Course Articles

Editor’s note: This text-based course is an edited transcript of the webinar, Boundary Issues and Dual Relationships in Social Work, presented by Frederic Reamer, PhD.

Learning Outcomes

After this course, participants will be able to:

• Identify ethics and risk management issues related to professional boundaries and dual relationships.
• Apply relevant ethics standards to manage boundaries and dual relationships.
• Use protocols designed to protect clients and help prevent litigation and ethics complaints.

Introduction and Key Concepts

Let me start with several key concepts. First, I think it is important to acknowledge that until the 1990s, the social work profession did not explore boundary issues in great depth. We've always been aware of some obvious issues. For example, involving intimate or sexual relationships with clients and former clients. Beyond that, there was not much in-depth exploration of the nuances, the challenging issues until the 1990s, and this reflects what I think is the remarkable maturation of social workers’ understanding of and exploration of ethical issues in the profession.

It is easy, I think to demonstrate that in the 1990s, there was a sea change when along with many other professions, social workers began to really appreciate the complexity involved in ethical challenges that emerged in our work.

In my opinion, boundary issues occur when practitioners relate to clients in more than one relationship, and dual or multiple relationships can occur simultaneously or consecutively. Dual or multiple relationships can occur in three different contexts:

1. They can arise in a professional relationship. For example, when a former client of ours becomes a colleague. I have been involved in a number of cases where that in fact has happened, where a social worker is attending a meeting in-person or via Zoom with staff members at the agency, and another participant was once a former client who got training in social work became a colleague and is now interacting in a professional way.
2. They can arise in social relationships. Many of you, I suspect have encountered clients in the community. Sometimes these are very brief innocuous encounters that do not present any significant complications, but some of you may, for example, live in small and rural communities where it is virtually impossible, not to have social encounters with clients or former clients, and some of these can become quite complicated.
3. They can arise in business relationships. You might be thinking, what business relationships? Who would go into business with a client? Well, I have in fact, testified in several litigation cases and licensing board cases where social workers entered into a business relationship with a client or former client, and it erupted and led to a lawsuit or a licensing board complaint or both.

This is kind of a global definition of boundary issues and dual or multiple relationships. There is a very important conceptual distinction between what we call simultaneous dual relationships and consecutive relationships that involve boundary issues. 

Simultaneous Dual/Multiple Relationships

In my experience, sometimes we encounter clients simultaneously. For example, we may live in a small and rural community. We have children that are of similar ages, they are in class together, and we are interacting as social worker and client. And on other days of the week, we may be encountering each other as parents of our children who have become playmates in their respective third grade class. That is a simultaneous dual relationship. 

Another example, you may be a social worker who goes to a church or a mosque or a synagogue, and you encounter a client in your congregation; whether it is in-person or a remote service, and you are interacting simultaneously, not in the very moment, of course, but during the period of time, when you are providing professional services, you are also interacting with your client in a place of worship. 

Consecutive Dual/Multiple Relationships

Then there are so-called consecutive dual relationships where for example, social workers may encounter clients quite some time after they have terminated services. So, a year later, two years later, all of a sudden you find out that your former client is working in your place of employment. As I mentioned earlier, as an example, or in the digital age, sometime after termination of services, you get a Facebook friend request from a former client, and that raises an interesting boundary issue with regard to whether it is permissible to engage in an online relationship with a former client.

So, dual relationships can be simultaneous that is they occur during the time you are  providing services to clients or consecutively following the termination of services. 

Examples of Boundary and Dual Relationship Challenges in Social Work

Let me give you some examples of boundary and dual relationship challenges in social work. I have divided them into two groups:

• Before the digital age
• Since the onset of the digital age

When I first got involved in my exploration of boundary and dual relationship issues in the early to mid 1990s, there was no digital technology. I was not thinking about, I was not lecturing about, I was not writing about any boundary issues that involve online relationships, for example, or electronic communications, because the technology simply didn't exist. But now these issues have become quite pervasive in contemporary social work.

Before the Digital Age

Before the time we are in now, where many of us are providing services remotely to clients, we may have online or text exchanges with clients or email exchanges, before any of this technology was available, there were lots of boundary issues in social work, examples include:

• Responding to clients’ personal questions (self-disclosure)
• Managing gifts from clients
• Managing invitations from clients (e.g., lifecycle events)
• Managing boundaries in small and rural communities
• Hiring former clients (e.g., substance use disorder treatment programs)
• Intimate relationships with former clients 

Responding to clients’ personal questions (self-disclosure)

 I imagine all of you have been asked personal questions by clients. So how old are you? Lets say you are relatively young and you have a client who is an adolescent or a relatively young parent of a child who thinks you are not much older than them. How old are you? Where do you live? 

Clients might look at your left hand to see if there is a ring on the finger. They are curious to know, whether you are married. They might ask you, are you married? Do you have any children? Are you a person of faith? If so, which one? If not, why not?

 These are perfectly reasonable questions. We are not surprised when clients ask them, and social workers throughout history have had to make decisions about whether to disclose personal information to clients.

As it relates to self-disclosure, I think there are three options:

• One option is you do not disclose any personal information because of potential boundary issues.
• Option two is you answer the client's questions honestly and routinely.
•  Option three, you are selective. You use your judgment about whether to disclose personal information to clients keeping in mind the client's clinical challenges and the possible ramifications of self-disclosure.  

Self-disclosure is an issue that is been around a long, long time. So, nothing particularly new there. 

Managing gifts from clients

I imagine that many of you have been offered gifts by clients. And you have had to make decisions about whether to keep the gift, whether to say to a client “I am not permitted to accept a gift because of the policy in my agency around boundaries.” These are clinical judgments that involve both ethical and boundary related issues. And you know option one is, never accept gifts from clients. Option two always accept a gift from clients. Option three, it depends on the nature of the gift, the client's clinical issues, the possible implications of accepting a gift and so forth.

Managing invitations from clients 

 I imagine that many of you have received invitations from clients. A client who invites you to the wedding, the graduation ceremony, the christening of the baby, because you are so important in the client's life. The client would like you to be there. Well, this is again, not a new issue and we have to make ethical and clinical judgments about whether to ever accept that invitation. Should we always say no? Or is it reasonable to go? If it is reasonable to go based on what considerations?

Managing boundaries in small and rural communities

Some of you may be living in relatively small and rural communities. Notice I say small communities. Over the years, I have had the opportunity to lecture in a number of international settings on military bases that employ social workers. These are social workers who live and work on military bases in Japan, in Italy, in Korea and other remote places in Bahrain, in Djibouti, and Diego Garcia in the middle of the Indian Ocean. These are not rural communities to the strict sense, but these are small communities and it is inevitable that social workers, (the ones I have met in these locations) will encounter their clients, some of whom are active duty military personnel or their dependents, their spouses, their children, their partners. They are going to encounter them on the base, at the swimming pool, at the mess hall, and/or at the exchange when they are shopping. They have to manage boundary issues in these small communities.

Hiring former clients

Again, these are not new issues. Some of you may work in settings that on occasion, or even as a matter of routine hire former clients. I see this most often in substance use disorder treatment programs where employers think that some former clients who are stable have a lot to offer clients because of their lived experience. They can empathize in a unique way because they have lived substance use challenges. I fully understand why some programs hire former clients, and I also recognize that can introduce some very complicated boundary issues. 

A number of years ago, I testified in a case in a Southern State that was prosecuted literally prosecuted by the Attorney General's Office, who alleged that the social worker who was executive director of a prominent behavioral health agency violated state law and violated prevailing ethical standards because that social worker hired several former clients without allegedly complying with a prominent standard related to boundaries in dual relationships. 

When I testified in that case, I did not say when I was on the witness stand, that I oppose hiring former clients in all instances, what I said in my testimony under oath is that I believe when social workers hire former clients, they must comply with widespread, widely embraced ethical standards related to boundaries and dual relationships, and conflicts of interest.

They have to hire them in a very specific way addressing issues related to privacy and confidentiality and potential conflicts of interest. You don't just hire them and leave it at that. But again, that is not a new issue. I know that a number of mental health agencies have also hired former clients who have struggled with mental illness who are stable and doing well. They can be of great help to other clients who are struggling with symptoms of schizophrenia or bipolar disorder, anxiety symptoms, other mood disorders, and so forth. 

Intimate relationships with former clients 

The final example, before the digital age, is intimate relationships with former clients. This is not a new issue. Throughout social work's history, there have been instances where there was evidence that a social worker became involved in an intimate or sexual relationship with a former client. The debate was whether that violated prevailing ethical standards.

Do we believe that once a client always a client, a client in perpetuity, there are no exceptions? Some of our sister behavioral health professions such as psychology, they have different ethical standards than social work does with regard to whether it is ever permissible to engage in an intimate relationship with a former client. The American Counseling Association, the Association for Marriage and Family Therapist, they have somewhat different standards than social work does with regard to this issue, but again, this is not a new issue. 

Since the onset of the digital age

Since the onset of the digital age, I have seen a number of really complicated, rather novel boundary and dual relationship issues that I had never seen in my career until the emergence of online and distance technology. So here are some examples:

• Clients searching online for information about social worker
• Searching online for information about clients
• Responding to current clients’ Facebook “friend” request
• Managing Facebook relationships with former clients
• Managing after-hours digital communications
• Social workers and clients “see” each other’s homes during virtual sessions

These are not exhaustive. These are simply examples, I have been involved in all of these cases.

Clients searching online for information about social worker

 Clients search online for information about you, and because their online searches are likely to find information about you, this can introduce some really complicated boundary issues. In other words, instead of asking you where you live, instead of asking you whether you have any children and so forth, they may be able to find out that information online by doing a Google search or a Facebook search. I know for a fact that there is a good chance clients will learn personal information about you, that they might bring up in a clinical session.

For example, I was involved in a case where a social worker was pulled over by the police for driving under the influence. It turns out that the social worker who did not have a history of driving under the influence, had been taking some medication for a medical condition, was not supposed to have alcohol, but did have some alcohol and was pulled over and charged with driving under the influence. Well, a client did an online search and found the “blurb” online, describing the social workers arrest, and brought it up in a clinical session. Ironically that client had been court ordered for counseling because that client had been charged on three different occasions with driving under the influence. So, you can imagine how that led to a very complicated clinical discussion. 

Searching online for information about clients

The other side of that coin is that of course we have to make decisions about whether it is permissible to search online for information about clients. All of us have the capacity to turn on our computers or our smartphones or our tablets, and to search for information about clients without their knowledge or their consent. And if we were in a room together, which of course we are not, but if we were in a room together, I would ask how many of you know, what the current NASW Code of Ethics says about conducting online searches for information about clients without their knowledge or consent.

I had the opportunity and privilege to chair the national task force that wrote the Code of Ethics adopted by NASW in the 1990s, and recently served with several colleagues on a task force to update that code, to include new, very different standards pertaining to social workers’, use of technology. We added a very explicit standard having to do with social workers’ online searches for information about clients, without their knowledge or consent. That is a complicated boundary issue that did not exist when many of us became social workers.

 If we were in a room together, I would ask how many of you are familiar with the relatively new practice standards? These are national practice standards jointly adopted by the National Association of Social Workers, the Association of Social Work Boards, the Council on Social Work Education, and the Clinical Social Work Association, that includes a number of boundary related standards having to do with our use of technology, including the issue that I just mentioned, conducting online searches for information about clients without their knowledge or consent.

I would argue every social worker must know what is in the current version of the Code of Ethics. Every social worker must know what is in these national practice standards related to our use of technology, specifically related to management of boundaries. We are held to these standards. 

Responding to current/former clients’ Facebook “friend” request

Another example, responding to current clients’ Facebook friend requests, obviously that introduces a boundary issue. It introduces a dual relationship issue. And as I mentioned a little while ago, we also may get these so-called Facebook friend requests from former clients. Well, should the standards be the same as they are when we get a request from a current client, or is it different? If we get a request from a former client, does it depend on the nature of that relationship? 

Managing after-hours digital communications

Because of technology, we now have the option to engage with clients after hours, after so-called normal working hours. So, what are the potential boundary issues? If you have an online exchange by text, by email, by Facebook private messaging, by LinkedIn, or something like that during the weekend, when you are not ordinarily working, what kind of boundary issue might that introduce? 

Should you have guidelines regarding your after-hours online interactions with clients and should you be sharing those guidelines with clients? We never used to have to think about these issues, but we do now.

Social workers and clients “see” each other’s homes during virtual sessions

Many of you may be providing distance or remote services to clients that may have started when we first heard of COVID-19 and the pandemic, and may continue beyond that. As a result of the virtual services or the distance services we are providing to clients, you may now see the inside of client's homes. 

You may meet their children who come on camera and they look at the camera, even though mommy or daddy said, "Leave me alone. Please don't come in. The door's closed. I am having an important meeting," but the four-year-old opens the door anyway and comes over to the laptop and looks and sees you and says, "Who's that mommy?" Starts waving, and then you have to respond. 

What do you say? “For reasons I am not at liberty to disclose. I am not going to tell you who I am.” You know, you are not going to handle it that way, presumably, but you have to figure out what to say, how to manage that boundary when you are interacting with clients’ family members, during your virtual online counseling session.

You might see how tidy or untidy their homes are. You are getting information. It is like doing a virtual home visit in some limited respects, even though you are not providing home-based services in the literal sense that introduces a boundary issue. 

The other side of that coin, is that your client may see the inside of your home. If you are providing services from home you may set up a virtual screen or you may have a private space, although we know that not every social worker has that luxury, and there are some social workers who have a difficult time finding private space in their own homes and clients may see the inside of some of their personal space.

Your child may march into the room, even though you said, "Please leave me alone. Please don't come into the room," but your three-year-old child may not read the sign on the door, may disobey, so to speak and all of a sudden your client is meeting your child. Who is now on-screen. Well, that is an interesting and challenging boundary issue.

 Those are some examples of boundary and dual relationship issues that have been around a long time before the so-called digital age and then in more contemporary times now that we're using technology so pervasively. 

Boundary Issues: Key Concepts

Let me share with you some key concepts. The first bullet point on slide six is a quote from colleagues of mine, Gutheil and Brodsky. I love this definition and this pertains to clinical relationships where they say, "A boundary is the edge of appropriate behavior at a given moment in the relationship between a client and therapist, as governed by the therapeutic context and contract." 

I realize that may seem a little abstract, but let me break it down a bit. I love this concept of a “boundary is the edge of appropriate behavior”. The challenge in social work of course, is to try to figure out where that edge is and to not cross that edge. I do not think that is always easy.

 Notice the use of the terms therapeutic context and therapeutic contract. So, what does that mean? One of the things I am going to argue is that some boundary issues are black and white. Do not have sex with a client. Okay, we all understand that. Do not exchange graphic-text messages, which we call sexting, a term that did not exist, when many of us became social workers. Do not engage in text or sext messages with a client. That is easy, that is a black and white issue.

Although I think that a lot of boundary issues are not black and white, but they're gray. And in fact, there are multiple shades of gray where reasonable, thoughtful, prudent social workers may disagree about how that boundary issue ought to be handled. The context, what Gutheil and Brodsky referred to as the “therapeutic context”, that makes a difference. 

For example, are you providing home-based services? That is a therapeutic context, where by definition, the boundaries I think are likely to be somewhat looser or more elastic because you are in the client's home. If you live and work in a small community like a military base or a rural community, that is a different therapeutic context than if you are providing traditional office-based services in a large city, such as Los Angeles or Chicago or Boston or New York or Miami where the therapeutic context is different. You are not as likely to encounter those clients in the community. It is not as likely that your respective children are going to be playmates. We would not be shocked if that happened in a small rural community, right? That is not to say it ca not happen in Los Angeles or Chicago or Boston or New York or Miami. It is just less likely to happen. So, the context, I think, is important.

 Here is another example. Some of you may work in agencies that provide addictions services, chemical dependency services. I know from my experience that, that is a unique therapeutic context to use Gutheil and Brodsky's language, by which I mean, and most of the programs that I have collaborated with or consulted with on occasion have people on staff who are in recovery, that is the model. Because of that therapeutic context, it is not unusual for staff, some of whom are social workers to share some of their personal story with clients. That is part of the reason why they are on staff, because they are in recovery. They are there as role models, and that is quite different from other settings where self-disclosure would not be permitted. 

By way of another example, in addition to my duties as a professor, I have spent many years working in prisons. In a prison setting, a social worker typically does not share personal information with inmates. It is just not the norm. 

Are there some exceptions? I am sure there are, but that (as in prison setting)  therapeutic context is quite different from a community-based program that serves people who struggle with addictions, where some of the staff were hired because they are in recovery, different therapeutic context, and I would argue different norms pertaining to self-disclosure.

I would argue that dual or multiple relationships are not necessarily unethical. I do not believe that all relationships are unethical. I think some are, and I think some are not.

For example, I think there are times when it is appropriate for social workers to share some limited personal information with clients in some circumstances. Does that constitute a boundary issue? Yes.

Do I think it is inherently unethical? No. I think for example, that there are some limited circumstances where it may be appropriate for a social worker to accept a modest gift from a client. There may be relevant cultural issues to refusing that gift, and refusal of the gift could have dire clinical consequences.  I think it may be permissible in some limited circumstances for a social group to accept a gift, I have done that. I also think there are other circumstances where I would not accept a gift. I think it is too loaded. The boundary issues are too complicated, and so it depends on the circumstances.

 So, to reiterate, I think some dual or multiple relationships are unethical and some are not. It is important to distinguish between boundary crossings and boundary violations. I think this is a wonderfully useful and a very important distinction. 

Boundary Crossings

We typically define boundary crossings as acceptable, perhaps inevitable or unavoidable dual relationships. So, let me break that down a bit. I would argue, that there are times when some limited carefully selected personal information might be disclosed by a social worker to a client without violating ethical standards. I think it is acceptable. You may live in one of those small or rural communities where it is inevitable that you are going to encounter clients in the community outside of the professional context. And that is a boundary crossing. That is not inherently unethical. It is just a fact of life, and it requires skillful management of those boundary issues. 

You may have yourself, a spouse or a partner who works with your client. And so, this is a boundary crossing, right? You may be at a holiday event that your spouse or partner's firm has sponsored, you show up because you are invited, and then you discover that your client is there because your client works at that agency or has done some business with that agency. There you are in this social setting, does that mean it is an inherent boundary violation? I do not think so, but I do think it requires skillful management because it is a boundary crossing. 

Boundary Violations

Boundary violations in contrast are unacceptable exploitation of clients. These involve serious conflicts of interest. As you might imagine, examples would be having a sexual relationship with a client or entering into a business relationship with a client. That kind of thing. It is unacceptable and often involves exploitation and an inherent conflict of interest.

Boundary Issues and Dual Relationships: A Typology

I have consulted on and testified in many litigation cases and many licensing board cases involving social workers where boundary violations were part of the evidence. A number of years ago, when I began to recognize how common or how pervasive boundary and dual relationships are in social work, I began to gather a lot of data. I teach research and I teach statistics, so I actually practice what I preach.  I gathered a lot of data on social workers' encounters with a broad range of boundary issues. When I analyzed the data, I identified five patterns:

• Intimate relationships
• Emotional and dependency needs
• Personal benefit
• Altruism
• Unavoidable and unanticipated circumstances

I will summarize them briefly and then go into a bit more depth. Number one, intimate relationships. Notice it does not say sex. It includes sexual relationships with clients and former clients, but I was aiming for a somewhat broader concept of intimacy. It can be very intimate self-disclosure without sexual contact. There can be a very intimate friendship with a client or former client, that is not sexual in nature, but there is an element of intimacy. Then there is what I call emotional dependency needs. I know that is kind of a clunky label, and I wish I could have come up with something a bit more succinct and elegant. I did not succeed. What I mean by that, is that in my experience, based on the data that I have collected over many years is that some of the boundary and dual relationship issues that emerged in social work involve the intersection between our emotional needs, our dependency needs, and our interactions with clients. Sometimes our efforts to address our own emotional needs and to manage our own dependency issues will lead to some complex boundary issues, but not necessarily intimate in nature. 

The third pattern that I found is what I call personal benefit. These are cases where the evidence suggests that the boundary issue, the dual relationship issue included some benefit to the social worker. For example, a social worker who did accept a rather expensive gift from a client, or a social worker whose client had some very unique, specialized skill as a physician, as a nurse, as an accountant, as a house painter, where the client performs favors for the social worker, where there is a personal benefit for the social worker. These are not abstract examples. I have testified in court cases and in licensing board cases where social workers allegedly derived a personal benefit from a client that constituted a boundary violation. 

And fourth, cases involving altruism. One of the things that I really love about being a social worker and I mean this, is that it provides me with a regular opportunity, day-to-day, sometimes night to night, depending upon the context to encounter social workers who are very caring, giving people. I love the fact that our profession is filled with practitioners who care so much about others. I find that very satisfying. I would not be a very good business person. I am just not cut out to do that kind of thing.

I like being in a profession, surrounded by colleagues who care about others.  I applaud that feature of our profession and our professional community. I have discovered there is a slippery slope. There is a downside, a potential downside. I have been involved in quite a few court cases and quite a few licensing board cases where the evidence suggested that the social worker was so nice, was so giving, performed favors for clients that crossed the line, that constituted either a boundary crossing that was problematic or a boundary violation. It was not out of some sort of self-serving intent. A social worker who gets involved sexually with a client that is self-serving, I am talking about cases where the evidence suggests the social worker was very giving, very generous, very altruistic, and it led to a major boundary problem.

The final category that I identified when I examined the data after this large-study that I conducted, I describe as unavoidable unanticipated circumstances. We did not see it coming. We did not intend for there to be a boundary problem, but it landed in our lap, so to speak. 

Intimate Relationships

We do not have the time to explore these in great depth, although intimate relationships, examples include: 

• sexual relationships (current and former clients): varied code of ethics standards
• physical contact: absolute v. relative prohibition 
• providing services to former lover
• sexual relationships with clients’ relatives or acquaintances
• sexual relationships with supervisees, trainees, students, colleagues
• intimate gestures (e.g., notes, meals, gifts)
• sexualized messages online/social networking

 I have examples of all of these, real life examples from my consultation with social workers around the United States and abroad and my consultation as an expert witness in court cases and my involvement as an expert witness in licensing board cases. So these are not hypothetical, these are drawn from real life cases, sexual relationships with current and former clients.

The ethical standards in social work are different from the ethical standards in psychology, which are different from the ethical standards in the counseling profession, mental health counseling profession, and so on. 

Social work has the unique language in its Code of Ethics that my colleagues and I put in there for the first time in 1996, when we completely rewrote the Code of Ethics. We did not just revise. We came, we started over, and we had to make a decision about social workers' relationships with former clients. And as you may know, I hope you know, our code does not say, well, it cannot happen within two years of termination.

Psychology's code says that, ours does not. It does not say within five years, it says basically once a client, always a client, a client in perpetuity. Our code recognizes there may be some very limited exceptions depending on unique circumstances. It says that in our Code of Ethics, we are the only profession whose code says what I just said. 

The reason we have that exception in there is that when my colleagues and I sat in Washington DC, and we drafted the Code of Ethics, we had this very honest conversation about whether we thought there was ever any exception to the prohibition along the lines of once a client, always a client, and all of us recognized, and maybe some very narrow exceptions, outside, for example, of clinical relationships, not all social workers or clinicians, should the same rules govern non-clinical relationships, right?

