We must also consider how our identities are experienced by them, and how we enact or acknowledge our privileges as part of their therapeutic work. It is incumbent upon us to be vigilant of our own clinical or personal biases that may compound these harmful social messages.   

Clinical practice
So, what happens when clients receive gender-critical messages? How does this affect their sense of selves and pride in their identities and confidence in coming out or transition? How does this impact dysphoria (i.e., marked distress related to incongruence with one’s assigned sex at birth)? How can we best support them in this fight? I have worked with many self-identified trans feminine clients who tell me about struggling with their “inner TERF,” or self-talk that says to them they will never be “woman enough,” or accepted by any woman, trans or cis (for different reasons), or that they worry about being truly seen by others. These voices become almost automatic, and for some create a freeze response—leaving them stunted and unable to consider what their lives might be like if they continued their journeys. It impedes their motivation to do anything; it can leave some of them incredibly depressed and anxious and prevents taking steps to help alleviate dysphoria. In essence, this is a recursive process of trauma, which could be compounded by other traumatic life events. We know from the literature that trauma can lead to heightened risk in this population, but it can also lead to resilience building, which is an important clinical consideration (Mizock & Lewis, 2008; Singh & McKleroy, 2011; Testa, Jimenez, & Rankin, 2014).

As a cisgender white woman, I believe it is imperative to prioritize trans voices in my work and am eternally grateful that one of the trans women I have worked with named Lily* was willing to provide her voice to this issue. I asked Lily to include whatever thoughts she felt comfortable sharing about her experience with femininity and TERF-ism, and their impact. She addresses messaging she receives in public and private spaces, as well as her inner experience and self-dialogue. Lily ends with discussing what has been important in her therapy.

“The first thing I want to address is how TERF messaging doesn’t exist in a vacuum; there’s a lot of existing self-doubt that the ‘inner TERF’ taps into. A transition road map where one takes hormones and has surgeries and then lives ‘stealth’ (i.e., not coming out to others), is in some ways the easiest self-doubt response to the claim that trans women are not ‘real’ women. This makes my ability to even see myself as a woman contingent upon meeting the standards put forth by the cisgender community.”

“Another point to note is that there are levels to dysphoria. One is an inherent sense of wrongness with aspects of my body, but the things I’m most uncomfortable about are also the things that stand out to me the most as ‘male’ and make it feel impossible for me to ever be accepted as a woman by others. Consciously, I know I have the same features as cisgender women, but that understanding doesn’t help much.”

“While trans representation in public is improving, the fact remains that in popular media and among trans YouTube personalities, the projected image of femininity is not only cis normative, but young and pretty, and usually thin and white. There aren’t examples of people presenting femininity while still being visibly trans or speaking of that experience positively.”

“Also compounding my self-doubt is the fact that I’ve been told by family members that I ‘just don’t look like a woman’ to them. Their message is I don’t meet the standard of a ‘real woman.’ Even well-intentioned friends can inadvertently talk about their pasts in ways that remind me that I did not have the same socialization, which feels like another unbridgeable gap between myself and womanhood. Anti-trans feminists also use the aspect of socialization to exclude trans women from feminine acceptance. The result is I end up in a no-win scenario, where dysphoria wins. If I do nothing, I’m stuck, but activities that should be affirming (experimenting with clothes or makeup), often make me feel worse because they don’t have the desired effect.” 

“I started in therapy because my distress over gender issues had reached a point where it couldn’t be ignored. At that time, I didn’t feel entitled to words like ‘trans,’ ‘woman,’ or ‘lesbian,’ because I didn’t believe I met a threshold to claim them. For many of us, our therapists are the first people we come out to, so having our identities validated in multiple ways and being appropriately gendered at all times provides a base from which we can begin to confront internalized negative messages. This also establishes a foundation of trust from where I can be comfortable discussing coming out and social transition.”

“In therapy, I went out in public in ‘girl mode’ for the first time. While this was very affirming, I became flooded with self-doubt, imposter syndrome, and dysphoria when sitting with a cis woman. My therapist and I were able to name and label these feelings and work through them. In the end, her ownership, validation, and explanations of how cis normative feminism ‘boxes,’ forces comparisons, and harms us provided new invaluable perspectives. Therapy has helped me break out of intellectual knots I can tie myself into. I have now passed the point of needing to know or explain what it means for me to be a woman and can simply know and accept that I am one. It is becoming easier to own the words that describe me and use them in social settings while enjoying the internal progress that represents.”

Implications for clinicians

Lily’s thoughts allude to two clinical processes: prioritizing client voices and checking one’s own biases. If we really want to know our clients, we need to see them for who they truly are. As therapists who promote authenticity, growth, and change, we need to support trans feminine clients in expressing themselves authentically. This includes embracing an expansive definition of femininity and acknowledging their struggles and complex experiences with femininity.

To promote authenticity, we can 1) model safety and empathy, and 2) caution ourselves against promoting any of the “shoulds” of femininity, directly or indirectly. It can be harmful to endorse a certain way of being or expression as feminine, and this would simply reinforce the harmful effects of what clients see in the media and experience relationally.

As we are working to understand the unique challenges of trans feminine clients, clinicians can uncover exceptional strengths they have built in the face of marginalization. Recent literature has noted that supporting safe relational bonds (i.e., romantic partner, family of origin, friends, colleagues, etc.) can help transgender women combat the impact of transphobia (Coppola, Gangamma, & Hartwell, in press). Connecting with other trans people during identity development has also been shown to benefit psychological well-being (Testa et al., 2014). Helping trans feminine individuals find even one other person who can be a united front against transphobia with them can mobilize resilience.

In consonance with many other clinical topics, we need to educate ourselves, not rely on clients to educate us. To research and actively consider these issues helps us remain curious and open. As the gender-critical feminist movement has pathologized trans feminine people, we cannot allow a recurrence of that in therapy. When we can honor the whole person, then we are most effectively promoting healing and change. When we can find flexibility and multiplicity, we are empowering our clients to do the same.

*The name of this client has been changed and other identifiers are not included in order to protect anonymity.

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