 I remember that discussion very clearly from the 1990s when we came up with some very unique circumstances, which we thought constituted reasonable exceptions, but our code is very clear. The presumption is once a client, always a client, a client in perpetuity, and the burden is on the social worker to demonstrate that there are any grounds for any exception to that physical contact. Our Code of Ethics does not say, you are never permitted to have any physical contact with a client. What it says is physical encounters with clients are discouraged. They can constitute boundary violations, and that there may be some limited exceptions to that. So, I imagine many of you have shaken client's hands. You may have a client who during a clinical session was in deep emotional distress, and spontaneously reached out to hug you for comfort.

There was not anything sexual about it. It was for comfort. Well, are you suppose to back off and say, no, I can't hug you? How do you handle that?  So, we acknowledge in the Code of Ethics that there may be some limited exceptions to this prohibition. The presumption is no physical contact, but there may be some limited exceptions. Providing services to a former lover. This is not hypothetical. I have been involved in cases where a social worker began clinical services, the delivery of clinical services to a client who years earlier had been a lover of that social worker. Well, that raises some interesting boundary issues where there is an element of intimacy. Sexual relationships with clients, relatives, or acquaintances obviously that can introduce some conflicts of interest that are quite complex. Sexual relationships with supervisees, with trainees, with students, or with colleagues, can clearly introduce very complicated boundary issues. 

Intimate gestures 

Many of you, I suspect over the years have received a very, very sincere, thank you note from a client and it might have been signed “love”, not in the, I love you intimate kind of way, but love with a different connotation as an expression of affection. 

 I have also been involved in cases where a client sent an affectionate note, saying “I am sorry” or a social worker sent an affectionate note to a client after the death of a client's spouse or a child, and the social worker signed it “love”, as an affectionate gesture. And that became an issue when that relationship ruptured for other reasons down the line, or when a client gives a very, very intimate gift to a social worker. 

We know that some clients develop a crush on a social worker and may decide to give a gift, like chocolate chip cookies or a drawing. Nothing particularly intimate about that, but lets say it is an item of clothing, maybe even intimate apparel, right? This has actually happened, and a social worker has to manage that kind of intimate gift. Now with the advent of digital technology and sexualized messages, I have testified in several cases, three, and I am involved in a fourth right now where the evidence indicates that a practitioner and a client exchanged sexually explicit graphic online messages. This is known as sexting. Sadly, the evidence in the cases in which I have been involved in and the one case I am involved in right now, the evidence includes digital images exchanged between practitioners and clients. Very troubling.

Natural History of Boundary Violations

 Some years ago, I came across this research conducted by Simon, a psychiatrist on boundary violations. When I read this years ago, I thought this is a very helpful overview of what I have seen occur when there are boundary violations involving intimacy. Simon, the psychiatrist also examined a large collection of boundary cases, boundary related cases, involving intimacy and outlined what he describes is the natural history of boundary violations.

Now I am not suggesting, and I do not think Simon suggests that this progression always occurs in this order. That it is always this linear. I do not think that is the case, but when I first read this years ago, I thought to myself, this is exactly what I have observed in many cases, there is a gradual erosion of the therapist neutrality where the social worker or the other mental health professional takes a special interest in that particular client. There is something about that relationship that is unique, and the boundary violation begins between the chair and the door. I think that is a lovely phrase that captures what I have observed in some of these cases where at the end of a clinical session, there's some chit-chat, you know, the client is getting up ready to leave the room.

What are you doing this weekend? "Oh, I am going to a concert, an Aerosmith concert." The client says, and the social casino." I love Aerosmith. Where is it? I didn't even know there was going to be a concert." And they chat about Aerosmith, and they are not talking about clinical issues, but they connect around a musical concert. But the violation begins between the chair and the door, and now with, virtual or distance counseling, it could occur online at the end of a clinical session, socialization of therapy, where there is increased time, spent discussing non-therapy issues. 

The therapist discloses confidential information about other clients, because the relationship with this client is so special. But this is not hypothetical. I have interviewed clients who felt like they were violated by a social worker who said the social worker shared with me information about other clients, because the social worker thought I was so special.

Therapist self-disclosure begins where the social worker begins to share information with the client about her or his own life. What is going on in her/his own life. Why? Because the social worker trusts that special client. And when there is face-to-face or in-person counseling, not distance counseling, there may be some physical contact. The hand on the shoulder, the hand on the knee. Kind of subtle at first, where it is sexualized, the therapist gains control over the client where there is increased dependency. I testified in one case where the social worker ended up balancing the client's checkbook, because the client felt unable to do it, increased dependency, extra-therapeutic context occur, right?

When we do not have to physically distance, there is lunch, there is a drink after hours, therapy sessions extended in time, often scheduled for the end of the day, because there is no one waiting for the next session. In some of the cases I have been involved in and Simon as well, the therapist stops billing the client because we now have this unique relationship of dating and then sex. So, what Simon aptly describes as the natural history of boundary violations, again, not always this linear. 

Emotional and Dependency Needs

The next category, what I describe as emotional independency needs that might include friendships with current and former clients, community contact with clients, where you encounter them at your church, at your mosque, at your synagogue, and you share this special interest; that is unrelated to your professional work together and there's some social contact. And it is very satisfying perhaps. Self-disclosure, as I mentioned a little while ago, I do not think all self-disclosure is inherently unethical. I think sometimes it is, as I say here, judicious, that is the term I like. It is very thoughtful. It is very purposeful. It is very limited. It is saying to the nine-year-old child, who is grieving the loss of a pet "I remember when I was about your age, my cat, oh, I loved that cat. My cat's name was Kitts, I love that cat. My cat died." It is empathy. That is self-disclosure judicious, right? 

As opposed to what I call gratuitous self-disclosure, gratuitous means unnecessary above and beyond what's appropriate or necessary, where the social worker shares personal information with the client that it is not appropriate across the line. The client should not know about the social worker struggles in his own personal intimate relationships. 

Unconventional interventions

 I have testified in cases and I am not exaggerating here. This is not a hyperbole, whereas an alleged therapeutic intervention. The social worker traveled with a client, shared a room at a bed and breakfast. I am not making this up. They had dinner together. Candlelight, went on a camping trip together, and the social worker alleged in court, and I was there to hear the testimony that this unconventional intervention was legitimate. She called it “reparenting therapy” for this client who had a trauma history that the social worker believed that she was functioning as a surrogate parent to kind of normalize parenting, this vulnerable client. 

That relationship ruptured, no great surprise. The client filed a complaint against the social worker. I testified in that case and heard that social worker try to defend traveling with a client, dining with a client, sharing a room at a bed and breakfast with a client all under the name of an allegedly therapeutic intervention. 

Affectionate communications

Those notes signed “love” where there is an emotional quality to it. That suggests there may be something about this relationship, which goes beyond the professional. 

Online Relationships: Social Media and Social Networking

And now with digital technology, text messages and email messages and Facebook posts that have an emotional element to them, right? And we have to think very differently. I would argue, but the way we interact with clients using technology because of the boundary issues that can emerge, I find that many people are so much more casual with their online communications. They do not edit it as carefully or they do not word them so carefully, and the wording might suggest to a client that this relationship goes beyond the professional, particularly if it is exchanged late at night or on weekends, outside of normal working hours. 

Personal Benefit

The third category is personal benefit. Examples from real cases where a social worker ends up in a client's will, the client appreciated the social worker. That is an interesting boundary issue with clearly potential personal benefit to the social worker or where the social worker enters into a business relationship with the client or the former client.

I testified in a case where a social worker literally became an investor in a client's business and the relationship ruptured.  I had to testify about the boundary issues involved when a social worker seeks to benefit personally by investing in a client's business. 

I know of social workers who live in rural communities, for example, who may get paid in the form of fruit or vegetables or livestock, or where a client who doesn't have much money is the house painter and offers to paint the social worker's house, which clearly needs paint. The social worker has a home office. The outside of the house is peeling, and this is how the client wants to pay for social work services. 

Our Code of Ethics has in it a very lengthy standard regarding bartering. If you do a word count, it is the longest standard in the Code of Ethics, and when we put that in there in the 1990s, we had a difficult time saying clearly and succinctly what the ethical standard ought to be. We do not prohibit bartering. What we say is we discouraged bartering because it can introduce all kinds of boundary issues. Suppose the client paints the social worker's home and six months later it begins to peel badly. Then the social worker has to address that issue with the client, “can you repair the defective paint?”, but they have a clinical relationship.

Therefore, our Code of Ethics discourages bartering, but it also acknowledges it, this is why it is a lengthy standard, because there may be reasonable exceptions because of the cultural context, living and working in a small rural community where bartering is part of the culture. 

Some of you may have clients who have special skills and expertise as physicians, as nurses, as auto-mechanics, and stockbrokers who may offer to share their skill, their knowledge, or their expertise with you. With this potential personal benefit, they may want to perform favors for you. Clients may want to give you gifts, meals, and/or invite you to events where there is a personal benefit to you and an element of a conflict of interest. 

Some of you may now have websites where you have considered having clients provide online testimonials. Well, you are likely to benefit from that. Is it appropriate to ask a client to give you a testimonial that you will post on your website? It is for your benefit, not theirs, right? Technology has introduced that issue. 

Altruism

Giving clients gifts, offering clients favors, meeting clients in social or community settings, having a clinical session at the coffee shop, because it is more relaxed and is less formal, and you think this is going to be helpful to this client who is just not comfortable coming to the formal office. Or providing clinical services on your smartphone while you are walking because you want to be helpful to this client, who wants a more relaxed, informal way to interact. 

Because of the technology you might decide to be available late at night to a client who is vulnerable in crisis, or on weekends, and you want to be accommodating. You are altruistic or caring, but those latenight communications, those weekend communications outside of normal working hours may introduce complex boundary issues. 

As an aside, I now recommend that all social workers have what we call social media policies that explain to clients in very user-friendly language, how we handle boundaries online on the internet. We should say to them, we cannot be their Facebook friends and the reasons why in a very kind way and that we are not available at all hours of the day and night for online text and communications. We should explain when we are available and how to reach us if there is an emergency. I think we have to have these policies in place and share them with clients. When many of us started our careers, there was no need for that because of the technology did not exist. 

Unavoidable and Unanticipated Circumstances

The final category, unavoidable and unanticipated circumstances. As I mentioned, several times, unique boundary issues that arise because some social workers live in close geographical proximity to their clients, and the norms in small and rural communities, I think, inevitably must be different. Boundaries there are more elastic almost by definition. We have personal lives. Some of us may be actively involved in church, synagogue, mosque communities, where we may interact with clients who are members of that same community.

You may be a member of a LGBTQ community, you may be involved in a Black Lives Matter effort that a client joins, where your lives intersect in the community whether in person or online. Professional encounters, the former client, who is so inspired by the help you provided that the former client decides to become a social worker and ends up becoming a colleague of yours. Those social encounters, where it turns out that your sister is dating somebody new who is going to join you for Thanksgiving dinner, and it turns out it is your client.

 Unavoidable and unanticipated. How do you handle that one? And then the possibility of overlapping social networking or social media relationships. You may not be a Facebook friend with your client, but one of your Facebook friends, may be Facebook friends with a client. I call that the transitive property of Facebook. 

You remember to call from like eighth or ninth grade, the transit of property in math, if A is greater than B and B is greater than C, then a is greater than C. I call this the transitive property of Facebook. You may not be friends on Facebook with the client, but your client may be Facebook friends with one of your Facebook friends. And because of the privacy settings, your client may see lots of stuff on your Facebook friend’s site that is about you. Your life may intersect that way. 

The bottom line is, I think all of us in social work, encounter boundary and dual relationship issues. Some of them are easy. We know what to do, do not have sex with the client. We get that one, do not enter into a business relationship with a client. We get that one. But then, beyond these black and white issues are the issues that are saturated with gray and multiple shades of gray, where we have to make decisions sometimes very difficult decisions about how to handle these boundary issues. When we live in small and rural communities, when our agency has hired a former client, when we are considering sharing some personal information with a client for all the right reasons; and what I have found in my career is that this concept of standard of care is so helpful.

Standard of Care in Social Work: Managing Boundaries

The concept of standard of care has been part of the American landscape since the late 1800s. There is a very famous court case known as Coombs v. Beede, which introduced this concept into U.S. law. This is a case that started in Lewiston, Maine and ended up reaching the State Supreme Court. Without getting into all the details, what the Supreme Court said is whenever the court is trying to determine how a professional should have behaved in any circumstance, whether it is a doctor, or a nurse, or an engineer (in the late 1800s, social work was in its infancy, so the court was not thinking about social work), the standard should be what a reasonable and prudent professional, with the same or similar training would have done under the same or similar circumstances. 

So, it goes like this, in my opinion, and this is my lived experience in court cases, in court rooms, in licensing board cases, in licensing board hearings (I have been involved in many of them) Courts of law and licensing boards are going to try to assess and determine how would a reasonable social worker have handled self-disclosure in that circumstance? How would a reasonable social worker have handled hiring a former client? How would a reasonable social worker have handled having a friendship or an intimate relationship with a former client? How would a reasonable social worker have handled the gift, the client offered? Et cetera, et cetera. We call it the reasonable person's standard. It is been in the law for a very long time.

Then there is prudent. The dictionary definition of prudent is careful and cautious. The expectation is that when a social worker, for example, thinks about the possibility of sharing personal information with a client, the social worker will be thoughtful about it. The social worker will be careful and cautious and will not be impulsive. Social workers who are impulsive about self-disclosure in my experience, find themselves in hot water. As I said earlier, I think there is such a thing as judicious self-disclosure, it is prudent, it is careful, it is cautious.

 A social worker who makes a decision about how to handle a gift that a client has offered, does not simply say, "Hey, thank you very much. That was very sweet of you." I think it is important to be careful and cautious. What is the nature of the gift? What are the client's clinical issues? What would it mean to accept this gift from this client? Are there cultural issues to be considered here? That is careful, that is cautious.

 Should I respond to the after hours text messages or email messages or Facebook posts that I am concerned about, or does that introduce a boundary issue? I need to be careful. I need to be cautious. I testified recently in a very complex licensing board case where a very caring social worker, someone who was truly altruistic in my opinion, and that was my testimony, was so concerned about a vulnerable teenage client that the social worker had late at night, online exchanges, lengthy exchanges, using Facebook private messaging, that in my opinion, crossed the line.

The social worker shared personal information during some of those exchanges, the teenager's postings were of a very intimate nature late at night. This case blew up because the child's mother discovered all of these exchanges online and filed a licensing board complaint. This very caring social worker in my opinion, was neither reasonable nor prudent. The social worker was not careful, was not cautious, and was sanctioned by the licensing board. 

Two Views of the Standard of Care

• Substantive standard of care
• Procedural standard of care
  • Consult colleagues and supervisors
  • Review relevant ethical standards
  • Review relevant laws, policies, and regulations
  • Review national practice standards
  • Review relevant literature
  • Obtain legal consultation, when necessary
  • Consult ethics committee, if available 
  • Document decision-making steps

I list two views of the standard of care, what I call the substantive standard of care, where we generally agree. We generally agree on what the standard of care is. Do not have sex with a client; do not enter into a business relationship with a client. Substantive standards of care related to boundaries and dual relationships.

But as I have said several times, I think often reasonable social workers can disagree. Especially with regard to self-disclosure, hiring a former client, and how to manage boundaries in a small rural community.

Reasonable minds can differ on some of these issues. And in those cases, I say a reasonable and prudent social worker, the elements of standard of care would think procedurally. That is why I call this the procedural standard of care. And very briefly, I would argue there are eight key elements, when in doubt about how to manage these boundary issues, get consultation, talk to your supervisor if you have one. Think it through with colleagues.

 I think it is so important. Next review, relevant ethical standards. And the NASW Code of Ethics has a number of boundary related standards that did not exist until January 1st, 2018. They did not exist, but they are in there now. We have to know them. Review relevant laws, policies, and regulations regarding relationships with former clients. They may be embedded in your licensing statute and regulation in your state. 

Next, national practice standards. As I mentioned, we now have national practice standards created by the task force. The task force that I was privileged to chair. National practice standards related to the use of technology. And we put in there, these standards adopted by NASW, ASWB, CSWE, and CSWA. We put standards in there specifically related to boundaries and dual relationships, and we are held to those. 

Review relevant literature. There is literature, prominent literature in social work, on the issues that I have been discussing today. Judges, lawyers, and licensing boards consider that part of the standard of care, so it behooves us to know what is in that literature. When a necessary, consult a lawyer, if it is really complicated, for example, if you are considering hiring a former client. If a client offers a gift, I am not running to a lawyer. I got to think that through on my own or with colleagues. If a client asks me how old I am, where do I live, do I have any children? I am not going to run to a lawyer, but if I work in an agency and I am considering hiring former clients, I want a legal consult because that potentially could lead to some very complex risk management issues.

If I work in an agency that has an ethics committee I would consult that committee. And finally, I would document very carefully every step I took, the consultation, reviewing the Code of Ethics, reviewing relevant standards; I would document all of that, just in case questions surface. 

Risk Management Strategy

• Set unambiguous boundaries at the beginning of the professional-client relationship.
• Evaluate possible dual relationship and boundary considering:
  • amount of social worker’s power over client
  • duration of relationship
  • conditions surrounding termination
  • client’s clinical profile
  • prevailing ethical standards
• Consider whether a dual relationship in any form is warranted or justifiable.
• Is the relationship exploitative? 
• Is the relationship likely to harm the client?
• Ask yourself “For whose benefit?” (Latin: Cui bono?) 
• Pay special attention to incompatible roles (e.g., clinician-client, administrator-secretary, supervisor-supervisee, instructor-student)
• In ambiguous circumstances, consult with colleagues, ethical standards, agency policies, regulations, statutes.
• Discuss relevant issues with all relevant parties, especially clients.
• Work under supervision whenever boundary issues are complex and risk is significant.
• If necessary, refer the client to another professional to minimize risk and prevent harm.
• Document  key aspects of the decision-making process and consultation.

This is a summary of a risk management strategy that I find very helpful. This is my effort to summarize key elements, to try to establish ambiguous boundaries at the beginning, and what we ought to keep in mind when we are evaluating possible dual relationships, including the nature of our relationship with clients and whether we have any power.

For example, if I am a probation/parole officer or a social worker, I have a lot of power over my client. I think it depends on how long the relationship has endured, the conditions surrounding termination, my client's clinical issues, and prevailing ethical standards. Therefore, I need to explore whether there is any alternative. Can I refer this client? If I work in a small rural community that may not be an option. Is there any evidence of exploitation? I love this Latin phrase. You'll see at the bottom of the left-hand side of this slide. In Latin cui bono, for whose benefit, if I am self-disclosing, for whose benefit? If I accept a client's gift, for whose benefit? I need to think about possible incompatible relationships. I need to think about whether the ethical standards in social work, would prohibit this kind of dual relationship, and so on and so forth.

Summary

 I have shared with you a number of references that you may want to review. If you are interested in this topic, some of this literature explores boundary and dual relationships that do not involve technology. Some of this literature explores boundary and dual relationship issues that involve technology. I want to thank you for being a social worker. I hope you learned something that is very useful that you can take with you moving forward. And most of all, I hope you have come to appreciate how complex boundary issues and dual relationships are in social work. 

Question and Answers

What would be your biggest recommendation for social workers that work in those rural environments, where their children go to school with their clients, or there is just, co-mingling of all those different relationships because they are in such a small environment?

This is a great question. So here is what I typically recommend, acknowledge the “elephant”, so to speak. In other words, if I am a social worker on the military base, and again, I have met many social workers that work on a military base in other nations, if I live in rural Idaho or Northern Maine or other rural communities. When I begin working with a client, I would say something like not first thing, but you know, in that first conversation, by the way, as this is a small community, whether it is a military base or another rural community, as you know, this is a small community and it is possible we are going to encounter each other in the community at the supermarket, at church, or we might know people in common, we might end up at the same parties.

Those things happen around here. And the client is going to understand that. So, I want to talk with you about how I handle those situations. If I bump into you in the community, I am not going to acknowledge you, please do not be assaulted. I want to respect your privacy and we can always talk about it later if we have these sort of awkward, uncomfortable encounters. But I want you to know that I am going to do my very best to maintain very professional boundaries with you, and some clients I think will understand that instantly they know exactly what the concept of boundaries on this. Others may not be very well-informed about this. You might have to spend a few minutes talking about the concept of professional boundaries and why that is so important for privacy reasons to avoid a conflict of interest.

But I guess bottom line is I would acknowledge this upfront at the beginning of the relationship. And that is something that somebody who is a clinician in the middle of Manhattan or in Los Angeles may not need to do in quite the same way. And by the way, I would add that I would also include at the front end of the relationship some acknowledgment of the kinds of boundary issues that might emerge online, right? So it is not just the geographical encounters like in-person, but you are in a rural community and you know we may intersect on Facebook and here is how I handle that. So, that is my advice.

References

Refer to the course handout for a complete list of references. 

This text-based course is an edited transcript from a live webinar presented by Christina Marsack-Topolewski, PhD, MSW, LMSW.

Introduction

It is a pleasure to present this comprehensive overview of ADHD and its ethical and practical implications for clinical providers working with women. The number of women diagnosed with Attention-Deficit/Hyperactivity Disorder continues to increase, bringing to light a unique set of challenges and considerations. Women frequently manage a multitude of life responsibilities and demands, which can present significant daily hurdles when coupled with ADHD. Living with ADHD can affect nearly every aspect of life, including one's professional life, financial stability, educational pursuits, the experience of motherhood, and other interpersonal relationships.

Furthermore, for women navigating life with ADHD, these challenges can be compounded by the presence of co-occurring conditions. This article will provide a framework for understanding the distinct complexities and journeys that women with ADHD often encounter. It will also discuss various interventions, strategies, and resources designed to support women with ADHD and their loved ones, acknowledging that the impact of ADHD extends beyond the individual to their entire relational network.

Learning Outcomes

After engaging with this material, participants will be able to:

• Identify the characteristics, signs, and symptoms of ADHD in adulthood that are unique to women.
• Describe co-occurring conditions commonly experienced by women with ADHD.
• Explain practical and evidence-based strategies to support women with ADHD and their loved ones.

Limitations and Risks

Supporting women with ADHD can be complex, and their coinciding needs can be wide-ranging. This discussion will not cover every aspect of these topics. Therefore, continued and additional training and education on this topic are recommended. Treatment and approaches to support individuals with ADHD and other comorbid challenges do not coincide with a one-size-fits-all approach. Practitioners should engage in cultural humility at all times and acknowledge cultural variations in mental health and treatment. Adequate support often requires the use of a multi-disciplinary team to ensure comprehensive treatment.

What is ADHD?

According to the guidelines from the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5), the criteria for individuals ages 17 and older include:

“Frequent inattention, seen through at least five of the following, for at least six months, in a way that is inappropriate developmentally”:

• Careless mistakes and lack of close attention to detail
• Difficulty paying attention on tasks
• Does not listen when addressed
• Gets too side-tracked to finish chores or workplace duties
• Loses materials or equipment necessary for tasks
• Forgetfulness in daily living
• Difficulty in organizing tasks
• Easily distracted; daydreaming
• Difficulty or dislike of work that requires sustained mental effort
• Procrastination

(American Psychiatric Association, 2022)

Continued - What is ADHD?

Per the guidelines from the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5), the criteria for individuals ages 17 and older also include:

“Frequent hyperactivity and impulsivity, seen through at least five of the following, for at least six months, in a way that is inappropriate developmentally”:

• Fidgeting, squirming, tapping
• Leaves seat when expected to sit
• Running or climbing at inappropriate times, feelings of restlessness
• Inability to play quietly
• Is often “on the go” and/or “driven by a motor”
• Talks excessively
• Blurting out responses
• Trouble waiting for turn
• Interrupting, intruding in conversations

Note: Six or more symptoms of inattention and/or hyperactivity-impulsivity are required for children up to age 16.

(American Psychiatric Association, 2022)

These diagnostic criteria provide a foundational understanding of ADHD. However, it is crucial to recognize that the manifestation of these symptoms can differ significantly between genders, particularly in adulthood. For individuals over the age of 17, the presence of at least five symptoms in either the inattention or hyperactivity-impulsivity domain, persisting for at least six months in a developmentally inappropriate manner, is indicative of ADHD. The impact of these symptoms on daily functioning across multiple settings is also a key diagnostic consideration.

ADHD Symptoms

Other symptoms commonly observed include:

• Poor time management (e.g., trouble multitasking)
• Emotional dysregulation (e.g., frequent/chronic stress, constant state of worry)
• Low frustration tolerance
• Mood swings
• Challenges focusing on a task
• Difficulties coping with stress
• Temper

(Mayo Foundation for Medical Education and Research, 2024)

When considering ADHD symptoms in adulthood, particularly for women, the challenges often extend beyond the core diagnostic criteria. Poor time management, including difficulties with multitasking, can profoundly impact adult life, where demands are often high and varied. Emotional dysregulation, manifesting as frequent stress, constant worry, or mood swings, can significantly affect an individual’s well-being and relationships. A low frustration tolerance can lead to interpersonal difficulties, especially in demanding roles such as parenting. Many women with ADHD report feeling overwhelmed by the daily tasks required to manage a household and career, often leading to internal frustration and self-criticism. The inability to focus on tasks and difficulties in coping with stress further exacerbate these challenges, contributing to a sense of being perpetually behind or unable to meet expectations.

ADHD in Adults

These conditions are required, too:

• Before age 12, must experience several inattentive or hyperactive-impulsive symptoms
• The symptoms must impact the person in at least two settings
• Clear evidence that the symptoms “interfere with or reduce the quality of” the person’s social, school and work activities
• Another mental disorder doesn’t better account for the symptoms

(American Psychiatric Association, 2013)

For an adult diagnosis of ADHD, it is essential to establish a developmental history of symptoms appearing before age 12. This underscores the understanding of ADHD as a neurodevelopmental disorder. Furthermore, the symptoms must be pervasive, affecting the individual in at least two significant settings, such as home, school, work, or social environments. This criterion highlights the functional impairment caused by ADHD, distinguishing it from transient difficulties. The impact must be clearly evident in a reduction of quality in social, academic, or occupational functioning. Finally, it is crucial to rule out other mental disorders that might better explain the symptoms, although co-occurring conditions are common and will be discussed further.

Symptoms may be common in women

• Racing thoughts
• Talking excessively
• Difficulty maintaining relationships
• “A scarred and wounded self-esteem”
• Stigma associated with their condition

(Holthe & Langvik, 2017)

Research indicates that certain ADHD symptoms are more commonly observed in women. These include racing thoughts, which can contribute to anxiety and overwhelm, and talking excessively, which may be a manifestation of internal hyperactivity. Difficulty maintaining relationships is a significant concern, often stemming from challenges with consistency, emotional regulation, or perceived social missteps. Many women with ADHD report a "scarred and wounded self-esteem," resulting from years of struggling with undiagnosed or misunderstood symptoms, leading to feelings of inadequacy or failure. The stigma associated with their condition further compounds these emotional burdens, often leading to shame and a reluctance to seek help or disclose their diagnosis. These gender-specific manifestations are crucial for clinicians to recognize for accurate diagnosis and tailored intervention.

Struggles Associated with Dysexecutive Functioning & ADHD

Visible:

• Running late, not making deadlines
• Presenting as “scattered”
• Outward aggression, frustration

Invisible:

• Self-esteem and self-efficacy implications
• Loneliness and isolation
• Internal frustration
• Anxiety
• Depression

The challenges associated with dysexecutive functioning in ADHD can be categorized into visible and invisible struggles. Visible struggles are those observable by others, such as consistently running late, failing to meet deadlines, appearing disorganized or "scattered," and exhibiting outward aggression or frustration. These external manifestations often lead to negative feedback from colleagues, family members, and friends, reinforcing feelings of inadequacy.

Invisible struggles, though less apparent to others, are deeply impactful. These include significant implications for self-esteem and self-efficacy, as women with ADHD may internalize their difficulties as personal failings rather than symptoms of a neurological condition. This can lead to profound feelings of loneliness and isolation, as the effort to maintain relationships becomes overwhelming or as perceived failures lead to withdrawal. Internal frustration is a constant companion, a silent battle against one's own cognitive processes. Furthermore, anxiety and depression are frequently co-occurring invisible struggles, often stemming from the chronic stress of managing ADHD symptoms and the emotional toll of perceived failures and social misunderstandings. Recognizing both visible and invisible struggles is essential for a holistic understanding of the impact of ADHD on women.

Masking of Symptoms

May mask in the following ways:

• Avoid interrupting others (by being quiet)
• Compensatory strategies to support routines and organization
• Exhibit perfectionistic tendencies
• Mirror what others do (e.g., this is common to other conditions and masking)
• Try very hard to focus and be overly conscientious
• Engage in substance misuse (e.g., this may hide/manage their symptoms in social environments)
• Engage in socially appropriate sports and physical activities – which may also mask symptoms

Masking can diminish the adverse effects of ADHD. Masking can be exhausting.

Masking is a common coping mechanism for women with ADHD, where they consciously or unconsciously hide their symptoms to conform to social expectations or avoid negative judgment. This can manifest in various ways, such as deliberately avoiding interrupting others by remaining quiet, even when they have something to contribute. Many develop elaborate compensatory strategies to maintain routines and organization, which, while effective in presenting a semblance of order, can be incredibly draining. Exhibiting perfectionistic tendencies is another form of masking, as an intense focus on flawless execution can be an attempt to overcompensate for perceived deficits in attention or organization. Mirroring the behaviors of others in social situations is also common, allowing them to blend in and avoid drawing attention to their struggles.

The effort to try very hard to focus and be overly conscientious is a constant internal battle, leading to significant mental fatigue. In some cases, individuals may engage in substance misuse as a maladaptive coping mechanism to hide or manage their symptoms in social environments, seeking to calm racing thoughts or reduce anxiety. Furthermore, engaging in socially appropriate sports and physical activities can also serve as a form of masking, as these activities may provide an outlet for hyperactivity or a structured environment that temporarily alleviates symptoms. While masking can temporarily diminish the adverse effects of ADHD in social or professional settings, it is an incredibly exhausting process that can lead to burnout, increased anxiety, and a profound sense of inauthenticity.

Executive Functioning

Executive functioning refers to a set of cognitive processes that are crucial for controlling behavior and operating effectively in daily life. These functions act as the "orchestra conductor" of the mind, enabling individuals to plan, organize, reason, and problem-solve. For individuals with ADHD, particularly women, challenges in executive functioning can profoundly impact various aspects of their lives.

Consider the intricate process of planning a trip: it involves booking flights, coordinating layovers, checking luggage, navigating security, and arranging accommodation and transportation. For a woman with ADHD, these seemingly straightforward tasks can become overwhelming due to difficulties with planning, sequential thinking, and managing multiple steps. If children are involved, the complexity escalates further, requiring meticulous organization of their belongings, car seats, and schedules. The ability to foresee potential issues, prioritize tasks, and maintain focus throughout such a multi-step process relies heavily on intact executive functions.

When executive functions are impaired, even routine daily activities can become monumental challenges. This can lead to visible struggles, such as missed deadlines and disorganization, and invisible struggles, including low self-esteem, internal frustration, and social isolation. Understanding the specific executive functioning deficits a woman with ADHD experiences is paramount for tailoring effective interventions. The goal is to develop strategies and coping mechanisms that support these cognitive processes, enabling her to navigate daily demands more effectively and enhance her overall quality of life. This includes recognizing and capitalizing on her strengths, as many individuals with ADHD possess remarkable creativity, quick thinking, and the ability to generate novel ideas, which can be leveraged in various settings, particularly in the workplace.

Diagnosis

Women in adulthood are equally likely to be diagnosed with ADHD as men.

• Misdiagnosis
• Underdiagnosis
• Overdiagnosis
• Late-diagnosis (Long & Coats, 2022)

The diagnostic landscape for ADHD presents unique considerations for women. While childhood diagnoses show a significant male-to-female ratio (approximately 3:1, with 75% boys compared to 25% girls), this ratio tends to equalize in adulthood. This suggests a notable pattern of underdiagnosis in girls during childhood, potentially due to masking behaviors, differing symptom presentations, or societal expectations that often lead to girls’ symptoms being overlooked or misattributed. Consequently, many women receive a late diagnosis in adulthood, often after years of struggling with unexplained difficulties and accumulating negative self-perceptions.

The phenomenon of misdiagnosis is also prevalent, as ADHD symptoms in women can overlap with or be mistaken for other conditions like anxiety, depression, or bipolar disorder. Conversely, there is also a concern for overdiagnosis in some contexts. The implications of late diagnosis are significant; women may miss out on early interventions and the development of effective coping strategies, leading to a cumulative impact on their self-esteem, relationships, and professional lives. The elevated demands of adulthood, such as managing careers, households, and families, can make undiagnosed or unmanaged ADHD particularly challenging, with potentially severe consequences like job loss or financial instability. Therefore, increased awareness among clinicians about the unique presentation of ADHD in women is crucial for timely and accurate diagnosis.

Prevalence of ADHD

• Childhood prevalence: 7.8 to 9.5% of children in the United States (Polancyznk et al., 2014)
• Adulthood prevalence: 4.4% of adults in the United States (Kessler et al., 2006)
• Global estimates:

• Persistent adult ADHD (with a childhood onset) = 2.58% or 139.84M in 2020
• Symptomatic adult ADHD (regardless of childhood onset) = 6.76% or 366.33M in 2020 (Song et al., 2021)

The prevalence of ADHD varies across different age groups and global regions. In the United States, childhood prevalence ranges from 7.8% to 9.5%, encompassing both boys and girls. For adults in the United States, the prevalence is estimated at 4.4%. Global estimates provide a broader perspective: persistent adult ADHD, defined as having a childhood onset, was estimated at 2.58% or approximately 139.84 million individuals in 2020. Symptomatic adult ADHD, which includes individuals regardless of childhood onset, showed a higher global prevalence of 6.76%, affecting around 366.33 million people in 2020. These figures underscore the widespread nature of ADHD across the lifespan and globally, emphasizing the importance of understanding its impact on diverse populations, including women. The disparity between childhood and adult prevalence, particularly the equalization of gender ratios in adulthood, highlights the need for continued research and clinical attention to how ADHD manifests and is diagnosed in women.

Propensity of ADHD

• About 2.5% of adults have ADHD (Simon et al., 2009); keep in mind other estimates indicate adults with ADHD comprise 2-4% of the population.
• Men’s and women’s rates of ADHD
• Men’s and women’s rates of risky/impulsive behaviors are similar.
• Women with persistent ADHD tended to be less likely to have hyperactive symptoms and to drive recklessly, but women had more anxiety (Cortese et al., 2016).

While general estimates suggest that about 2.5% to 4% of adults have ADHD, the gender-specific nuances are particularly insightful. As previously noted, the rates of ADHD diagnoses tend to equalize between men and women in adulthood, a significant shift from the childhood prevalence. Interestingly, research indicates that men and women with ADHD exhibit similar rates of risky or impulsive behaviors. However, a study by Cortese and colleagues (2016) found that women with persistent ADHD were less likely to present with overt hyperactive symptoms and were less prone to reckless driving compared to their male counterparts. This subtle difference in symptom presentation further contributes to the underdiagnosis of ADHD in women, as their hyperactivity may manifest more internally as racing thoughts or excessive talking rather than overt physical restlessness. A notable finding from this research is that women with ADHD often experience higher levels of anxiety, which aligns with broader population trends where women are more frequently diagnosed with anxiety disorders. This increased anxiety can complicate the clinical picture, sometimes leading to ADHD symptoms being overshadowed or misattributed to anxiety alone. Understanding these gender-specific propensities is vital for accurate assessment and tailored therapeutic approaches.

Co-Occurring Conditions in Women with ADHD

Co-occurring conditions

Adults with ADHD have a greater likelihood to experience other co-occurring conditions.

• Anxiety
• Autism spectrum disorder
• Depression
• Bipolar disorder
• Substance use disorder

(Micai et al., 2023; Pehlivanidis et al., 2020)

The presence of co-occurring conditions is a significant aspect of ADHD in adulthood, particularly for women. Research consistently demonstrates that adults with ADHD have a substantially higher likelihood of experiencing other mental health conditions. Common co-occurring conditions include anxiety disorders, which often manifest as chronic worry, panic attacks, or generalized anxiety. Autism spectrum disorder (ASD) can also co-occur with ADHD, presenting a complex diagnostic picture where symptoms of both conditions may overlap or exacerbate each other. Depression, including major depressive disorder, is frequently observed, often stemming from the chronic stress, emotional dysregulation, and interpersonal difficulties associated with unmanaged ADHD. Bipolar disorder is another condition that can co-occur, making differential diagnosis and treatment planning particularly challenging due to the fluctuating mood states. Finally, substance use disorders are also more prevalent among adults with ADHD, sometimes used as a maladaptive coping mechanism to self-medicate or manage overwhelming symptoms. Clinicians must be vigilant in screening for these co-occurring conditions to provide comprehensive and integrated care. A recent meta-analysis by Micai et al. (2023) highlighted the elevated risks, noting that adults with ADHD face five times the risk of comorbid anxiety, 4.5 times the risk of major depression, 8.75 times the risk of bipolar disorder, and 4.6 times the risk of substance use disorder compared to individuals without ADHD. This underscores the critical need for a thorough assessment that considers the full spectrum of potential co-occurring challenges.

Many domains of life impacted

ADHD in women can profoundly impact numerous domains of life, often due to the elevated social, employment, financial, relational, and functional demands placed on adults. The expectation to juggle multiple roles and responsibilities can become immensely overwhelming when compounded by ADHD symptoms.

• School and Work Life: Challenges in academic and professional settings are common. This can include difficulties with organization, time management, focus, and meeting deadlines, leading to underperformance, job changes, or unemployment. A study by Biederman et al. (2021) found that adults with ADHD were less likely to be currently employed (52% vs. 72% of peers without ADHD) and experienced more job changes over a decade (5.4 vs. 3.4). They also reported less satisfaction with family, social, and professional lives.
• Social Challenges: Intimate relationships, friendships, and peer interactions can be strained. Difficulties with listening, impulsivity in conversation, or inconsistency in plans can lead to misunderstandings and relationship breakdowns. Morley and Tyrrell (2023) found that female university students diagnosed with ADHD in adulthood reported significant social, academic, and psychological difficulties, including stigmatization and social discrimination.
• Family and Parenting: For women who are mothers, the demands of parenting can be particularly challenging. Managing household tasks, children's schedules, and personal needs while contending with ADHD symptoms can lead to immense frustration and feelings of inadequacy. The constant juggle often results in a feeling of being "at the bare bones" in terms of daily functioning, as one client described it, struggling to keep even basic necessities like milk in the fridge.
• Sleep Quality: Poor sleep hygiene is frequently reported, which further exacerbates ADHD symptoms and negatively impacts overall functioning and well-being.

The cumulative effect of these impacts can significantly diminish a woman's quality of life, highlighting the urgent need for tailored support that addresses the multifaceted nature of ADHD in adult women.

Case Example #1

Married mother of 4 struggles with ADHD (diagnosed in childhood), OCD, and anxiety. Spouse does not “believe in” mental health conditions. A lot of shame surrounding challenges. Mother has developed many coping strategies – still difficult. Balancing work, house obligations, and child rearing is immensely overwhelming.

This case illustrates the profound complexities faced by women with ADHD, particularly when compounded by co-occurring conditions and unsupportive family dynamics. The client, a married mother of four, grapples with a childhood diagnosis of ADHD, alongside obsessive-compulsive disorder (OCD) and profound anxiety. A significant barrier to her well-being is her spouse's disbelief in mental health conditions, which creates an environment of shame and discourages her from seeking or utilizing necessary support, including medication or therapy. Despite having developed numerous coping strategies since her early diagnosis and achieving professional success, the immense demands of balancing work, household obligations, and child-rearing have become overwhelmingly challenging. The added pressures of children's illnesses, childcare issues, or school breaks further intensify her struggles, especially within a traditional household where domestic responsibilities are primarily hers. This scenario highlights the critical need for interventions that not only address the client's symptoms but also navigate complex family systems and societal expectations.

Case Example #2

Female in early 40s, twice exceptional. Has childhood diagnosis of ADHD, anxiety. History of an eating disorder. Recent divorce – now back to the workforce. Recently single (now single mother of 3 children). New work position acquired around the time of her divorce. Struggling with meeting and juggling the multi-faceted needs of work, motherhood, home life, food in fridge. FMLA.

This case exemplifies the compounding stressors that can overwhelm a woman with ADHD, particularly during significant life transitions. The client, a female in her early 40s, is "twice exceptional," indicating both giftedness and a neurodevelopmental diagnosis. She has a childhood diagnosis of ADHD and anxiety, coupled with a history of an eating disorder. Her recent divorce has thrust her back into the full-time workforce after a significant hiatus, adding immense financial and logistical pressure. Now a single mother of three children, she finds herself struggling to meet the multifaceted demands of her new work position, motherhood, and maintaining a functional home life, to the extent that even basic tasks like keeping food in the refrigerator become a struggle. Her anxiety is heightened, and she experiences daydreaming at work, impacting her ability to meet professional demands. The severity of her challenges has led her to explore options like the Family and Medical Leave Act (FMLA) to gain a temporary reprieve and re-stabilize. This case underscores the need for comprehensive, tailored support that considers the interplay of ADHD with past traumas, co-occurring conditions, and current life circumstances, emphasizing the importance of practical strategies and external supports to manage overwhelming daily responsibilities.

Shared Terminology

• Autonomy: Making informed, independent decisions. Having control over own actions, choices, and life.
• Self-determination: The ability to determine what is best for yourself without force or coercion.

In the context of ethical practice, understanding autonomy and self-determination is paramount when working with women with ADHD. Autonomy refers to an individual's capacity to make informed, independent decisions and to have control over their own actions, choices, and life. For women with ADHD, this can be particularly challenging due to the internal and external pressures they face, including societal expectations and the impact of their symptoms on decision-making processes. Clinical providers must work to nurture and foster a therapeutic relationship predicated on respect and empowerment, helping clients to understand their diagnosis and its implications within their multifaceted lives.

Self-determination is closely related, emphasizing an individual's ability to determine what is best for themselves without external force or coercion. In cases where a client's environment, such as a spouse who dismisses mental health conditions, undermines their ability to make choices about their care, clinicians must support the client in finding ways to exercise their self-determination, even if it means adopting more private or "close to the vest" coping strategies. The ethical imperative is to help clients recognize and build upon their strengths, providing hope and a framework that extends beyond the challenges of ADHD, while also acknowledging the gender-specific pressures that women with ADHD often navigate. This involves a delicate balance of validating their experiences, offering practical support, and advocating for their right to make choices that enhance their well-being.

Ethical Considerations & Complexities in Supporting Women with ADHD and their Families

• Balancing viewpoints and perspectives
• Self-determination and autonomy should be at the forefront of all conversations
• Strength-based approach
• Using the client at the forefront of planning and treatment
• Safety is key
• Dreams for now and the future
• What’s realistic and doable?
• Capitalizing on supports
• Using relevant formal supports
• Importance of support from informal support networks
• Robust social networks
• Community (reduction of social isolation and loneliness)
• Changing and evolving needs
• Women with ADHD
• Other supports and their capacity

Supporting women with ADHD and their families involves navigating a complex ethical landscape that requires careful consideration of multiple factors. A primary ethical consideration is the need to balance various viewpoints and perspectives, particularly when family members hold differing beliefs about mental health. The principles of self-determination and autonomy must remain at the forefront of all clinical conversations, ensuring that the woman's right to make informed decisions about her care is respected, even if those decisions diverge from external recommendations.

A strengths-based approach is crucial, focusing on identifying and leveraging the client's inherent abilities and resources. This involves placing the client at the forefront of planning and treatment, ensuring that interventions are tailored to her unique needs and aspirations. Safety is always a key consideration, especially when symptoms or co-occurring conditions might pose risks to the individual or others. Clinicians should also explore the client's dreams for both the present and the future, helping to establish goals that are realistic and doable within her current context.

Capitalizing on both formal and informal supports is vital. Formal supports include professional services, while informal support networks, such as friends, family, and community groups, play a critical role in reducing social isolation and loneliness. It is important to foster robust social networks, recognizing that the give-and-take dynamic of relationships is essential for long-term sustainability. The needs of women with ADHD and their support systems are constantly changing and evolving, requiring clinicians to remain flexible and adaptive in their approach. This includes assessing the capacity of other supports within the family unit to ensure that the burden of care is not unduly placed on any one individual.

Ethics & ADHD in Women

Code of Ethics – Ethical Principles

• Service
• Dignity and Worth of the Person

• Who decides?
• Right to decline treatment and other recommendations

• Importance of Human Relationships

(National Association of Social Workers, 2023)

The ethical principles guiding practice with women with ADHD are deeply rooted in core professional codes of ethics. The principle of Service emphasizes the clinician's commitment to helping people in need and addressing social problems. For women with ADHD, this means providing comprehensive support that extends beyond symptom management to address the broader impacts on their lives, including employment, relationships, and overall well-being.

The principle of Dignity and Worth of the Person is paramount. This involves recognizing and respecting the inherent value of each individual, regardless of their diagnosis. A critical aspect of this principle is acknowledging the client's autonomy and their right to self-determination. This raises questions such as "Who decides?" when it comes to treatment plans and life choices. It firmly establishes the client's right to decline treatment and other recommendations, even if the clinician believes they would be beneficial. This requires a delicate balance of providing informed guidance while respecting personal agency.

Finally, the Importance of Human Relationships underscores the significance of building strong, collaborative relationships with clients and their support networks. This principle recognizes that individuals are interconnected and that interventions are most effective when they consider the broader family and community context. For women with ADHD, fostering robust social networks and ensuring instrumental engagement with others can significantly enhance their quality of life and well-being. This also extends to the clinician-client relationship, which should be built on trust, empathy, and mutual respect.

Ethical Responsibilities to Clients

Social workers respect and promote clients' right to self-determination and assist clients in their efforts to identify and clarify their goals. Social workers may limit clients’ right to self-determination when, in the social workers’ professional judgment, clients’ actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others.

(NASW Code of Ethics, 2023)

(Principle E): Respect for People's Rights and Dignity: Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination. Psychologists are aware that special safeguards may be necessary to protect the rights and welfare of persons or communities whose vulnerabilities impair autonomous decision making.

The ethical responsibility to clients, particularly those with ADHD, centers on upholding their right to self-determination. As outlined in the National Association of Social Workers (NASW) Code of Ethics, social workers are mandated to respect and promote clients' autonomy, actively assisting them in identifying and clarifying their personal goals. This means empowering women with ADHD to make choices about their lives and treatment, even when those choices may differ from professional recommendations. However, this right is not absolute; clinicians may ethically limit self-determination when a client's actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others. This requires careful professional judgment and a clear understanding of the boundaries of intervention.

Similarly, the American Psychological Association (APA) Code of Conduct, under Principle E, emphasizes "Respect for People's Rights and Dignity." Psychologists are expected to respect the inherent dignity and worth of all individuals, along with their rights to privacy, confidentiality, and self-determination. The APA code also acknowledges that special safeguards may be necessary to protect the rights and welfare of vulnerable individuals or communities whose vulnerabilities might impair their autonomous decision-making capacity. This is particularly relevant for women with ADHD, who may experience cognitive or emotional challenges that impact their ability to make fully autonomous decisions at all times. Therefore, clinicians must balance the promotion of self-determination with the responsibility to protect clients from harm, always striving to empower them while ensuring their safety and well-being.

Ethics & ADHD in Women

Code of Ethics – Ethical Responsibilities to Clients

1.02 Self-Determination

The principle of self-determination, as articulated in ethical codes such as the NASW Code of Ethics (Section 1.02), is a cornerstone of responsible clinical practice with women with ADHD. This principle mandates that clinicians respect and actively promote their clients' right to make their own choices and decisions. For women navigating life with ADHD, this means empowering them to identify their own goals and clarify what they want for their lives, rather than imposing external expectations or solutions.

In practice, this translates to collaborative treatment planning where the woman with ADHD is an active participant in setting her therapeutic objectives. It involves providing her with comprehensive information about her diagnosis, potential interventions, and available resources, allowing her to make informed choices. This also means respecting her right to decline certain treatments or recommendations, even if they are medically or clinically advised, provided her decision does not pose a serious, foreseeable, and imminent risk to herself or others. The clinician's role is to support her in exploring the implications of her choices, fostering her capacity for independent decision-making, and building her confidence in managing her condition. This ethical stance ensures that interventions are client-centered and uphold the dignity and autonomy of the individual.

Practical and Evidence-Based Strategies

Treatment Goals

• Ensure the recognition of strengths and use a strengths-based approach
• Start with the basics
• Develop effective strategies and coping mechanisms
• Support facets of life that are impacted
• Help clients move toward better physical and psychological functioning
• Provide support to address multi-faceted impacts of ADHD and other co-occurring conditions
• Seek pathways to elevate strengths and build self-esteem
• Enable clients to live full, meaningful, and rewarding lives

Effective treatment for women with ADHD is guided by several key goals, all centered on empowering the individual and enhancing her overall quality of life. A foundational goal is to ensure the recognition of strengths and consistently employ a strengths-based approach. This involves identifying and building upon the woman's unique talents, resilience, and positive attributes, fostering a sense of self-efficacy and hope.

Another crucial goal is to "start with the basics." This means addressing fundamental areas of functioning that may be impacted by ADHD, such as sleep hygiene, nutrition, and foundational organizational skills. By establishing a solid foundation, clients can build confidence and gradually integrate more complex strategies. The development of effective strategies and coping mechanisms is paramount, equipping women with practical tools to manage their symptoms and navigate daily challenges.

Treatment should also aim to support all facets of life that are impacted by ADHD, including employment, relationships, finances, and parenting. This holistic approach ensures that interventions are comprehensive and address the real-world difficulties clients face. A core objective is to help clients move toward better physical and psychological functioning, promoting overall health and well-being.

Furthermore, it is essential to provide support to address the multifaceted impacts of ADHD and any co-occurring conditions. This often requires an integrated approach that considers the interplay between various diagnoses. Ultimately, treatment goals should seek pathways to elevate strengths and build self-esteem, counteracting the years of negative self-perception that many women with ADHD experience. The overarching aim is to enable clients to live full, meaningful, and rewarding lives, recognizing their inherent worth and potential beyond their diagnosis.

Practical Solutions

• Understand unique needs, realities, and experiences of women and pair supports accordingly
• Help loved ones understand what ADHD is like and daily implications
• Focus on solving problems, being proactive
• Take breaks
• Exercise and physical activity
• Focus on strengths
• Family meetings – to help with communication and routines
• Establish and utilize routines
• Visual and auditory supports
• Maintain a healthy lifestyle
• Financial organization and money management
• Symptom management skills
• Prioritize sleep, self care, and well being
• Consider (when applicable) employment supports

Implementing practical solutions for women with ADHD requires a tailored approach that acknowledges their unique needs and experiences. Firstly, it is crucial to understand the specific realities and challenges women face and to pair supports accordingly. This might involve addressing the societal pressures of juggling multiple roles, such as career, motherhood, and household management.

Educating loved ones about what ADHD is like and its daily implications is vital. This can foster empathy and understanding, reducing blame and promoting a more supportive environment. Encouraging a focus on problem-solving and proactive strategies helps clients move beyond reactive responses to challenges. Incorporating regular breaks, exercise, and physical activity can significantly improve attention, mood, and overall well-being.

A consistent emphasis on strengths is essential, helping women with ADHD recognize and leverage their unique abilities, such as creativity, quick thinking, or hyperfocus in areas of interest. Implementing family meetings can improve communication and establish clear routines, which are highly beneficial for managing ADHD symptoms. Establishing and consistently utilizing routines, supported by visual and auditory aids, can provide much-needed structure and predictability.

Maintaining a healthy lifestyle, including prioritizing sleep, self-care, and overall well-being, is foundational for symptom management. Developing financial organization and money management skills is also critical, as ADHD can often impact financial stability. Specific symptom management skills, tailored to individual needs, should be taught and practiced. Finally, when applicable, exploring and implementing employment supports can help women with ADHD thrive in their professional lives, ensuring reasonable accommodations and strategies for workplace success. These practical solutions, when consistently applied, can significantly enhance a woman's ability to manage ADHD and improve her quality of life.

Consider Dynamics in Couples

NON-ADHD PARTNER:

• Feelings
• Behaviors
• Internal narrative

ADHD PARTNER:

• Feelings
• Behaviors
• Internal narrative

When ADHD is present in one partner, the dynamics within a couple can become particularly complex, impacting both the individual with ADHD and their non-ADHD partner. Understanding the distinct feelings, behaviors, and internal narratives of each partner is crucial for effective intervention.

For the non-ADHD partner, common feelings include anger, frustration, sadness, and disappointment. They may feel overwhelmed by the perceived disorganization, forgetfulness, or impulsivity of their ADHD partner, leading to resentment and a sense of carrying an unequal burden. Their behaviors might include nagging, micromanaging, or withdrawing emotionally. The internal narrative of the non-ADHD partner often revolves around themes of "I have to do everything," "I'm not being heard," or "Why can't they just try harder?" They may struggle to differentiate between intentional neglect and ADHD symptoms, leading to personalizing their partner's challenges.

For the ADHD partner, feelings often include shame, guilt, inadequacy, and frustration. They may feel misunderstood, criticized, or constantly "beaten down" by their partner's reactions. Their behaviors might include procrastination, avoidance, or defensiveness when confronted about symptoms. The internal narrative of the ADHD partner often involves self-criticism, such as "I'm not good enough," "I'm always letting people down," or "I'm trying my hardest, but it's never enough." They may struggle with emotional dysregulation, leading to mood swings or outbursts, which further strain the relationship.

Effective couples therapy for ADHD involves helping both partners understand ADHD as a neurological condition, not a character flaw. It focuses on developing communication strategies, establishing clear expectations, and implementing practical solutions for managing symptoms. The goal is to foster empathy, reduce blame, and create a supportive environment where both partners feel understood and valued, moving towards a more balanced and harmonious relationship dynamic.

Parenting with ADHD

Medications may not last long enough through the day so that moms can both work effectively at the office and do caregiving duties when they get home (Seay, 2022).

In the article, Terry Matlen, an ADHD consultant, recommended moms:

• Help their families understand what ADHD is like
• Focus on solving problems, not blaming
• Take breaks to cool down or re-energize
• Have family meetings and learn how to communicate
• Create routines

Parenting with ADHD presents a unique set of challenges for mothers, often exacerbated by the demanding nature of modern life. One significant issue is the duration of ADHD medication efficacy; many mothers find that their medication wears off before they finish their workday, leaving them unmedicated for the demanding caregiving duties upon returning home (Seay, 2022). This can lead to increased struggles with organization, patience, and executive functioning during critical evening hours.

Terry Matlen, a renowned ADHD consultant, offers valuable recommendations for mothers navigating these complexities. She emphasizes the importance of helping family members, including children and partners, understand what ADHD is like. This fosters empathy and reduces misunderstandings, shifting the focus from blame to collaborative problem-solving. Matlen also advises mothers to prioritize self-care by taking breaks to cool down or re-energize, acknowledging the immense mental and emotional toll of managing ADHD while parenting. Implementing family meetings can be instrumental in improving communication and establishing clear routines, which are vital for creating a predictable and supportive home environment. Routines provide structure that can significantly alleviate the organizational challenges inherent in ADHD, benefiting both the mother and her children. By adopting these strategies, mothers with ADHD can enhance their parenting effectiveness and improve overall family dynamics.

Potential Concerns for Women and their Families

• Shortage of medications and generic medication
• Are ADHD medications harmful? Role of medication
• Organizational challenges
• Listening skills
• Whether medication should be stopped during pregnancy

Several potential concerns can impact women with ADHD and their families, requiring careful consideration and clinical guidance. A significant issue that has emerged is the shortage of ADHD medications, particularly generic versions. This can lead to disruptions in treatment, increased stress, and difficulties in maintaining symptom control, profoundly affecting daily functioning and quality of life.

Another common concern revolves around the safety and role of ADHD medications, especially during sensitive periods like pregnancy. Women often grapple with questions such as "Are ADHD medications harmful?" and "Whether medication should be stopped during pregnancy." These are complex decisions that require thorough discussion with medical professionals, weighing the risks and benefits for both the mother and the developing fetus.

Beyond medication, organizational challenges are a pervasive concern. These can manifest in various aspects of home life, work, and personal management, leading to chronic stress, missed appointments, and a sense of being perpetually overwhelmed. Difficulties with listening skills, a common ADHD symptom, can impact communication within relationships, leading to misunderstandings and frustration for both the woman with ADHD and her family members. Addressing these concerns requires a multi-faceted approach that combines medication management (when appropriate), behavioral strategies, organizational tools, and open communication within the family unit.

Special Considerations for Motherhood while Navigating Life with ADHD

Motherhood, while profoundly rewarding, can be exceptionally challenging for women navigating life with ADHD. The inherent demands of raising children—from managing schedules and household tasks to providing consistent emotional support—can exacerbate ADHD symptoms and create significant stress.

• Organizational Structures, Routines: The need for robust organizational structures and consistent routines becomes paramount. ADHD can make it difficult to establish and maintain these, leading to chaos and overwhelm. Clinicians can help mothers develop practical systems for managing household chores, meal planning, and children's activities, often utilizing visual aids and reminders.
• Visual Supports: Visual supports, such as chore charts, visual schedules, and color-coded organizational systems, can be invaluable tools for both the mother and her children. These external aids reduce the reliance on working memory and executive functions, making daily tasks more manageable.
• Outside Supports: Leveraging outside supports is crucial. This can include formal supports like professional organizers, ADHD coaches, or childcare assistance, as well as informal supports from family, friends, or community groups. Delegating tasks and accepting help can significantly alleviate the burden.
• Divisions of Duties in the Household: Equitable divisions of duties within the household are essential, especially if a partner is present. Open communication about responsibilities, acknowledging the impact of ADHD on certain tasks, can prevent resentment and foster a more collaborative environment. For single mothers with ADHD, this might involve creative solutions for outsourcing tasks or building a strong support network.

Ultimately, supporting mothers with ADHD involves a holistic approach that acknowledges the unique interplay between ADHD symptoms and the demands of parenting, providing tailored strategies to promote both the mother's well-being and a stable, nurturing environment for her children.

Tips for Clinicians Supporting Moms with ADHD

• Support use of routines
• Make problem solving a focus
• Help client avoid blame
• Support efforts to accept the reality of living with ADHD
• Support home structure to benefit all family members, including children

(Agnew-Blais et al., 2022)

Clinicians supporting mothers with ADHD can employ several effective strategies to enhance their clients' well-being and family functioning. Firstly, consistently supporting the use of routines is paramount. Routines provide predictability and structure, which are incredibly beneficial for individuals with ADHD in managing their daily lives and reducing cognitive load. Helping mothers establish and adhere to consistent schedules for themselves and their children can significantly alleviate stress and disorganization.

Secondly, making problem-solving a central focus of therapy is crucial. Instead of dwelling on past mistakes or perceived failures, guide clients to identify specific challenges and collaboratively develop practical, actionable solutions. This empowers mothers to feel more in control and capable of navigating difficulties.

Thirdly, it is vital to help clients avoid blame, both self-blame and external blame. Many mothers with ADHD internalize their struggles as personal failings, leading to shame and guilt. Clinicians can reframe these challenges as symptoms of a neurodevelopmental condition, fostering self-compassion and reducing the emotional burden. Similarly, addressing any blame from family members and facilitating understanding can create a more supportive home environment.

Fourth, supporting efforts to accept the reality of living with ADHD is a significant therapeutic step. Acceptance does not mean resignation but rather a realistic understanding of the condition's impact and a commitment to developing effective coping mechanisms. This can lead to greater self-awareness and a more adaptive approach to daily life.

Finally, clinicians should actively support the development of a home structure that benefits all family members, including children. This might involve strategies for decluttering, creating designated spaces for belongings, and implementing consistent household rules. By creating an organized and predictable home environment, clinicians can help reduce chaos, improve family dynamics, and enhance the overall quality of life for everyone involved. Resources from organizations like CHADD on coaching, organization, time management, and Cognitive Behavioral Therapy (CBT) can be invaluable tools for both clinicians and clients.

Care Techniques

• Awareness
• Medication (stimulants, nonstimulants, off-label use of anti-depressants)
• Cognitive-behavioral therapy, relaxation training, stress management, couples or family therapy
• Job mentoring, job/behavioral coaching in executive functioning skills
• Sleep hygiene
• Focus on strengths
• Digital detox and limits
• Exercise
• The power of…

• Laughter
• Knowledge
• Influence over ADHD

A comprehensive approach to caring for women with ADHD involves a combination of techniques tailored to individual needs. Awareness is the foundational step; understanding ADHD as a neurodevelopmental condition, rather than a character flaw, is crucial for both the individual and their support system.

Medication often plays a significant role in managing ADHD symptoms. This includes stimulants, nonstimulants, and sometimes off-label use of antidepressants, all of which should be carefully considered and managed by a medical professional.

Therapeutic interventions are equally important. Cognitive-behavioral therapy (CBT) helps individuals identify and change negative thought patterns and behaviors associated with ADHD. Relaxation training and stress management techniques equip clients with tools to cope with the chronic stress and emotional dysregulation that often accompany ADHD. Couples or family therapy can address relational dynamics strained by ADHD, fostering better communication and understanding.

For professional life, job mentoring and job/behavioral coaching in executive functioning skills can provide targeted support for workplace challenges, such as time management, organization, and task completion.

Prioritizing sleep hygiene is essential, as poor sleep can exacerbate ADHD symptoms. Strategies to improve sleep quality, such as consistent sleep schedules and a conducive sleep environment, are vital.

A consistent focus on strengths helps to build self-esteem and confidence, allowing women with ADHD to leverage their unique talents and abilities. Implementing digital detox and limits can reduce distractions and improve focus in an increasingly connected world. Regular exercise is a powerful tool for managing symptoms, improving mood, and reducing anxiety.

Finally, recognizing the power of laughter, knowledge, and influence over ADHD can be transformative. Laughter provides emotional release and perspective. Knowledge empowers individuals to understand their condition and advocate for their needs. And fostering a sense of influence over ADHD, rather than being controlled by it, cultivates agency and resilience. These care techniques, when integrated thoughtfully, can significantly improve the quality of life for women with ADHD.

Strategies and Supports

• Balancing expectations, roles, and responsibilities
• Pomodoro technique
• Task decomposition/breaking down of tasks
• Reminders
• Section 504 - Access, Reasonable accommodations

Effective strategies and supports are essential for women with ADHD to navigate their daily lives successfully. A key area of focus is balancing expectations, roles, and responsibilities. Women often face immense pressure to excel in multiple domains, and ADHD can make this balance particularly challenging. Clinicians can help clients identify realistic expectations, prioritize tasks, and delegate responsibilities where possible, fostering a more sustainable lifestyle.

Practical techniques can significantly aid in managing attention and productivity. The Pomodoro Technique, for instance, involves working in focused intervals (e.g., 25 minutes) followed by short breaks, which can help maintain concentration and prevent burnout. Task decomposition, or breaking down large tasks into smaller, more manageable steps, reduces overwhelm and makes daunting projects feel more achievable. Utilizing various reminders, such as digital alarms, sticky notes, or visual cues, can compensate for forgetfulness and aid in task initiation and completion.

In educational and employment settings, understanding and advocating for Section 504 access and reasonable accommodations is crucial. Section 504 of the Rehabilitation Act of 1973 prohibits discrimination based on disability and ensures that individuals with disabilities have equal access to programs and activities. For women with ADHD, this might translate to accommodations such as extended time on assignments, a quiet workspace, flexible scheduling, or access to assistive technology. By implementing these strategies and leveraging available supports, women with ADHD can enhance their executive functioning, improve productivity, and experience greater success and well-being in all aspects of their lives.

Practical Tips for Women with ADHD

• Practice wellness
• Stay active and connected with others
• Connect with others and find community
• Develop a support system
• Check out community resources and events
• Consider being a part of a faith-based community
• Recognize internal signs and symptoms that may co-occur/be associated with ADHD
• Support co-occurring conditions

For women living with ADHD, integrating practical tips into daily life can significantly enhance well-being and symptom management. A fundamental tip is to practice wellness holistically, encompassing physical, mental, and emotional health. This includes prioritizing adequate sleep, nutritious eating, and stress-reduction techniques.

It is crucial to stay active and connected with others. Regular physical activity can help manage hyperactivity and improve focus, while social engagement combats feelings of isolation. Actively seeking to connect with others and find community is vital. This might involve joining support groups, clubs, or shared interest groups where individuals can relate to similar experiences, fostering a sense of belonging and reducing loneliness.

Developing a robust support system—including friends, family, and professionals—provides a safety net and a source of encouragement. Additionally, exploring community resources and events can open doors to new opportunities for learning, social interaction, and practical assistance. For some, considering involvement in a faith-based community can offer spiritual support, a sense of purpose, and a structured social environment.

Finally, it is important to recognize internal signs and symptoms that may co-occur or be associated with ADHD, such as anxiety, depression, or emotional dysregulation. Being attuned to these internal cues allows for proactive management and seeking appropriate support for co-occurring conditions. By integrating these practical tips, women with ADHD can build resilience, enhance their coping skills, and cultivate a more fulfilling and balanced life.

Keep in mind…

Supports can be put in place to manage and alleviate the symptoms of ADHD. In the family and other contexts, striving for interdependence is key. Use the strengths to balance the needs of the total unit.

It is crucial to remember that while ADHD presents significant challenges, effective supports can be implemented to manage and alleviate its symptoms. The goal is not to eliminate ADHD, but to empower individuals to thrive despite its presence. In family and other relational contexts, striving for interdependence is key. This means fostering an environment where individuals can rely on each other's strengths and support each other in areas of weakness, rather than expecting complete self-sufficiency from every member. By recognizing and utilizing the unique strengths of each individual, the needs of the entire unit can be balanced, leading to greater harmony and collective well-being. This collaborative approach ensures that the burden of ADHD is shared, and that everyone contributes to creating a supportive and functional environment.

Remember

There is always something that can be done to help women living with ADHD improve their quality of life (which also helps the overall family quality of life). Consider helping individuals develop routines, strategies, coping mechanisms, and opportunities to build on strengths, augment social supports, and build self-esteem.

It is a fundamental truth that interventions and support can always be provided to help women living with ADHD enhance their quality of life. This improvement extends beyond the individual, positively impacting the overall family quality of life. Clinical providers should focus on empowering these women by assisting them in developing practical routines, effective strategies, and adaptive coping mechanisms. Creating opportunities to build on their inherent strengths is paramount, fostering a sense of self-efficacy and competence. Furthermore, actively working to augment their social supports—both formal and informal—can combat isolation and provide a vital network of assistance and understanding. Ultimately, the consistent effort to build self-esteem is crucial, helping women with ADHD to recognize their inherent worth and capabilities, leading to a more fulfilling and meaningful life.

Additional Information & Resources

DSM-5 Diagnostic Criteria in ADHD

See link for DSM-5-TR diagnostic criteria (pages 2-7): https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/508/10-1659_ADHD_QRG_P97097.pdf

https://www.aafp.org/dam/AAFP/documents/patient_care/adhd_toolkit/adhd19-assessment-table1.pdf?ref=clarityxdna.com

Resources

Resources for Adults with ADHD (copy and paste links into a new browser window):

• ADHD Fact Sheets (Note: there is a whole section of resources for adults with ADHD and parents)

• https://chadd.org/understanding-adhd/adhd-fact-sheets/

• Attention Deficit Disorder Association (ADDA)

• https://add.org/resources/

• CHADD

• https://chadd.org/for-adults/overview/

• National Institute of Mental Health

• https://www.nimh.nih.gov/health/publications/adhd-listing

Resources - Books

• ADHD & Marriage, where “The ADHD Effect on Marriage” author Melissa Orlov and psychiatrist and author Dr. Ned Hallowell blog about marriages when at least one spouse has ADHD. Hallowell, his wife (Sue Hallowell), and Orlov wrote “Married to Distraction.”
• “Executive Functioning Skills for Adult ADHD: Proven Techniques and Exercises to Learn Time Management, Increase Focus, and Stop Procrastinating,” by Catherina Kaylie
• “FAST MINDS: How to Thrive If You Have ADHD (Or Think You Might),” by Craig Surman, Karen Weintraub, and Tim Bilkey
• “Faster Than Normal: Turbocharge Your Focus, Productivity, and Success with the Secrets of the ADHD Brain” by Peter Shankman, who was diagnosed with ADHD in his 30s
• “Smart But Stuck: Emotions in Teens and Adults with ADHD,” by Thomas E. Brown, PhD
• “Taking Charge of Adult ADHD,” by Russell A. Barkley, PhD
• The New York Times 6 Books for adults living with ADHD (March 24, 2024): https://www.nytimes.com/2024/03/25/well/mind/adult-adhd-books.html

How to Engage in Consistency in Parenting as a Parent with ADHD

Resource: https://www.youtube.com/watch?v=1XvM9WSHgZI

Workplace Accommodations

Video: https://www.youtube.com/watch?v=-Cfatp1gy-8

Employees in the Workplace

Video: https://www.youtube.com/watch?v=_HXV2doQVlM

Supports and Resources - Websites for women with ADHD:

Website: https://www.qbtech.com/blog/top-6-must-visit-websites-for-women-with-adhd/

Books for Women with ADHD:

Website: https://www.additudemag.com/slideshows/adhd-books-for-women/#:~:text="The Queen of Distraction"&text=Written by a psychologist, this,and respected psychologist Sari Solden.

Information regarding Women and ADHD

Website: https://www.understood.org/en/topics/adhd-women

Kaleidoscope Society

Website: https://www.kaleidoscopesociety.com/

Duke Center for Girls & Women with ADHD

Website: https://adhdgirlsandwomen.org/

Verywell Mind

Website: https://www.verywellmind.com/add-symptoms-in-women-20394

ADDitude

Website: https://www.additudemag.com/category/adhd-add/adhd-in-adults/add-women/?srsltid=AfmBOorsazRsrqhshU8sI3xhryVJpBhtfxgnZY18IGNpQ0-g_t58f0yT

ADDA – Attention Deficit Disorder Association

Website: https://add.org/women-with-adhd/

References

Agnew‐Blais, J. C., Wertz, J., Arseneault, L., Belsky, D. W., Danese, A., Pingault, J. B., ... & Moffitt, T. E. (2022). Mother's and children's ADHD genetic risk, household chaos and children's ADHD symptoms: A gene–environment correlation study. Journal of Child Psychology and Psychiatry, 63(10), 1153–1163.

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Attoe, D. E., & Climie, E. A. (2023). Miss. Diagnosis: A systematic review of ADHD in adult women. Journal of Attention Disorders, 27(7), 645–657.

Biederman, J., Faraone, S. V., Spencer, T. J., Mick, E., Monuteaux, M. C., & Aleardi, M. (2021, February 4). Functional impairments in adults with self-reports of diagnosed ADHD: A controlled study of 1001 adults in the community. Psychiatrist.com. https://www.psychiatrist.com/jcp/functional-impairments-adults-self-reports-diagnosed/

Bradley, S., Parzych, I., Platts, J., & Powell, L. (2025). Understanding and harnessing differences in women with ADHD: A qualitative study. Neurodiversity, 3, 27546330251317199.

Cortese, S., Faraone, S. V., Di Martino, A., & Castellanos, F. X. (2016). ADHD in women and girls: An update on the clinical picture and treatment. Current Psychiatry Reports, 18(1), 1-10.

Da Silva, A. G., Malloy-Diniz, L. F., Garcia, M. S., & Rocha, R. (2020). Attention-deficit/hyperactivity disorder and women. In J. Jr. Renno, G. Valadres, A. Cantilino, J. Mendes-Ribeiro, R. Rocha, & A. G. da Silva (Eds.), Women’s mental health (pp. 215–219). Springer Nature Switzerland. https://doi.org/10.1007/978-3-030-29081-8

Holthe, M. E. G., & Langvik, E. (2017). The strives, struggles, and successes of women diagnosed with ADHD as adults. Sage Open, 7(1), 2158244017701799.

Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Conners, C. K., Demler, O., ... & Zaslavsky, A. M. (2006). The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. American Journal of Psychiatry, 163(4), 716–723. https://doi.org/10.1176/ajp.2006.163.4.716

Long, C. J., & Coats, J. L. (2022). Missed diagnosis: A systematic review of ADHD in adult women. Journal of Attention Disorders, 27(7), 645–657.

Martin, J. (2024). Why are females less likely to be diagnosed with ADHD in childhood than males? The Lancet Psychiatry, 11(4), 303–310.

Mayo Foundation for Medical Education and Research. (2024). Adult attention-deficit/hyperactivity disorder (ADHD). Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/adult-adhd/symptoms-causes/syc-20350878

Micai, M., Fatta, L. M., Gila, L., Caruso, A., Salvitti, T., Fulceri, F., Ciaramella, A., D’Amico, R., Del Giovane, C., Bertelli, M. O., Romano, G., Schünemann, H. J., & Scattoni, M. L. (2023). Prevalence of co-occurring conditions in children and adults with autism spectrum disorder: A systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews, 155, 105436. https://doi.org/10.1016/j.neubiorev.2023.105436

Morley, E., & Tyrrell, A. (2023). Exploring female students’ experiences of ADHD and its impact on social, academic, and psychological functioning. Journal of Attention Disorders, 27(10), 1129–1155.

National Association of Social Workers. (2023). Read the code of ethics. https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English

Pehlivanidis, A., Papanikolaou, Κ., Mantas, V., Kalantzi, E., Korobili, K., Xenaki, L. A., Vassiliou, G., & Papageorgiou, C. (2020). Lifetime co-occurring psychiatric disorders in newly diagnosed adults with attention deficit hyperactivity disorder (ADHD) or/and autism spectrum disorder (ASD). BMC Psychiatry, 20(1). https://doi.org/10.1186/s12888-020-02828-1

Polanczyk, G. V., Willcutt, E. G., Salum, G. A., Kieling, C., & Rohde, L. A. (2014). Psychiatric comorbidities in children and adolescents with ADHD: A meta-analysis of clinical and community samples. European Child & Adolescent Psychiatry, 23(9), 833–848.

Rivas-Vazquez, R. A., Rivas-Vazquez, A. R., & Rivas-Vazquez, A. M. (2023). Masking in ADHD: A systematic review. Journal of Attention Disorders, 27(10), 1083–1094.

Seay, B. (2022, April 14). SuperMom is overrated! ADDitude. https://www.additudemag.com/parenting-moms-with-adhd-advice-help/

Simon, V., Czobor, J., Bálint, S., Mészáros, Á., & Bitter, I. (2009). Prevalence and correlates of adult attention-deficit hyperactivity disorder: A systematic review and meta-analysis. Psychological Medicine, 39(2), 195–208.

Song, P., Zha, M., Yang, Q., Zhang, Y., Li, X., & Rudan, I. (2021). The prevalence of adult attention-deficit hyperactivity disorder: A global systematic review and meta-analysis. Journal of Global Health, 11. https://doi.org/10.7189/jogh.11.04009

Additional Current References

Baggio, S., da Cunha Gonçalves, L., Heller, P., Wolff, H., & Gétaz, L. (2025). Informed Consent in Vulnerable Populations: The Case of Detained Persons with Attention Deficit Hyperactivity Disorder. Journal of Empirical Research on Human Research Ethics, 1. https://doi-org.ezproxy.uu.edu/10.1177/15562646251340474

Giray, L. (2025). Cases of Using ChatGPT as a Mental Health and Psychological Support Tool. Journal of Consumer Health on the Internet, 29(1), 29–48. https://doi-org.ezproxy.uu.edu/10.1080/15398285.2024.2442374

Harkness, K., Bray, S., Durber, C. M., Dewey, D., & Murias, K. (2025). Assessing the Contribution of Measures of Attention and Executive Function to Diagnosis of ADHD or Autism. Journal of Autism & Developmental Disorders, 55(4), 1353–1364. https://doi-org.ezproxy.uu.edu/10.1007/s10803-024-06275-9

Maffly-Kipp, J., & Morey, L. C. (2025). Detecting Attention Deficit Hyperactivity Disorder and its feigning using the Personality Assessment Inventory. Applied Neuropsychology: Adult, 32(3), 730–739. https://doi-org.ezproxy.uu.edu/10.1080/23279095.2023.2207215

Pehlivanidis, A., Kouklari, E.-C., Kalantzi, E., Korobili, K., Tagkouli, E., & Papanikolaou, K. (2025). Self-reported symptoms of attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and affective lability in discriminating adult ADHD, ASD and their co-occurrence. BMC Psychiatry, 25(1), 1–14. https://doi-org.ezproxy.uu.edu/10.1186/s12888-025-06841-0

This text-based course is an edited transcript of the webinar, Supporting Queer and Trans Clients in the Current Political Climate: Ethical Dilemmas and Interventions in Trying Times, presented by Giselle Levin, PsyD on October 6, 2025.

Course Overview

This course provides a comprehensive examination of the current sociopolitical landscape affecting queer and transgender clients in the United States. It explores the profound impact of anti-transgender legislation, media rhetoric, and healthcare bans on the mental health and psychosocial functioning of gender-diverse individuals. Through the lens of minority stress theory and clinical case studies, the course outlines specific ethical dilemmas mental health providers face, including issues related to detransition, "Do-It-Yourself" (DIY) hormone therapy, and documentation safety. Ultimately, it provides clinicians with actionable interventions and advocacy strategies to support client resilience and navigate these complex challenges.

Course Information

Giselle Levin, PsyD (they/she/he), is a licensed psychologist in the state of California specializing in transgender healthcare and sex therapy. Giselle completed their doctorate at Pace University in New York, NY, and trained as a postdoctoral resident in LGBT mental health at the San Francisco VA Medical Center. They currently work as a gender specialist at the University of California San Francisco - Child and Adolescent Gender Center. Giselle is a member of UCSF’s Mind the Gap consortium of gender-affirming providers for youth and is in the process of completing their AASECT sex therapy and WPATH transgender healthcare certifications.

Disclosures

• Presenter Disclosure:

  • Financial: Dr. Giselle Levin, PsyD received an honorarium for presenting this course. Giselle Levin has published articles on transgender healthcare, sex therapy, multiple minority stress, and adapting evidence-based interventions for marginalized populations.

  • Non-financial: Giselle Levin has no relevant non-financial relationships to disclose.

• Content Disclosure: This learning event does not focus exclusively on any specific product or service.

• Sponsor Disclosure: There is no external sponsor for this course.

Limitations/Risks

• Practitioners should cultivate cultural humility and cultural competence while committing to respect the diverse ethical and legal obligations associated with different regions and cultures.

• This course is geared toward mental health professionals who already possess fundamental knowledge and skills necessary to work with LGBT individuals.

• Ensure that you have adequate training prior to working with the above populations; consult or refer out as necessary.

• You are ethically required to refer out if you hold significant negative bias toward LGBT individuals.

• Reparative/conversion therapy is unethical and harmful.

Ethics Codes

Below are links to Ethics Codes for some of the major behavioral health professions. Please ensure you always refer to your own ethical code.

• AAMFT: https://www.aamft.org/Legal_Ethics/Code_of_Ethics.aspx

• ACA: https://www.counseling.org/resources/aca-code-of-ethics.pdf

• APA: https://www.apa.org/ethics/code

• NBCC: https://nbcc.org/assets/ethics/nbcccodeofethics.pdf

• NAADAC: https://www.naadac.org/code-of-ethics

• NASW: https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English

Learning Outcomes

After this course, participants will be able to:

• Explain at least three reasons for increased mental health concerns in queer and trans clients, including substance use, depression, suicidality, anxiety, self-harm, and disordered eating.

• Analyze ethical conflicts and considerations when working with queer and trans clients, including youth and their families.

• Identify two interventions that can be used with queer and trans clients to mitigate the impact of minority stress on mental health.

Current Climate

It's Going Down in History...

The current sociopolitical environment in the United States and globally is characterized by a significant intensification of rhetoric and policy directed against transgender and gender-diverse individuals. Providers and clients alike are navigating a period that some historical records may eventually classify as a time of persecution. For example, Wikipedia currently hosts an article titled "Persecution of transgender people under the second Trump administration," highlighting the severity with which these legislative and social shifts are being documented and perceived.

The rhetoric has shifted dangerously from pathologizing transgender individuals as "mentally ill" to framing them as "actively malicious" or as "terrorists." This progression—from stigmatization to dehumanization—is a known trajectory in the persecution of marginalized groups. This dehumanization manifests in several specific ways:

• Removal of Legal Rights: There are active efforts to strip transgender individuals of legal protections and recognition.

• Purge of Trans Government Employees: Reports indicate threats to the careers of transgender individuals working within the federal government and military sectors.

• Restriction on Passports and International Travel: New policies and proposals threaten the ability of transgender people to travel freely and safely.

• Promotion of Trans Healthcare Misinformation: Major news outlets, including those traditionally viewed as progressive, have published articles that question the validity and safety of gender-affirming care, causing confusion even among supportive allies.

• Attempts to Shut Down and Intimidate Providers: Clinics providing gender-affirming care (GAC) face threats to funding and legal intimidation, leading some to close or cease services.

• Portrayal of Trans People as Social Threats: The framing of transgender individuals, particularly trans women, as threats to women and children contributes to a hostile social environment.

Passport Updates

The ability to obtain accurate identification documents is a critical component of safety and social functioning for transgender individuals. Recent executive orders and legal challenges have centered on the inclusion of "biological sex" on passports, threatening to reverse progress made in allowing gender markers that align with an individual's identity (such as "X" markers or allowing self-selection of "M" or "F").

While lower courts have blocked some discriminatory policies, allowing some individuals to successfully update their documents, the threat of reversal remains. For example, a transgender man who passes as cisgender male may have a driver's license with an "M" marker. If his passport were forced to revert to an "F" marker based on birth assignment, international travel would become dangerous. Presenting a passport with a female marker while appearing phenotypically male in countries with strict gender laws or hostile climates could lead to harassment, detainment, or violence.

Furthermore, these restrictions impact families. Parents of transgender children express profound fear regarding travel. A parent of a six-year-old transgender girl, who has socially transitioned and lived as a girl for years, may fear that traveling internationally could result in accusations of child abuse or the removal of the child from their custody if documents do not align with the child's presentation. These fears effectively trap families within the country, limiting their freedom of movement.

State-by-State Map for GAC Youth Bans

The legal landscape regarding gender-affirming care for youth is a patchwork of bans, restrictions, and protections that varies significantly by state. It is crucial for providers to understand that the bans targeting gender-affirming care often prohibit treatments that are deemed medically necessary by every major medical association in the country.

A critical ethical and legal distinction exists regarding these bans: the medications being banned for gender-affirming care are often legal and routinely prescribed for other conditions. For instance, puberty blockers (GnRH analogues) are the standard treatment for precocious puberty (puberty occurring too early). A child with precocious puberty can access these medications with standard parental consent. However, in states with bans, a transgender child seeking the exact same medication to pause puberty for gender-affirming purposes—a fully reversible intervention—is denied access. This highlights the discriminatory nature of the legislation, which targets the identity of the patient rather than the safety of the medication.

Image Caption: As of 2025, over 25 states have enacted bans on best practice medical care for transgender youth, with some states making it a felony crime to provide such care (Movement Advancement Project, 2025).

As illustrated in the map above, the legal status of care is volatile:

• Felony Crime to Provide Care: Enacted in states such as North Dakota, Oklahoma, Idaho, Alabama, South Carolina, and Florida.

• Bans to Provide Care: Enacted in over 20 states including Texas, Utah, Georgia, and North Carolina.

• Protections: States like California, New York, and Minnesota have enacted "shield laws" or remain states where care is legal.

However, legality does not guarantee access. Even in "green" states, clinics may face immense pressure to stop providing care due to funding threats or harassment.

Other GAC Updates

Beyond state laws, other systemic threats are eroding access to care:

• Surgical Centers: Many surgical centers have voluntarily stopped providing care to youth under 19, even in states where it remains legal for those under 18 with parental consent. This age limit is often a reaction to executive orders or fear of litigation rather than clinical guidelines.

• Clinic Closures: Some major medical centers have shut down their gender health programs entirely due to political pressure, effectively abandoning patients who rely on them for hormone management and mental health support.

• Funding Threats: There are ongoing threats that the Centers for Medicare & Medicaid Services (CMS) could withdraw federal funding from hospitals that provide gender-affirming care. Because most major hospitals rely on CMS funding for their general operations, this threat endangers the financial viability of entire medical institutions, forcing them to choose between financial survival and providing specialized care.

Tracking Anti-Trans Legislation

Given the rapid changes in legislation, mental health providers must stay informed about the laws in their specific jurisdiction. Reliable resources for tracking this information include:

• Erin in the Morning: An independent journalist providing an "Anti-Trans Legislative Risk Assessment Map" and frequent updates.

• ACLU: Tracks anti-LGBT bills moving through state legislatures.

• Trans Legislation Tracker: A comprehensive database of bills impacting transgender rights.

Impact on Patients

Increase in DSM-5 Symptoms & Decrease in Psychosocial Functioning

The hostile political climate has a direct and measurable impact on the mental health of queer and transgender clients. Clinicians are observing a rise in clinical symptoms and a decline in psychosocial functioning across the lifespan, from young children to older adults.

Commonly observed symptoms include:

• Depression and Anxiety: Exacerbated by chronic uncertainty and fear.

• Suicidality and Self-Harm: Rates are rising as hope for a safe future diminishes.

• Disordered Eating: Often linked to attempts to control body shape or suppress secondary sex characteristics.

• Somatic Complaints: Many children present with gastrointestinal (GI) issues, often linked to anxiety or avoiding school bathrooms due to safety concerns.

• School Refusal: Children are increasingly refusing to attend school due to bullying and lack of safe facilities.

• Social and Family Conflict: The political climate has polarized families, leading to rejection or conflict where there may previously have been tolerance.

• Decreased Job Performance: The stress of potential job loss (e.g., for military or government employees) impacts professional functioning.

Research supports these clinical observations. A study by Lee et al. (2024) found statistically significant increases in suicide attempts among transgender youth aged 13-17 in the first year after state-level anti-transgender laws were enacted. Furthermore, exposure to news about anti-transgender legislation is associated with higher levels of depression, anxiety, and physiological stress responses (Dhanani & Totton, 2023). Restar et al. (2024) also found that transgender adults living in states with hostile policy environments reported significantly higher symptoms of depression and anxiety compared to those in more protective states.

Understanding Increase in Symptoms

The correlation between the political landscape and mental health symptoms is driven by several factors:

• Reduced Access to Care: Patients fear losing access to hormones or puberty blockers. For a young person who has socially transitioned, the prospect of undergoing an endogenous puberty that contradicts their gender identity is terrifying.

• Bullying and Harassment: School environments have become increasingly hostile, with reports of physical assaults and death threats against queer students becoming more common.

• Job Instability: Transgender individuals in the military or federal sectors face the potential erasure of their careers.

• Media Exposure: Constant exposure to dehumanizing media rhetoric acts as a chronic stressor. While some clients may try to disconnect, many feel a need to monitor the news to assess threats to their safety ("knowing the hunter is out there").

• Fears of Future Discrimination: Anxiety is often future-oriented, focused on the potential for forced detransition, family separation, or the need to flee the country.

Minority Stress Theory

Minority Stress Theory provides a framework for understanding how societal stigma translates into individual mental health outcomes. It posits that marginalized groups face chronic stress distinct from the general population.

Image Caption: The relationship between external stressors and internal psychological processes leading to adverse health outcomes (Testa et al., 2015).

As defined by Testa et al. (2015), the theory divides stressors into:

• Distal Stress Factors (External): These are objective events such as discrimination, rejection, victimization, and non-affirmation of identity.

• Proximal Stress Factors (Internal): These are the internal psychological processes resulting from the distal stressors, including internalized transphobia, expectations of rejection, and concealment of identity.

These factors combine to degrade mental and physical health, leading to higher rates of suicide and chronic illness.

Multiple Minority Stress

Clients often hold multiple marginalized identities, leading to compounded stress (intersectionality). Clinicians must consider the unique experiences of:

• BIPOC Communities: particularly Black, Indigenous, and Latinx transgender individuals who face racism alongside transphobia.

• Immigrant Communities: Undocumented families may fear that seeking gender-affirming care will draw attention to their immigration status.

• Religious Minorities: Jewish and Muslim transgender individuals may face rising antisemitism or Islamophobia in addition to transphobia.

• People with Disabilities: There is a high overlap between neurodivergence (specifically autism) and gender diversity. Attacks on disability rights and healthcare access further marginalize this population.

• Veterans: Those relying on the VA for care face specific anxieties regarding federal policy changes.

Increase in Disordered Eating

Disordered eating in the transgender population is often functionally different from that in cisgender populations. It can be a mechanism to manage gender dysphoria by altering the body. For example, starvation may be used to stop menstruation or reduce breast tissue development, while other behaviors might be used to reduce muscle mass or curves.

Research indicates that gender-affirming hormone therapy (GAHT) is protective against disordered eating. When individuals can access hormones that align their physical body with their gender identity, the need to use maladaptive eating behaviors to control their body often decreases. Conversely, losing access to GAHT may precipitate a relapse into disordered eating. Additionally, logistical barriers, such as the lack of safe bathrooms, can lead to restrictive behaviors (avoiding food and water) to prevent the need to use the restroom during the school or work day.

The Dangers of Conversion Therapy

With the restriction of affirmative care, some political factions promote "conversion" or "reparative" therapy as an alternative. This practice attempts to change a person’s sexual orientation or gender identity.

Data from the 2015 U.S. Transgender Survey highlights the extreme danger of this approach. Youth exposed to conversion therapy had a 55% increase in the risk of attempting suicide compared to those who were not. The risk of running away from home also doubled. These risks were highest for those exposed to the practice at a young age (between 11 and 14) (Campbell & van der Meulen Rodgers, 2023).

Mental health professionals have an ethical mandate to "Do No Harm." Engaging in or referring clients to conversion therapy violates this fundamental ethical principle.

Ethical Dilemmas

The current political climate creates complex ethical dilemmas where legal mandates, client safety, and clinical best practices may conflict.

Can You Support Detransition?

Case Study: Jay Jay is an 80-year-old transfeminine nonbinary veteran who, after a lifetime of suppressing their identity, began estrogen therapy. They experienced great joy in developing a feminine body. However, due to economic factors, Jay lost their housing in San Francisco and had to move to a rural area in Oregon to afford a home. In this new environment, Jay perceived a high threat of transphobia and physical violence. Consequently, Jay decided to stop taking hormones and "detransition" to ensure their physical safety.

Ethical Consideration: Clinicians may struggle with supporting a client in stopping a treatment that clearly benefits their mental health. However, in this case, the detransition is driven by external safety concerns rather than an internal shift in identity. Research indicates that over 82% of individuals who detransition do so because of external factors like family rejection or societal stigma, rather than a realization that they are not transgender.

In this scenario, the clinician’s role is to respect the client's self-determination and safety needs. Supporting Jay involves validating the unfairness of the situation, helping them grieve the loss of their authentic expression, and prioritizing their physical safety and housing stability.

When Clients Choose to Go DIY

Case Study: Jasper Jasper is a 23-year-old trans man who wishes to take testosterone. However, he distrusts the medical establishment, fearing that a formal prescription could be tracked or cut off by future legislation. Instead, he obtains testosterone from an unregulated source ("DIY"). He wants to continue therapy to process the changes but refuses to see a medical provider for the hormones.

Ethical Consideration: This presents a dilemma regarding scope of competence and safety. A therapist cannot prescribe or manage medication. However, refusing to treat Jasper could alienate him from his only source of mental health support.

The recommended approach is harm reduction. Similar to working with a client who uses substances or engages in self-harm, the clinician does not condone the risky behavior but works to minimize danger. This involves:

• Acknowledging the client's valid fears of the medical system.

• Educating the client on the risks of unmonitored hormone use (e.g., polycythemia, liver strain).

• Encouraging any possible safety steps (e.g., "If you won't see a doctor for a prescription, would you consider getting blood work done at a private lab to check your levels?").

• Discussing safe injection practices.

Documentation & Ethics

With the Department of Justice and other entities issuing subpoenas for medical records of transgender patients, documentation has become a safety issue.

Key Questions for Clinicians:

• Diagnosis: Do you include a diagnosis of Gender Dysphoria (F64.0)? While necessary for insurance coverage, it can also serve as a flag in medical records. If a client is paying out of pocket or seeking therapy for unrelated issues (e.g., anxiety), is the diagnosis necessary?

• Names and Pronouns: Do you document the client's chosen name and pronouns in the official chart, or keep them in a separate "shadow" file? Documenting them validates the client but could expose them if records are seized.

• Relationship Status: How are same-sex partners documented?

Intervention: Adopt a consent-forward approach. Have transparent conversations with clients about documentation. Ask: "I want to respect your identity, but I also want to protect your privacy. Here are the risks and benefits of documenting your chosen name in the official record. What do you prefer?"

Should We Delay GAC?

Case Study: Molly Molly is a 16-year-old trans girl who has socially transitioned and is desperate to start estrogen. Her therapist and doctors agree it is medically appropriate. However, her parents, while affirming of her identity, are terrified of the political climate. They want her to wait until she is 18 or until the political situation stabilizes to ensure her safety.

Ethical Consideration: This is a conflict of values: Safety vs. Authenticity. The parents prioritize physical safety; Molly prioritizes the quality of her life and her authentic development.

Intervention: The clinician's role is to facilitate a values-based conversation. For Molly, living as a boy might feel like a fate worse than the risk of discrimination. The therapist can help the family navigate this by validating the parents' fear while highlighting that denying care also carries severe risks (e.g., suicidality, worsening dysphoria). The goal is to help the family find a consensus that respects the adolescent's developing autonomy and the reality of their dysphoria.

Can Therapists Be Political?

Historically, mental health professions encouraged neutrality. However, the current context challenges this stance.

• The Personal is Political: The DSM-5 itself is a sociopolitical document, not just a scientific one. The laws governing practice are political. Conceptions of mental health are shaped by societal values.

• Ethical Obligation: Hope and Puckett (2024) argue that mental health providers are ethically required to engage in advocacy. Silence in the face of legislation that harms clients can be complicit.

• Scope of Advocacy: Advocacy can take many forms, from voting and calling legislators to attending protests or simply creating a safe, affirming space in the therapy room.

Image Caption: Engaging in public advocacy is one form of ethical action for mental health providers (Image: G. Levin).

Recommendations

General Recommendations for Providers

1. Consultation: Do not make decisions in isolation. Consult with legal experts regarding state laws and with colleagues regarding ethical gray areas.

2. Avoid Rash Decisions: Do not preemptively strip all charts of pronouns or cease care based on rumors. Base actions on verified legal and clinical information.

3. Communication: Clearly communicate your stance on privacy and advocacy to your clients. Knowing their therapist is "on their team" is a vital intervention in itself.

4. Advocacy: Engage in advocacy appropriate to your capacity. "Be loud" where you can.

5. Self-Care: Vicarious trauma is real. Find your own sources of resilience and joy.

Building Rapport

• Explicit Allyship: Do not assume clients know you are safe. State clearly that you are committed to LGBT rights.

• Proactive Inquiry: Do not wait for the client to bring up the news. Ask: "I know there has been a lot of heavy news regarding trans rights lately. How is that impacting you?"

• Knowledge: Do not place the burden of education on the client. Stay informed about major legislative updates so the client does not have to explain basic news events to you.

Recommendations for Patients: The Crash Pad

Clinicians can use the metaphor of a "Crash Pad" with clients. If the client feels they are climbing a dangerous cliff (navigating society), they cannot control whether they fall (legislation/discrimination), but they can build a crash pad to catch them.

Components of a Crash Pad:

• Community: Connection with other trans people.

• Supportive Individuals: A trusted cousin, friend, or therapist.

• Affirming Environments: A workplace or hobby group where they are respected.

• Practices: Meditation, exercise, or art that grounds them.

• T4T Relationships: "Trans for Trans" relationships, where partners share a mutual understanding of the gendered experience, can be a profound source of safety and intimacy.

Image Caption: The "Crash Pad" intervention helps clients visualize and strengthen their support network.

Queer/Trans Joy as Resistance

While it is necessary to discuss trauma and safety, it is equally important to center Queer and Trans Joy. Encouraging clients to access joy—through community events, pride celebrations, or personal expression—is a form of resistance against a system that seeks their misery

Recommendations for Parents

Parents often ask how much they should share with their children about the political climate.

• Assess Capacity: Consider the child's age and emotional maturity.

• Assume Knowledge: Children often know more than parents realize through social media and peers.

• The "Need to Know" Approach: A parent can ask, "Do you want to know what is going on in the news, or do you want me to handle it?"

  • Example: A father asked his 12-year-old daughter this question. She replied that she just wanted to be a kid. The father agreed to carry the burden of political awareness and advocacy so she could focus on her childhood. This is a model of protective parenting.

Using a Values-Based Approach

When clients or families feel stuck, a values clarification exercise can be powerful.

Image Caption: Mapping conflicting values helps clients understand their decision-making process in complex situations.

Clinicians can help clients identify their core values (e.g., Authenticity, Safety, Family Harmony) and acknowledge that these values may currently be in conflict. There is no single "right" answer; different clients will prioritize different values (like Jay choosing safety vs. Molly choosing authenticity).

Resources

Providing clients with concrete resources is an essential intervention.

• Relocation and Logistics:

  • Keshet Move to Thrive: Offers interest-free loans for relocation.

  • Project Open Arms: Resettlement project for trans families.

  • Elevated Access: Volunteer pilots providing free transportation to states with legal healthcare access.

• Legal and Support:

  • Trans Family SOS: Guiding families through legal and medical navigation.

  • Trevor Space: Online community for LGBTQ youth.

  • Human Rights Campaign: Emergency funds and resources.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425787

Campbell, T., & van der Meulen Rodgers, Y. (2023). Conversion therapy, suicidality, and running away: An analysis of transgender youth in the US. Journal of Health Economics, 89, 102750. https://doi.org/10.1016/j.jhealeco.2023.102750

Dhanani, L. Y., & Totton, R. R. (2023). Have you heard the news? The effects of exposure to news about recent transgender legislation on transgender youth and young adults. Sexuality Research and Social Policy, 20(4), 1345-1359. https://doi.org/10.1007/s13178-023-00869-7

Hope, D. A., & Puckett, J. A. (2024). Bans on evidence-based care for transgender and gender diverse people present risks for clients and dilemmas for mental health providers. Cognitive and Behavioral Practice, 31(1), 15-19. https://doi.org/10.1016/j.cbpra.2023.08.001

Lee, W. Y., Hobbs, J. N., Hobaica, S., DeChants, J. P., Price, M. N., & Nath, R. (2024). State-level anti-transgender laws increase past-year suicide attempts among transgender and non-binary young people in the USA. Nature Human Behaviour, 8(11), 2096-2106. https://doi.org/10.1038/s41562-024-01928-0

Movement Advancement Project. (2025). Healthcare laws and policies: Bans on best practice medical care for transgender youth [PDF]. Movement Advancement Project. https://www.lgbtmap.org/img/maps/citations-youth-medical-care-bans.pdf

Restar, A., Layland, E. K., Hughes, L., Dusic, E., Lucas, R., Bambilla, A. J., & Kershaw, T. (2024). Antitrans policy environment and depression and anxiety symptoms in transgender and nonbinary adults. JAMA Network Open, 7(8), e2431306. https://doi.org/10.1001/jamanetworkopen.2024.31306

Testa, R. J., Habarth, J., Peta, J., Balsam, K., & Bockting, W. (2015). Development of the Gender Minority Stress and Resilience Measure. Psychology of Sexual Orientation and Gender Diversity, 2(1), 65-77. https://doi.org/10.1037/sgd0000081

This text-based course is an edited transcript of the webinar, Moral Good Versus Moral and Ethical Duty in Mental Health Practice: Shoulds, Shalls, and What-Ifs, presented by Alan Barksy, JD, MSW, PhD, on February 19, 2025.

Introduction: Rationale

Ethical decision-making in mental health practice often presents complex challenges, requiring professionals to navigate a landscape where various obligations and desired outcomes may conflict. This article, based on a webinar presented by Dr. Allan Barsky, aims to delineate the critical distinctions between "moral good" and "moral duty" within the context of mental health practice. Understanding this differentiation is paramount for prioritizing actions, especially when conflicting obligations arise. While the desire to "do good" is a fundamental motivator for many entering helping professions, it is crucial to recognize when actions are merely commendable versus when they are mandated by professional, legal, or ethical standards. The discussion emphasizes that ethical issues are best managed through relational engagement and constructive conversations with clients, colleagues, supervisors, and supervisees. It also acknowledges that ethical and legal obligations can vary across regions and cultures, underscoring the need for practitioners to consult their specific codes of ethics, local laws, and seek supervision.

The core objective is to equip mental health professionals with the ability to:

1. Differentiate between moral goods and moral duties when making ethical decisions in practice.
2. Analyze ethical issues in practice situations through the lenses of moral goods and moral duties.
3. Identify how to best engage clients and co-professionals in discussions about these distinctions.

Risks and Limitations to the course include:

• Ethical and legal obligations may vary significantly between different regions and cultures. This training focuses on general principles and is not intended to be a substitute for consultation with your professional code of ethics, local laws, supervisors, or legal counsel.

Ethics Codes:

Below are links to Ethics Codes for some of the major behavioral health professions. Please ensure you always refer to your own ethical code.

• AAMFT
  • https://www.aamft.org/Legal_Ethics/Code_of_Ethics.aspx 
• ACA: 
  • https://www.counseling.org/resources/aca-code-of-ethics.pdf
• APA: 
  • https://www.apa.org/ethics/code 
• NBCC:
  •  https://nbcc.org/assets/ethics/nbcccodeofethics.pdf
• NAADAC: 
  • https://www.naadac.org/code-of-ethics
• NASW: 
  • https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English
• Ohio Laws and Administrative Rules
  • https://codes.ohio.gov/ohio-administrative-code/rule-4758-8-03

A preliminary poll conducted during the webinar revealed that 95% of participants reported being primarily guided by their moral or ethical duties, with only 5% guided by what is morally good. This initial finding sets the stage for a deeper exploration of why prioritizing duties is often essential, and how a nuanced understanding of these concepts can refine professional conduct.

Introduction: Key Concept

Distinguishing Goods & Duties

To effectively navigate ethical dilemmas, a clear understanding of "moral good" and "moral duty" is essential. While both relate to appropriate behavior, their implications for professional conduct differ significantly.

Key Concepts

• Moral Good: A moral good refers to an action, behavior, or personal quality that contributes positively to the well-being, flourishing, or dignity of individuals and society. These are commendable and desirable actions but are not necessarily required. For example, a mental health professional's desire to be helpful to others, often a driving force for entering the profession, aligns with the moral good of beneficence. Attending a professional development session, while beneficial for enhancing competence, is a moral good, not a strict moral obligation, unless it directly addresses a specific competency deficit that would otherwise lead to harm. There are generally no punitive consequences for not pursuing every moral good.
• Moral Duty: In contrast, moral duties are behavioral rules or requirements that are aligned with values or ethical principles. They are mandated and required, implying that failure to adhere to them can lead to negative repercussions, such as punishment or corrective actions by professional associations, licensing bodies, agencies, or even legal entities in cases of malpractice or criminal charges.

Ethics and Morals

While "ethics" and "morals" are often used interchangeably, it is useful to note their traditional distinctions. "Ethics" typically refers to professional guidelines, principles, and standards that govern one's conduct within a specific professional role (e.g., as a psychologist, counselor, or social worker). "Morals," on the other hand, are often associated with everyday behavior, guiding actions in non-professional contexts (e.g., as a parent, friend, or neighbor). However, for the purpose of this discussion, Dr. Barsky uses "ethics" and "morals" interchangeably to refer to guidelines for both appropriate and inappropriate behavior, regardless of professional context.

Related Concepts 

The distinction between moral good and moral duty can be further understood by examining related concepts.

• Aspirational Ethics (Moral Good): These are guidelines or rules within professional codes of ethics that inspire practitioners to go beyond the bare minimum. They represent values and principles that professionals aspire to, such as respecting dignity and worth, promoting human well-being, and advocating for social justice. These are "reaching for the stars" rather than just meeting baseline expectations. An example of a "supererogatory act" or "good deed" that goes beyond the call of duty is someone risking their life to protect another from harm during a shooting incident. While preventing harm is good, sacrificing one's own life is aspirational and not morally required.
• Mandatory Ethics (Moral Duty): These define the minimum acceptable standard of ethical or appropriate behavior. They employ language indicating what "must" or "shall" be done, or what is "prohibited." Failure to adhere to mandatory ethics can lead to accountability from professional bodies, licensing boards, agencies, and potentially legal action. Examples include prohibitions against exploiting clients sexually or financially.

(Chiappinotto et al., 2024)

Language

The language used in professional documents (codes of ethics, agency policies, contracts, laws) often indicates whether an action is a duty or a good.

• Mandatory (Duty): Words such as "shall," "will," or "must" denote a duty. Non-compliance typically carries consequences.
• Morally Good: Language like "should" suggests a desirable action but not a strict requirement. Sometimes "will" can also be used in an aspirational sense.

Distinguishing - Examples

To make these concepts concrete, consider the following examples.

Moral Good.

• Promote mental health: Advocating for policies that advance mental health or providing clients with suggestions for activities that promote their well-being.
• Treat clients with respect: Using preferred names and pronouns, employing strengths-based language, and ensuring basic needs are met.
• Demonstrate care: Showing empathy and compassion for clients struggling with personal challenges.
• Engage in self-care: Prioritizing one's own mental, physical, and social well-being to ensure effective service delivery.
• Continuously learn and enhance skills: Attending professional development sessions to improve practice.

Moral Duty.

• Act within areas of competence: Not attempting interventions (e.g., prescribing medication) for which one is not trained or licensed.
• Obtain informed consent: Clearly explaining services, choices, and their pros and cons, and ensuring clients make voluntary, informed decisions.
• Avoid dual relationships: Specifically, avoiding relationships that pose a significant conflict of interest, risk of harm, or exploitation of clients.
• Do no harm: Not intentionally or negligently causing harm to clients. While some therapeutic interventions may involve discomfort, the overall aim is beneficence.
• Do not have sexual relationships with current clients: This is a clear violation of professional duty across all licensed professions.

Bernard Gert's Common Morality

Bernard Gert, a prominent ethicist, developed a framework called "Common Morality," which outlines duties applicable to everyone, not just professionals. This framework is useful for distinguishing moral goods from moral duties and emphasizes baseline behaviors. His rules are often phrased as "do not," similar to the Ten Commandments, setting minimum standards (Gert, 2025).

Do Not Cause Harm

• Do not kill.
• Do not cause pain.
• Do not disable.
• Do not cheat.
• Do not deprive people of freedom (e.g., respecting client self-determination and informed consent).
• Do not deprive people of pleasure.

Do Not Violate Trust

• Do not deceive (e.g., obligations of honesty and integrity).
• Keep your promises (e.g., adhering to scheduled appointments or providing promised documentation).
• Do not cheat (e.g., not overbilling insurance).
• Obey the law (e.g., following licensing laws and continuing education requirements).
• Do your duty (e.g., fulfilling obligations to employers, maintaining records, providing supervision).

These duties underscore the special responsibility professionals have towards vulnerable clients, given the power imbalance and clients' potential struggles with mental health issues, poverty, or trauma.

What if...

When faced with a situation where a choice must be made between doing what is morally good and doing what is morally required, the ethical response is to choose what is morally required (a moral duty) over a moral good.

Example

A client urgently needs help due to a serious, imminent suicide risk, but the professional also needs time for self-care.

• Moral Good: Self-care. While important, it is not an absolute requirement at this specific moment.
• Moral Duty: Safeguarding individuals from serious, imminent, and foreseeable harm.
  In this scenario, the moral duty to protect the client from harm takes precedence. If no other professional can intervene, the responsibility falls to the current practitioner. This does not negate the importance of self-care but highlights the critical need to prioritize duties when lives are at stake.

Constructive "Moral" Discussions

Ethical decision-making is rarely a solitary process. Engaging clients, co-professionals, and others in constructive conversations about moral issues is crucial. This involves more than just making a unilateral decision; it requires active listening, empathy, and a willingness to explore diverse perspectives.

Engaging Clients, Co-professionals, or Others in Conversations About Moral Issues

When a conflict arises, rather than immediately deciding on the moral duty, it is beneficial to engage in a conversation. This involves the following.

• Understanding their concerns: Asking about their perspective, the facts leading to the concern, and perceived conflicting obligations.
• Allowing space to discuss moral choices: Creating an environment where individuals can express their views without judgment.
• Listening actively and encouraging reflection: Reflecting back what is heard, clarifying, and ensuring accurate understanding.
• Validating what others are saying: Showing understanding and appreciation for their viewpoint, even if there is disagreement. This aligns with Carl Rogers' principles of demonstrating respect, empathy, and genuineness.
• Using "we" language: Encouraging joint problem-solving and consensus-building rather than debate. This fosters a collaborative approach to ethical dilemmas.

Examples of Challenging Discussions

Discussions around complex moral issues can be particularly challenging. Examples include the following.

• End-of-life decisions: Whether to remove life support, or discussions around medical aid in dying in states where it is permitted.
• Abortion care: Navigating state laws restricting abortion and helping clients make decisions about appropriate, ethical, and legal care.
• Gender-affirming care: Addressing restrictions on care for youth and balancing professional beliefs with legal limitations.
• Suicide risk/Homicide risk: Intervening in situations where there is a risk of harm to self or others.
• Adult guardianship: Determining when state intervention is necessary to protect frail older adults or dependent individuals with disabilities.

Discussion Example - End-of-Life Decision Making

The way questions are framed can significantly impact the depth and openness of moral discussions.

Closed questions (limiting):

• "Should artificial respiration be removed?" (Yes/No)
• "Is it ethical to do something that hastens death?" (Confining)
• "Is there a duty to prolong life?" (Focuses on legal/moral duty, but limits broader discussion)

Open questions (facilitating discussion):

• "What is a good life?" (Encourages diverse perspectives on quality of life)
• "What do you believe about an individual's right to choose the timing and manner of their death?" (Opens up discussion on autonomy and personal beliefs)

Using simple, nonjudgmental language is crucial. Avoid jargon like "deontology" or "teleology." Instead, ask questions like "What are we required to do?" or "What are the consequences if we don't act in a particular way?" The language should be appropriate for the audience, promoting open and meaningful discussion (de Groot et al., 2017).

Moral Discussions

Effective moral discussions also involve:

• Option generation: Brainstorming a wide range of possibilities before evaluating them. For instance, in a case of potential elder abuse, options might include calling adult protective services, conducting a more in-depth assessment, facilitating family meetings, or seeking consultation without revealing identifying information.
• Inviting many perspectives ("hat switching"): Considering the situation from various viewpoints—e.g., the client's, family's, legal professional's, agency administrator's, or law enforcement's. This broadens understanding, even if it doesn't lead to agreement. For example, when law enforcement requests client information, clarify what information is being sought, the authorizing law, and the timeframes for response, and determine if legal advice is needed before complying.
• Clarifying and checking out what others mean: Not making assumptions. If a family member says, "I don't have time to take care of my father," explore the underlying reasons rather than assuming a lack of care. Neglect may not be intentional but could stem from work obligations, childcare responsibilities, or a complex family history. It is also important to help individuals distinguish between moral goods and moral duties. For example, while parents have a moral and legal duty to care for minor children, adult children do not have the same legal duty to care for their elderly parents, though it is a moral good. Exploiting parents, however, would be a violation of a moral and legal duty.

Application to Situations

Applying the distinction between moral goods and moral duties to specific practice situations helps clarify ethical obligations and guide decision-making.

Situation 1: Client Treatment

Scenario: A psychotherapist believes residential treatment would be beneficial for a client with an addiction, but the client prefers outpatient services.

Conflict: Respecting client autonomy versus promoting what the therapist believes is good for the client.

Analysis:

• Promoting good for the client (e.g., ensuring effective treatment): This is a moral good, but not a moral duty in itself. The therapist's professional judgment might suggest residential treatment is more effective, or even medically necessary for safe detoxification.
• Not coercing a client/Respecting client autonomy: This is a moral duty, as outlined in ethical codes and Gert's common morality (do not deprive of freedom). Imposing the therapist's will on the client, even with good intentions, violates this duty.

Prioritization: In general, prioritize client autonomy over promoting what you believe is good for the client, unless there are clear exceptions.

Exceptions:

• Lack of mental capacity. If the client lacks the mental capacity to make informed decisions, a surrogate decision-maker or legal intervention (e.g., Florida's Marchman Act for involuntary commitment for substance abuse) may be necessary.
• Legal mandates. If a client is mandated to specific services as part of a criminal sentence or probation.

Even when clients make choices that may lead to harm, the professional's role is to provide education, options, and support, and to be available if the client needs help, rather than overriding their self-determination.

Situation 2: Client Referral

Scenario: A colleague refers a client for cognitive therapy, but you decline due to a busy caseload.

Conflict: Moral good of helping clients/being generous with time versus moral good of self-care.

Analysis:

• Moral good of helping clients, being generous with time, and prioritizing client needs: These are commendable actions.
• Moral good of self-care: Limiting new clients to prevent burnout is also a moral good.

Distinction from Duty: There is no moral duty to accept every referral. However, there is a moral duty not to abandon clients in need. While this specific individual is not yet your client, the broader principle of not abandoning people in need still applies.

Options to Avoid Abandonment:

• Provide alternative referral sources.
• Explore organizations that accept Medicaid or offer pro bono services.
• Discuss waitlist options with the client/colleague.
• Suggest self-help support groups.
• Consider terminating with existing clients to create capacity for new, high-need cases.
• Explore the responsible use of AI programs for support, especially for clients on waiting lists (e.g., anxiety apps).
• Adjust current client frequency (e.g., bi-weekly sessions instead of weekly) to accommodate more clients.

The goal is to be creative and collaborative in finding solutions that promote good without breaching a duty.

Situation 3: Client Documentation

Scenario: You are providing therapy to a teenager whose parents have consented to treatment. The teen discloses being sexually active but asks you not to document this, as parents have access to records.

Conflict: Keeping promises to the client (confidentiality) vs. keeping promises to parents/following agency policy.

Analysis:

• Duties:

• Keep promises to the client and parents.
• Follow agency policy regarding documentation and information sharing.

• Moral Good (for the teen): Not documenting this information could foster greater trust, encourage the teen to be more open, and prevent them from closing down or terminating services. This also allows for continued counseling on safer sex practices.

Prioritization: Ideally, an agreement should be established in advance with both the parents and the teen regarding what information will be shared. Ethical codes often encourage such agreements when working with minors. If an agreement exists (especially in writing), adhering to it is a duty. Agency policies also constitute duties.

Considerations:

• Benefits of not documenting: Increased trust, continued engagement in therapy, opportunity to provide guidance on safer sex.
• Harms avoided: Teen's emotional distress, termination of therapy, parental overreaction if they discover the information from the therapist.
• Risks of not documenting: Parental anger if they eventually find out, potential termination of services by parents.

The aim is to balance duties (to client, parents, agency) with promoting the moral good (teen's trust and continued well-being). This might involve encouraging the teen to eventually disclose to their parents, facilitating that conversation, or finding ways to provide support without breaching confidentiality, while still adhering to established agreements and policies.

Questions and Answers

If a client chooses not to engage in a recommended higher level of care deemed clinically necessary after significant assessment, is it ethical to discharge them from your care?

In general, yes. Adults with mental capacity have the right to self-determination. If a client declines recommended services, they can discharge themselves, even "against medical advice." It is prudent to document this decision, and if possible, have the client sign an acknowledgment. Exceptions arise only in cases of mental incompetence or serious, imminent risk (e.g., suicide). In such cases, consultation with legal counsel or an ethics committee is advisable.

Is there a difference in how this should be handled if the client is seeing you face-to-face versus outpatient telehealth?

Mostly, the considerations are the same: informed consent, options, understanding consequences, and respecting confidentiality. However, assessing suicidal ideation can be harder remotely. If the client is at a distance, it's crucial to know local crisis intervention services and potential backup options (e.g., mental health services for a check-in), while being mindful not to invade privacy or provoke a negative reaction. Documentation of outreach efforts is important.

If a client is 18 years old and drinking alcohol, are you mandated to tell the parent?

This depends on state laws. The ideal approach is to have an agreement with the client (and parents, if applicable) beforehand about what information will be shared. Often, for youth, maintaining a safe space for open communication is prioritized over automatic disclosure, as reporting might lead to the youth closing down. Consult state laws and agency policies, and strive for pre-established agreements.

Is it ethical to refer a client to AI while on a waiting list? Personally and professionally, I don't believe we should have waiting lists. That is our obligation to try to connect them with a therapist that does, that does have openings immediately.

While ideally, waiting lists shouldn't exist, if they do, offering AI as one among various options can be ethical, depending on the nature and severity of the need. For example, apps for anxiety or problem-solving might be helpful. It should not be the only option. Providing a range of options (self-help groups, other therapists, AI) and discussing their pros and cons, along with potential follow-up, demonstrates a commitment to client well-being even when direct services are limited. The professional's duty is not to serve every client, but to act in their best interest, which may involve advocacy for immediate connection with other therapists.

Conclusions

The webinar concludes with several key takeaways that summarize the core principles discussed:

• Goods are good - not required: Moral goods are helpful and admirable, offering a sense of personal satisfaction, but they are not mandatory. There are no punitive consequences for not fulfilling every moral good.
• Duties are duties - mandatory or expected: Moral duties are obligations that are expected and mandated. Violating a duty can lead to accountability and consequences.
• Be aspirational - "reach for the stars": While duties set the baseline, professionals should strive to go beyond the minimum. Aspirational ethics encourage continuous improvement and proactive measures that often serve as excellent risk management strategies, ensuring clients receive comprehensive care even beyond strict requirements.
• Act prudently - duties are baselines: Prudent practice involves not just meeting the bare minimum but acting in a smart, well-trained, and wise manner. When unsure, consult with colleagues and supervisors, and meticulously document decisions, including options considered, their pros and cons, and the rationale for the chosen course of action. Ideally, this is done with client consent, though sometimes it may conflict with client preferences.
• We can, and often should, do more than the baseline: The ultimate message is to respect and fulfill one's duties as the foundational ethical standard, but to also embrace an aspirational approach, consistently seeking opportunities to provide care that exceeds basic requirements. This proactive stance contributes to better client outcomes and a more robust ethical practice.

By understanding and applying these distinctions, mental health professionals can navigate complex ethical landscapes with greater clarity, ensuring both compliance with mandatory duties and a commitment to aspirational, client-centered care.

References

American Counseling Association [ACA]. (2014). Code of ethics. https://www.counseling.org/docs/default-source/default-document-library/ethics/2014-aca-code-of-ethics.pdf?sfvrsn=55ab73d0_1

American Psychological Association [APA]. (2017). Ethical principles of psychologists and code of conduct. https://www.apa.org/ethics/code 

Barsky, A. E. (2017). Conflict resolution for the helping professions. Oxford University Press.

Barsky, A. E. (2023). Essential ethics for social work practice. Oxford University Press.

Barsky, A. E., & Barsky, J. D. (2024). Practice standards for addressing social justice in social work research. International Journal of Social Work Values and Ethics, 21(1), item 10. https://doi.org/10.55521/10-021-110; https://jswve.org/volume-21/issue-1/item-10

Chiappinotto, S., Igoumenidis, M., Galazzi, A., Kokic, A., & Palese, A. (2024). Between mandatory and aspirational ethics in nursing codes: A case study of the Italian nursing code of conduct. BMC Nursing, 23(1), 1-17. https://doi.org/10.1186/s12912-024-01697-3 

de Groot, J., & van Hoek, M. E. C. (2017). Contemplative listening in moral issues: Moral counseling redefined in principles and method. The Journal of Pastoral Care & Counseling, 71(2), 106–113. https://doi.org/10.1177/1542305017708155

Gardiner, D., McGee, A., Simpson, C., Ahn, C., Goldberg, A., Kinsella, A., Nagral, S., & Weiss, M. J. (2023). Baseline ethical principles and a framework for evaluation of policies: Recommendations from an international consensus forum. Transplantation Direct, 9(5), e1471. https://doi.org/10.1097/TXD.0000000000001471 

Grannan, D. (2022). What’s the difference between morality and ethics? Encyclopedia Brittanica. https://www.britannica.com/story/whats-the-difference-between-morality-and-ethics 

Gert, B. (2005). Morality: Its nature and justifications. Oxford University Press.

Knapp, S. J., Gottlieb, M. C., & Handelsman, M. M. (2024). Avoiding failures when applying principle-based ethics to difficult ethical situations in psychotherapy. Practice Innovations, 9(3), 205–214. https://doi.org/10.1037/pri0000239

Muñoz D. (2021). Three paradoxes of supererogation. Noûs, 55, 699–716. https://doi.org/10.1111/nous.12326

National Association of Social Workers [NASW]. (2021). Code of ethics. https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English 

Stanford Encyclopedia of Moral Philosophy. (2024). Moral responsibility. https://plato.stanford.edu/entries/moral-responsibility

Weisenmuller, C. M., & Luzier, J. L. (2023). Technology is a core competency in professional psychology. Training and Education in Professional Psychology, 17(3), 241–247. https://doi.org/10.1037/tep0000423 

Additional Current References

Note: The following resources have been included for members to view additional resources associated with this topic area. These resources were not used by the presenter when creating this course.

Coblentz, J. (2025). How (not) to theologize psychological distress: Lessons from thinking across conditions. Journal of Moral Theology, 14(1), 89–108. https://doi-org.ezproxy.uu.edu/10.55476/001c.127970

McLoughlin, S., Thoma, S., & Kristjánsson, K. (2025). Was Aristotle right about moral decision-making? Building a new empirical model of practical wisdom. PLoS ONE, 20(1), 1–48. https://doi-org.ezproxy.uu.edu/10.1371/journal.pone.0317842

Stagner, B. H., Livingstone, J., Gottlieb, M., DeMatteo, D., Chard, A., Perillo, J. T., Boness, C. L., Wise, R. A., & Fairfax-Columbo, J. (2025). Red Flag Laws: Psychologist duties and professional responsibilities. Professional Psychology: Research & Practice, 56(1), 4–18. https://doi-org.ezproxy.uu.edu/10.1037/pro0000600

Terris, C., & Tumilty, E. (2025). High hopes: Legal and ethical Issues with post-trial access to psychedelic drugs. Journal of Health Care Law & Policy, 28(1), 1–23. 

van Baarle, E., & van Baarle, S. (2025). Advancing ethics support in military organizations by designing and evaluating a value‐based reflection tool. Bioethics, 39(1), 5–17. https://doi-org.ezproxy.uu.edu/10.1111/bioe.13255

Editor’s note: This text-based course is an edited transcript of the webinar, Working with Transgender and Gender Diverse Youth: Navigating the Current Political Climate, Clinical Practice Guidelines, and Ethical Considerations, presented by Giselle Levin, PsyD.

Learning Outcomes

After this course, participants will be able to:

• Describe current mental health challenges facing transgender and gender-diverse youth.
• Identify standards and clinical practice guidelines for provision of gender-affirming care of youth.
• Apply clinical interventions to support transgender and gender-diverse youth coping with minority stress and other mental health challenges.

Limitations/Risks

• This presentation presents the fundamentals of working with trans and gender-diverse youth. Further training, supervision, and/or consultation may be required before working with specific patients. 
• Information in the presentation is generalized and may not apply to specific patients. Refer or consult as needed.
• Ethical and legal standards may differ from state to state. Ensure that you are familiar with the laws and ethics specific to your state. 
• Individual and cultural considerations should be explored prior to pursuing treatment and interventions.

Introduction

Today, we will explore how mental health professionals like you can support transgender and gender-diverse youth and their families in your practice. We will focus on the impact of minority stress, discussing its significance and associated mental health challenges. As a fundamental course, we'll introduce the standards of care, though we will not delve deeply into complex topics.

Assessing gender-diverse youth for readiness to begin puberty blockers, hormones, or surgeries requires a nuanced approach. Such medical gender-affirming care demands additional training, supervision, and consultation. You may encounter patients with complex needs that necessitate specialized attention. In these cases, always refer or consult based on your training level and comfort with the patient's specific situation.

We'll also cover some general information useful when dealing with particular cases. Understanding ethical and legal standards is crucial, which vary significantly from state to state. I will show a detailed map highlighting the various pieces of legislation proposed and passed across different states. Being aware of the laws in your state is essential, as is understanding the ethical codes specific to your professional field. For instance, as a psychologist, my guidelines might differ from those for Licensed Marriage and Family Therapists (LMFTs) or social workers. Lastly, we must consider individual and cultural factors before pursuing treatment or interventions. These preliminary considerations are vital in providing effective and sensitive care to your patients.

The Political Climate: Events, Legislation, and Articles

Let's examine the current political climate, focusing on recent events, legislation, and related articles. We'll start with anti-transgender bills in 2024. Remarkably, even though it's only April of 2024, there have already been 539 bills proposed across 41 states this year. This widespread legislative activity has affected nearly every state in the U.S. Of these bills, 21 have passed, 92 have failed, and the majority, 426, remain active. This volume of legislation underscores the significant attention and contention surrounding this issue.

What exactly do these bills entail? These bills target:

• Re-definition of sex
• Curriculum censorship
• School facilities bans (bathrooms, lockers)
• School sports bans
• Forced outing in schools

The redefinition of sex often stipulates sex as strictly binary—male or female—and identical to the sex assigned at birth. This conflation of sex and gender precludes any later changes in gender identity if it doesn't match the sex assigned at birth.

Another significant area is curriculum censorship. This includes bills that prevent discussions about LGBTQ+ individuals, particularly transgender and gender-diverse topics, within schools. It restricts teachers from using books with non-binary or transgender characters and limits educational resources and opportunities. Such bills also aim to censor or ban LGBTQ+ groups in schools and impose facility bans that restrict students from accessing certain facilities, like bathrooms, that do not align with their gender assigned at birth. 

For example, a transgender girl who fully presents as female would be compelled to use the boys’ bathroom or locker room. School sports bans are also prevalent, prohibiting transgender students from joining teams that align with their gender identity rather than their assigned sex at birth.

Forced outing is another concerning issue. This practice requires that transgender students be outed at school, making their transgender status known to teachers and peers, which can lead to bullying and create a hostile environment.

Healthcare restrictions are also widespread. These include age limits on accessing gender-affirming care and could even carry criminal penalties for providers who offer such care to transgender youth. Interestingly, these restrictions often exempt similar treatments for cisgender youth or mandatory treatments for intersex infants.

Speaking of intersex individuals—those whose biological characteristics do not fit typical binary notions of male or female bodies—it’s estimated that approximately 1.7% of the population is intersex. This might involve chromosomal differences or ambiguous genitalia. Many intersex infants undergo surgery without their consent, yet such procedures are generally not subject to the same restrictions as gender-affirming surgeries for older youth.

Additionally, there are prison restrictions that disproportionately affect transgender individuals in incarceration, often denying them access to essential gender-affirming treatments. Funding restrictions also play a role, blocking programs like Medicaid from covering necessary treatments for transgender individuals.

Religious exemptions are another barrier, allowing healthcare providers and others in the community to deny care or services to LGBTQ+ individuals based on religious beliefs. Lastly, there are significant hurdles regarding accurate IDs. Restrictive bills limit the ability to update gender information on official documents like birth certificates and driver's licenses, which can lead to discrimination and violence, as well as practical challenges in employment, housing, and travel.

In addition to the types of bills previously discussed, there are other anti-LGBTQ+ legislative actions that don't necessarily fit neatly into those categories. These include bans on marriage equality and bills that preempt or override local non-discrimination protections, stripping back established rights and safeguards for LGBTQ+ individuals.

Bills Passed in 2024

AL SB129: “Each public institution of higher education shall ensure that every multiple occupancy restroom be designated for use by individuals based on their biological sex.”

In higher education, policies now mandate that individuals use restrooms based on their biological sex, not their gender, gender identity, or presentation. This requirement overlooks the complexities of gender expression and identity.

ID H0421: “In human beings, there are two, and only two, sexes: male and female; (2) Every individual is either male or female; (3) An individual's sex can be observed or clinically verified at or before birth”

This is scientifically incorrect. As previously mentioned, an estimated 1.7% of people are intersex, meaning they possess sex traits that do not conform to the traditional binary. For example, someone with androgen insensitivity syndrome, a common intersex condition, is genetically male with XY chromosomes but is resistant to male hormones like testosterone. Consequently, they do not develop male characteristics and typically appear female at birth, often being designated as female despite lacking internal female reproductive organs and being infertile.

Another intersex condition, congenital adrenal hyperplasia, occurs in individuals with XX chromosomes who produce high levels of androgens. This can lead to ambiguous genitalia, where external genitalia may appear male, yet internal genitalia include a uterus. Therefore, the sex of someone with congenital adrenal hyperplasia cannot be definitively observed or clinically verified at birth.

These examples illustrate that such legislation is not grounded in science and is, in fact, scientifically inaccurate. It can be especially harmful not only to transgender individuals but also to those who are intersex.

WI AB377: “The three designations are 1) males, 2) females, and 3) males and females. The bill defines “sex” as the sex determined at birth by a physician and reflected on the birth certificate. The bill also requires an educational institution to prohibit a male pupil from participating on an athletic team or in an athletic sport designated for females. Finally, the bill requires the educational institution to notify pupils and parents if an educational institution intends to change a designation for an athletic team or sport.”       VETOED

This bill was vetoed, but it aimed to define sex strictly as male and female, the only designations deemed valid, a scientifically incorrect concept. Additionally, it stipulated that these designations be determined at birth. Under this bill, a male pupil—including a transgender girl—would not be allowed to participate on an athletic team or in a sport designated for females. Furthermore, the bill mandated that educational institutions notify students and parents if a transgender child was to join a sports team that aligned with their gender identity.

ID H0455: “Requiring students to share restrooms and changing facilities with members of the opposite biological sex generates potential embarrassment, shame, and psychological injury to students, as well as increasing the likelihood of sexual assault, molestation, rape, voyeurism, and exhibitionism; every public school restroom or changing facility accessible by multiple persons at the same time must be: (a) Designated for use by male persons only or female persons only; and (b) Used only by members of that sex.”

You can see that many of these rules deeply affect students, which is particularly concerning given that schools are already challenging environments for youth. Under these regulations, students would not be able to use restrooms that align with their gender identity. Interestingly, the rationale provided states that allowing students to share restrooms and changing facilities could lead to potential embarrassment, shame, and psychological injury. However, this concern appears to focus solely on cisgender students. The statement further suggests that this mixing increases the likelihood of sexual assault, molestation, rape, voyeurism, and exhibitionism.

Yet, there is no research supporting the claim that transgender individuals using bathrooms that align with their gender identity are more likely to perpetrate any form of sexual misconduct in those settings. Thus, these assertions are not backed by empirical evidence. Moreover, the policy mandates that public school restrooms and changing facilities, like locker rooms, be designated strictly for male or female use based on the sex assigned at birth.

WY SF0099: “No physician or health care provider shall: [...] Provide, administer, prescribe or dispense [...] prescription drugs that induce [...] puberty suppression or blocking prescription drugs to stop or delay normal puberty; [...] Supraphysiologic doses of testosterone to females [...] Supraphysiologic doses of estrogen to males.”

Here, we examine another bill that was passed, which prohibits physicians and healthcare providers from offering medical gender-affirming care to youth. This includes prescribing or dispensing drugs that induce, block, or delay puberty.

We'll discuss puberty blockers in more detail shortly. These medications are completely reversible and provide transgender youth with additional time to explore their gender identity and consider their options before making any irreversible decisions. Importantly, puberty blockers also spare them from undergoing puberty, which might be dysphoric and distressing. Once these blockers are discontinued, the individual will experience their natural puberty.

The bill also addresses testosterone and estrogen, which are used in hormone therapy. We will delve into the distinctions between puberty blockers and hormone therapy later. While the effects of hormone therapy are partially reversible, some aspects are irreversible. This bill bans both treatments, impacting the ability of transgender youth to receive care that could significantly ease their gender dysphoria.

ID S1352: “No person engaged in the practice of professional counseling or marriage and family therapy in the state of Idaho shall be required to provide counseling to or facilitate the counseling of a client in support of goals, outcomes, or behaviors that conflict with the sincerely held religious, moral, or ethical principles of the counselor or therapist.”

We're seeing that therapists who do not support transgender youth are not required to provide services, which, in a way, aligns with ethical obligations to refer patients when there is significant negative bias. Ethically, it is crucial that patients are treated by professionals who can support them without prejudice.

However, the situation is nuanced. While it is understandable that a transgender youth would not benefit from working with a therapist who harbors strong anti-trans sentiments, the legislation also allows therapists to refuse to facilitate counseling that supports the client's goals if these goals conflict with the therapist's moral principles. This aspect of the law can lead to a lack of support for transgender youth, as it permits professionals to decline to provide essential therapeutic services based on personal beliefs, potentially leaving vulnerable clients without necessary care.

I must emphasize that the ramifications of these bills extend beyond transgender individuals, affecting cisgender people as well. This is particularly evident in policies like bathroom bans or facility restrictions.

Consider, for instance, the impact on intersex individuals, who make up an estimated 1.7% of the population and do not fit neatly into the binary categories of male or female. They are directly affected by such legislation. But the implications also reach cisgender individuals. For example, women with polycystic ovarian syndrome (PCOS), a condition that can cause facial hair growth, may face discrimination in female restrooms despite being cisgender.

Moreover, societal assumptions about gender appearance can lead to accusations and challenges for cisgender individuals as well. Online and in public spaces, cisgender women and men are sometimes mistakenly identified as transgender, leading to harassment and discrimination. This can occur even with individuals who exhibit traditionally feminine or masculine traits—demonstrating that appearance alone is not a reliable indicator of someone's gender identity.

These legislative measures also affect children and youth, who may be subjected to similar forms of discrimination and misunderstanding. The scope of harm from such bills is wide, impacting not only those who are transgender but also many who are not, including those with certain medical conditions and the broader cisgender population.

Tracking Anti-Trans Legislation 

If you're interested in staying informed about anti-trans legislation, several excellent resources are available. "Erin In The Morning" offers a comprehensive Anti-Trans Legislative Risk Assessment Map, which details the status of proposed and passed bills in each state. This map is particularly useful for understanding the legislative risks and includes separate sections for adults and youth. Initially, much of this legislation targeted youth, but there is now also a significant amount aimed at adults.

Additionally, the ACLU is tracking 484 anti-LGBT bills. Their website provides updates on their progress, whether they have just been proposed or have already been passed. It’s a valuable resource for those looking to understand the broader scope of legislation affecting the LGBTQ+ community.

There is also a trans legislation tracker available online. This tool is specifically designed to follow legislation that directly impacts transgender individuals. Using these resources can provide a clearer picture of the legislative landscape and help you stay informed about changes that might affect your community.

In The News

Recently, there has been a noticeable increase in media coverage concerning gender-affirming care, particularly for youth. A prominent New York Times article raised concerns about the adequacy of mental health assessments for youth receiving such care. It suggested that co-occurring mental health issues were not adequately addressed, leading some individuals to ultimately detransition or express regret.

The World Professional Association for Transgender Health (WPATH), a key global organization in transgender healthcare similar to the American Psychological Association (APA), provides evidence-based standards of care. WPATH's latest manual, the Standards of Care 8, is accessible online at no cost and extensively cites the supporting research. WPATH also maintains a confidential forum for medical and mental health experts to discuss complex cases. Unfortunately, this forum was recently compromised by anti-trans activists, resulting in the unauthorized release and misrepresentation of confidential information in what became known as the "WPATH Files." 

Erin In The Morning responded with a detailed rebuttal, highlighting the misinterpretations and distortions of the leaked information, which seemed designed to fuel anti-trans rhetoric. This incident is just one example of the challenges facing medical and mental health providers working with transgender individuals, particularly youth. There have been cases of individuals posing as patients to expose providers, a form of healthcare fraud that adds to the already tense environment.

There are numerous anti-trans articles circulating. We'll discuss further how this affects transgender youth and explore ways you, as a provider, can take a supportive stance. It's crucial to understand that transgender healthcare, particularly for trans youth, is currently at the center of intense political controversy. This group has been singled out as a focal point for debate and conflict. Consequently, there is a significant amount of anti-trans rhetoric specifically targeting this vulnerable population. As healthcare providers, recognizing this context is essential for effectively supporting and advocating for transgender youth.

Trans and Gender-Diverse (TGD) Youth

Let's shift our focus to understanding trans and gender-diverse youth. First, it's important to clarify terminology. We often use the terms "trans and gender-diverse" or "trans and gender-expansive" because not all youth under this umbrella identify strictly as transgender. Additionally, some children who identify as gender-diverse in their youth may not retain these identities into adulthood. Gender diversity can be fluid and subject to change, which we'll explore further.

To provide some context on the broader spectrum of LGBT identification, let’s consider recent data. According to a Gallup Poll, which has been tracking LGBT identification since 2012, with the latest poll conducted in 2024, there are notable generational differences in how people identify. Among Boomers, only 5% identify as part of the LGBT community, compared to 10% of Millennials and a significant 25% of Gen Z—reflecting a substantial generational shift.

Specifically focusing on transgender identification, the numbers are smaller but still indicative of a generational change: 0.2% of Boomers, 1.1% of Millennials, and 2.8% of Gen Z identify as transgender. Most of the LGBT Gen Zers are bisexual, with about 15% identifying as such, which is a stark contrast to those identifying as gay or lesbian. Other identities within the LGBT spectrum, including transgender, represent smaller percentages but are crucial for understanding the full diversity within these communities.

Figure 1. Graph showing the percentage of people identifying as LGBTQ+.

Since the initiation of the Gallup Poll in 2012, which tracks LGBT identification among those aged 18 and older, there has been a noticeable increase in the percentage of individuals identifying as LGBT. Figure 1  provides a visual display of this information. In 2012, approximately 3.5% of the population identified as LGBT, a figure that rose to 5.6% four years ago and stands at 7.6% today. This significant increase suggests a changing landscape in societal acceptance and self-recognition of diverse sexual orientations and gender identities.

The rise in LGBT identification, particularly among Gen Z, where a large portion identifies as bisexual, may reflect greater societal acceptance and visibility. Older generations, like Boomers, who identify as LGBT are more likely to describe themselves as lesbian or gay, which may indicate a previous era's more restrictive understanding of sexuality. The broader acceptance of bisexuality today suggests that individuals who might not have previously explored or accepted this aspect of their identity now feel more comfortable doing so.

Moreover, the acceptance of non-binary identities within the transgender community has also grown. Historically, societal acceptance was generally extended only to those who presented themselves fully as either female or male—transgender women or men. There is increasing recognition and support for individuals who identify outside these binary categories, acknowledging those who feel they lie somewhere in the middle, embody elements of both, or do not fit into the binary at all. This shift is critical in understanding the increase in individuals identifying as transgender or non-binary.

Gender Diversity in Children

Gender diversity in children is a normal aspect of developmental progression. From as early as two or three years old, children begin to recognize and interact with the concept of gender, understanding its social elements. In preschool, it's common to see children gravitating toward certain toys or clothing traditionally associated with a particular gender—boys opting for dolls or wearing tutus and girls preferring boys' attire and rejecting the color pink.

It's crucial to recognize that such expressions of gender diversity in young children are not indicative of a pathological condition. Nor do they necessarily predict a future transgender identity or gender incongruence. For example, a boy who enjoys wearing tutus might grow up to identify as a man, possibly as a more feminine man or as a gay man, reflecting variations in sexual orientation rather than gender identity. Similarly, femininity in cisgender gay men or masculinity in straight women are expressions of gender diversity that don't strictly align with transgender or non-binary identities.

Gender expression in children is fluid and cannot reliably predict future gender identity. A child showing gender-diverse traits may grow up to identify within a range of possibilities—from continuing to embrace a gender-diverse identity, to identifying as a feminine man or masculine woman, or not aligning with any of these categories permanently. Essentially, there is no fixed path or clear predictor for how a child's gender identity will evolve.

Understanding this fluidity is vital in supporting gender-diverse children. We recognize gender diversity not as an anomaly but as a part of the broader spectrum of human development that occurs naturally alongside the emergence of gender awareness in children. This perspective is fundamental when discussing what gender diversity means for children and how to support their growth in a nurturing and affirming environment.

Gender Diversity in Adolescence

Gender diversity in adolescence presents unique considerations. In discussions about adolescence, including those within WPATH (World Professional Association for Transgender Health), we typically consider this period as extending from puberty to the age of maturity. However, the exact parameters of adolescence aren't strictly defined, as puberty can start very early in some children, and cognitive development, particularly executive control neural systems, continues into the mid-twenties. This development challenges the notion that turning 18 automatically signifies the transition from adolescence to adulthood, as cognitive development continues well past this age.

In the United States, the age of majority is 18, but it's important to recognize that this age can range from 15 to 21 in other countries. Moreover, turning 18 doesn't necessarily equate with immediate independence or adult responsibilities. Many individuals continue to depend on their parents well into their mid-twenties, which is why considerations relevant to adolescents often apply to transitional-age youth—those from the age of majority up to about 25. These young adults are navigating the complex journey from adolescence to full adulthood, dealing with both social and psychosocial challenges.

Legally, the standards of care for adolescents apply up until the age of 18. After this, adult standards of care take precedence. It's also crucial to acknowledge that some adolescents may experience gender incongruence from childhood, while others only encounter these feelings during puberty—a time of significant physical and gender development that can trigger the onset of gender dysphoria or incongruence.

Regarding terminology, "dysphoria" and "incongruence" are often used interchangeably, though they represent a diagnostic distinction between DSM-5 and ICD-11 frameworks. These terms describe a mismatch between an individual's gender assigned at birth and their experienced gender.

Adolescence is a pivotal time for gender identity development, which often begins in childhood but intensifies during puberty. Influences such as social media and peer interactions play significant roles in shaping gender expectations and identities during this time. As adolescents learn and navigate these influences, their understanding of gender and identity continues to evolve, making adolescence a critical period for support and guidance in gender identity development.

A comprehensive clinical approach is crucial when working with transgender adolescents. This approach is necessary partly because adolescents must be able to understand hypothetical situations to give informed consent for treatments that might have long-term effects. Children often struggle with this concept, but adolescents are generally developing the cognitive awareness needed to think about future consequences and cause-and-effect relationships. However, it's also common for adolescents to display risk-taking behaviors and experience a sense of urgency, perceiving time differently than adults.

Those of you who have worked with teenagers, especially those in distress like depression, might notice that they have difficulty envisioning a life different from their current situation. They often feel an immediate need for change, driven by a heightened sensitivity to rewards, which focuses their attention on short-term outcomes rather than long-term implications. Additionally, adolescents place significant importance on peer relationships, which can be a source of support or a risk factor, depending on the health of those relationships. As they seek more autonomy from their parents, the influence of their peers can become even more pivotal.

The variability in maturity among teenagers is notable. For example, a 17 or 18-year-old might exhibit less self-awareness and insight than a 14-year-old. This individuality means that when making decisions about gender-affirming medical treatments—which can have lifelong consequences—it's essential to consider a range of developmental factors.

This nuanced understanding of adolescent development informs our approach to their care. In my presentations on hormone therapy or surgery for adults, the focus on these developmental considerations is less intense, reflecting adults' greater maturity and decision-making capacity. However, with adolescents, we exercise heightened diligence during the assessment process to ensure that decisions about their care are made with a full understanding of the potentially irreversible effects. This careful approach is vital in supporting adolescents as they navigate these critical decisions.

Minority Stress & Mental Health in Trans and Gender-Diverse Youth

Minority Stress Theory

Let's delve into the topic of minority stress and its impact on the mental health of youth. Minority stress theory, developed by Meyer and seen in Figure 2, is a foundational framework for understanding the mental and physical health disparities observed in LGBT individuals, particularly transgender people.

Figure 2. Minority Stress Theory.

Research strongly supports the minority stress theory, suggesting that LGBT people face higher rates of mental and physical health issues. The question arises: Why does this disparity exist? The theory identifies two primary types of stress factors: distal and proximal.

Distal stress factors represent external stressors that significantly affect the well-being of transgender individuals. These include discrimination, rejection by family, peers, or institutions, victimization through physical or verbal abuse, and non-affirmation, such as being deliberately misgendered or called by incorrect pronouns.

The impact of these distal stress factors is profound, directly correlating with severe outcomes. They contribute to a heightened incidence of mental and physical health problems within the transgender community, particularly among transgender youth. Furthermore, these factors are strongly associated with the tragically high rates of suicide observed among transgender individuals.

The direct link between these external stressors and negative health outcomes underscores the critical need for supportive interventions and policies to mitigate these stressors and provide transgender individuals, especially youth, with safer, more affirming environments.

Proximal stress factors involve the internalization of the external stressors described as distal factors. These internal stressors include internalized homophobia or transphobia, where a transgender individual may feel there is something inherently wrong with them due to their identity, leading to feelings of shame, disgust, or severe self-criticism.

Additionally, negative expectations can heavily impact transgender individuals, especially youth. Many feel their future prospects are bleak—believing they will never succeed in personal relationships, career ambitions, or broader societal acceptance. This often results in low self-esteem and confidence, which may not always be directly linked to their gender identity in their own minds but stems from the ongoing internalization of societal rejection and stigma.

Concealment is another significant proximal stress factor. Many transgender individuals may hide their identity by engaging in activities like secretly trying on clothes that affirm their gender identity or purchasing and hiding such items to avoid detection and potential conflict. This behavior is a direct response to the fear and anxiety produced by societal judgment and lack of acceptance.

These proximal stress factors mediate the relationship between external pressures and the negative outcomes they cause, establishing a complex interaction where external abuses become internal struggles that further exacerbate health and well-being issues. This mediation illustrates how distal factors impact individuals directly and indirectly by fostering harmful internal narratives and behaviors.

Furthermore, the concept of multiple minority stress must be considered. This occurs when individuals identify with more than one marginalized group, compounding their experiences of stress and adversity. For example, a transgender person of color may face intersecting prejudices related to both their gender identity and race, intensifying their experience of minority stress and its associated impacts. Understanding and addressing these layered stresses is crucial for supporting the mental and physical health of transgender individuals, particularly those who are navigating multiple marginalized identities.

ADDRESSING Framework

The ADDRESSING framework, developed by Pamela Hayes (2008), is an essential tool for understanding the complexities of individual identity, particularly concerning marginalization, power, and privilege. This framework breaks down various categories contributing to an individual's identity, each linked to potential marginalization. Here's a brief overview of each component within the ADDRESSING acronym:

• Age: Young people and older adults often possess less societal power than adults aged 18 to 65, who typically have more influence.
• Disability (Developmental): Autism is a common example. Individuals with developmental disabilities may experience increased minority stress. Notably, there is a significant overlap between individuals who are autistic and those who are transgender, with higher incidences of autism among transgender populations and vice versa.
• Disability (Acquired): Conditions like traumatic brain injury or spinal cord injuries that occur later in life. Like developmental disabilities, these also lead to increased minority stress and can profoundly impact an individual’s life and identity.
• Religion: Religions other than Christianity often face more marginalization in predominantly Christian societies.
• Ethnicity: Ethnic minorities, or kids of color, generally experience greater marginalization compared to their white peers.
• Socioeconomic Status (SES): Individuals from lower socioeconomic backgrounds have less privilege than those from higher income brackets.
• Sexual Orientation: Within the transgender community, those who are heterosexual typically experience less discrimination compared to transgender individuals who are gay, lesbian, bisexual, or otherwise non-straight. For example, a transgender girl attracted to men is considered straight and may face fewer challenges than a transgender girl attracted to women or both genders. Transgender individuals who are straight have better mental health care. They have more privileges than transgender individuals who are also lesbian, gay, or bisexual.
• Indigenous Heritage: Individuals with indigenous backgrounds can face unique challenges and discrimination, adding another layer to their identity and experiences of marginalization.
• National Origin: The citizenship status of an individual, particularly when they are transgender, can significantly impact their mental health and well-being. Non-U.S. citizens, especially from countries with limited LGBT rights, face ongoing stress due to potential instability in their residency status. For example, I currently have a patient who is a transgender woman from India, sponsored by her company to work in the tech industry, which is notably volatile at the moment, especially in the Bay Area. She lives with the constant fear of losing her job, and if that were to happen, she believes she would have only about 30 to 60 days to find new employment or face deportation to India, where she would have far fewer protections.
• Gender: It's also crucial to acknowledge how gender affects experiences of privilege and marginalization. Transgender individuals and women typically have less privilege compared to cisgender men, facing numerous systemic barriers that impact their social, professional, and personal lives.

Understanding these dimensions of identity through the ADDRESSING framework helps to highlight the intersecting challenges faced by individuals, emphasizing the need for targeted support and inclusive policies to mitigate these pressures.

Impact of Minority Stress

The impact of minority stress on mental health disparities among transgender and gender-diverse youth is significantly influenced by their experiences of discrimination and rejection. Research confirms that support and acceptance from family, friends, and educational institutions play a critical role in the well-being of these youths. When their social environments embrace them, transgender and gender-diverse youth often show good psychological adjustment and resilience.

Conversely, when they lack support, the consequences can be severe. Distal stressors such as discrimination and rejection can lead to these youths feeling ostracized from their school life, exacerbating feelings of isolation. This external rejection often fosters internalized transphobia and low expectations, which can further deepen their sense of isolation and alienation.

Effective coping strategies involve proactive advocacy for inclusion, particularly within educational settings. Working directly with teachers to promote understanding and acceptance and fostering peer support networks are essential actions. Addressing the mental health needs of transgender youth thus requires a holistic approach that involves their families, peers, and schools. These elements are not just supportive aspects of their lives; they are pivotal determinants of a transgender youth's mental health outcomes.

Have You Heard the News? 

The impact of anti-trans legislation is a significant source of minority stress for transgender youth and young adults, manifesting as a profound distal stress factor. A study conducted between September and November of 2021 explored the implications of exposure to news about newly proposed anti-trans legislation and how perceptions of support for this legislation within one's social network—such as from parents or friends—affect these individuals.

The findings were concerning: news consumption related to this legislation was directly associated with increased rumination and physical health symptoms among trans youth and young adults. Furthermore, if these individuals perceived that their social network supported the legislation, they experienced even greater rumination, depressive symptoms, physical health symptoms, and an intensified fear of disclosing their identity.

The study also included open-ended questions, which revealed that this legislation not only affects access to gender-affirming healthcare but also impedes their ability to seek general healthcare services. Many avoid medical settings altogether due to fear of discrimination or past negative experiences. Additionally, the legislative climate has led to an increase in discrimination during medical treatment and prompted unhealthy coping responses among these individuals. These findings highlight a crucial message for policymakers: the laws they propose and enact have real and damaging effects on the mental and physical well-being of trans youth. 

Gender-Affirming Interventions for Trans and Gender-Diverse Youth

Gender-Affirming Care: Social Transition

Gender-affirming interventions for trans and gender-diverse youth are crucial for their well-being and are often misunderstood. Here’s an overview of what these interventions entail and the standards of care involved.

• Name change;
• Pronoun change;
• Change in sex/gender markers (e.g., birth certificate, identification cards, passport, school and medical documentation, etc.);
• Participation in gender-segregated programs (e.g., sports teams, recreational clubs and camps, schools, etc.);
• Bathroom and locker room use;
• Personal expression (e.g., hairstyle, clothing choice, etc.);
• Communication of affirmed gender to others (e.g., social media, classroom or school announcements, letters to extended families or social contacts, etc.). (Coleman et al., 2022)

Social transition is the primary approach for children who are prepubertal, typically younger than 10 or not yet at Tanner stage 2 of puberty. Medical interventions like hormones, puberty blockers, or surgeries are not considered for children who have not reached these developmental milestones. Social transition involves several reversible changes designed to affirm a child's experienced gender. This includes updating their name across various settings to reflect their gender identity, adopting pronouns that align with the child’s gender identity, and changing gender markers on official documents such as birth certificates, school records, and medical documents to reflect the child's affirmed gender. Children are also allowed to participate in activities and programs, such as sports teams, that align with their gender identity.

For prepubertal children, hormonal differences are not yet a factor, which supports their inclusion based on their affirmed gender rather than their sex assigned at birth. Facilitating access to bathrooms and locker rooms that correspond with the child’s gender identity is another aspect of social transition. Supporting the child in expressing themselves through clothing, hairstyle, and other forms of personal presentation that reflect their identity is also key. Additionally, helping to communicate the child’s gender identity to others, which might include social media announcements or letters to extended family members, is part of this process.

These elements of social transition are entirely non-medical and reversible. They are aimed at supporting the child in a way that affirms their identity, which is critical for their psychological and emotional health. 

Gender-Affirming Care: Prosthetics

In addition to social transition, other non-medical, gender-affirming interventions involve prosthetics or specific training to help individuals express their gender identity. These interventions, which do not involve medication or surgery, play a crucial role in aligning one’s external appearance with one's gender identity.

For masculinizing purposes, binders are often used. These compression garments are designed to flatten the chest, creating a more masculine appearance, and are suitable for individuals who have experienced breast development but are not seeking medical treatment. Packers, another form of prosthetic, are utilized to create the appearance of a bulge in the genital area, simulating the presence of a penis. STP (stand-to-pee) devices enable individuals who do not have a penis to urinate while standing. These devices are shaped to function as prosthetics and urinary aids.

For feminizing effects, gaffs and tucking are common practices. Tucking involves repositioning the penis and testicles to achieve a smoother appearance in tight clothing, while gaffs are specialized undergarments designed to hold these parts securely. Breast forms, worn to simulate the appearance of breasts, enhance the feminine silhouette. Wigs also play an essential role, particularly for individuals who desire longer hair or face challenges with hair loss.

Additionally, aesthetic procedures like laser hair removal aid in achieving a more consistent appearance with one’s gender identity, though their reversibility varies. Voice training is another critical aspect, helping individuals modify their vocal pitch and resonance to better match their gender presentation. While some may seek professional guidance for voice training, others might use self-guided methods.

These gender-affirming interventions, while non-medical, are vital components of the support system for transgender and gender-diverse individuals, offering additional ways to safely and comfortably express their identities.

Gender-Affirming Care

The final piece of gender-affirming care involves medical transition, which consists of three primary categories. The first category includes puberty blockers, also known as GnRH analogs. These blockers prevent the development of endogenous secondary sex characteristics, effectively pausing puberty. This intervention is fully reversible, with no impact on fertility or other puberty-related changes once the treatment is discontinued. Puberty blockers provide adolescents with additional time to explore their gender identity without the distress often associated with puberty. For instance, a 12-year-old at Tanner stage 2 might use puberty blockers to halt puberty, allowing time for further cognitive development and exploration before making decisions about hormones, which are only partially reversible.

Tanner stage 2 marks the onset of visible changes. For those designated female at birth, this stage typically starts between ages 9 and 11 and is characterized by the development of breast buds under the nipples, which may become itchy or tender. The areola, the darker area around the nipple, expands, and the uterus begins to grow. A small amount of pubic hair starts to appear. Tanner stage 2 generally begins around age 11 for those designated male at birth. Changes include enlargement of the testicles and the scrotum, with some pubic hair forming at the base of the penis. It is at this stage that puberty blockers are deemed appropriate, not earlier.

The second category of medical transition involves hormones. For individuals assigned male at birth, the regimen can include estrogen and testosterone blockers, while those assigned female at birth may receive testosterone. The effects of hormone therapy are partially reversible. For example, breast growth induced by estrogen does not recede when hormone treatment is stopped and would require surgical removal if desired. Prolonged hormone use can also impact fertility. Testosterone administration can lead to irreversible changes such as voice deepening and facial and body hair growth. Hair loss, another effect of testosterone, is also irreversible. Fertility effects are generally more reversible for those assigned female at birth taking testosterone compared to those assigned male at birth on estrogen and testosterone blockers.

The third category is surgeries, which are entirely irreversible. While reconstructive surgeries are possible, they do not fully reverse the original alterations. Masculinizing top surgery, or double mastectomy, is the most common procedure performed under age 18, typically starting at age 16. This procedure achieves a flatter chest appearance. Most other surgeries are recommended after age 18.

WPATH Standards of Care 8: Children

Continuing with the Standards of Care 8, we focus now on children, particularly those who are pre-puberty. It is crucial to emphasize that the standards of care do not involve any medical interventions for these children. Instead, the focus is on providing support through knowledge and understanding.

• 7.1 - We recommend health care professionals working with gender-diverse children receive training and have expertise in gender development and gender diversity in children and possess a general knowledge of gender diversity across the life span. 
• 7.2 - We recommend health care professionals working with gender-diverse children receive theoretical and evidenced-based training and develop expertise in general child and family mental health across the developmental spectrum. 
• 7.3 - We recommend health care professionals working with gender-diverse children receive training and develop expertise in autism spectrum disorders and other neurodiversity or collaborate with an expert with relevant expertise when working with autistic/neurodivergent, gender-diverse children
• 7.4 - We recommend health care professionals working with gender-diverse children engage in continuing education related to gender-diverse children and families. 
• 7.5 - We recommend health care professionals conducting an assessment with gender-diverse children access and integrate information from multiple sources as part of the assessment. 
• 7.6 - We recommend health care professionals conducting an assessment with gender-diverse children consider relevant developmental factors, neurocognitive functioning, and language skills. 
• 7.7 - We recommend health care professionals conducting an assessment with gender-diverse children consider factors that may constrain accurate reporting of gender identity/gender expression by the child and/or family/caregiver(s).
• 7.8 - We recommend health care professionals consider consultation, psychotherapy, or both for a gender-diverse child and family/ caregivers when families and health care professionals believe this would benefit the well-being and development of a child and/or family.
• 7.9 - We recommend health care professionals offering consultation, psychotherapy, or both to gender-diverse children and families/caregivers work with other settings and individuals important to the child to promote the child's resilience and emotional well-being.
• 7.10 - We recommend health care professionals offering consultation, psychotherapy, or both to gender-diverse children and families/caregivers provide both parties with age-appropriate psychoeducation about gender development.
• 7.11 - We recommend that health care professionals provide information to gender-diverse children and their families/caregivers as the child approaches puberty about potential gender-affirming medical interventions, the effects of these treatments on future fertility, and options for fertility preservation. 
• 7.12 - We recommend parents/caregivers and health care professionals respond supportively to children who desire to be acknowledged as the gender that matches their internal sense of gender identity. 
• 7.13 - We recommend health care professionals and parents/caregivers support children to continue to explore their gender throughout the pre-pubescent years, regardless of social transition. 
• 7.14 - We recommend the health care professionals discuss the potential benefits and risks of a social transition with families who are considering it. 
• 7.15 - We suggest health care professionals consider working collaboratively with other professionals and organizations to promote the well-being of gender-diverse children and minimize the adversities they may face.

Healthcare professionals working with gender-diverse children must be well-trained in gender diversity across the lifespan. This training should also encompass general child and family mental health and expertise in working with neurodiverse conditions such as autism spectrum disorders and ADHD. For those without direct training in these areas, collaboration with experts who possess this knowledge is essential. This is particularly important given the noted overlap between transgender identities and autism; many autistic children are trans, and vice versa, though the reasons for this correlation are not fully understood and continue to be a subject of research.

The diagnostic criteria for autism, primarily based on studies of cisgender boys, may not accurately reflect the experiences of cisgender girls or transgender children. Recent research indicates that the manifestation of autism characteristics can differ significantly in these groups compared to the established DSM-5 criteria. This highlights the necessity for ongoing education and adaptation of diagnostic approaches to better serve a diverse population.

WPATH also emphasizes the importance of continuous professional development. Healthcare providers are encouraged to pursue continuing education to stay abreast of evolving practices and theories, ensuring they are equipped to provide the most effective support. Conducting comprehensive assessments that integrate information from multiple sources is also recommended. These assessments should aim to develop tailored intervention recommendations that support the child's mental health and well-being without pushing medical transitions.

It is crucial that assessments and interventions neither encourage nor discourage a child’s gender expression. The goal is to support the child in a manner that respects their self-identified gender needs. Assessments should thoroughly consider the child's environment, including family, school, and community contexts, utilizing multiple informants such as teachers, parents, extended family members, and other community figures to comprehensively understand the child’s situation.

Understanding the legal context in which the child lives is also vital. For example, if a child resides in Texas, it is important to know the specific legal implications for transgender youth in that state. Assessments might explore various dimensions such as the child’s gender identity and expression, any dysphoria or incongruence they experience, the strengths and challenges faced by the child and their family, experiences of gender minority stress, levels of support within the school, faith community, and extended family, potential conflicts within the family regarding the child’s gender, and the child’s overall mental health.

In comprehensive assessments for transgender and gender-diverse children, it's vital to gather a detailed medical and developmental history. This includes identifying any potential risks such as past trauma, abuse, suicidality, and co-occurring family stressors like chronic illness, homelessness, or poverty. Understanding the mental health of parents, caregivers, and siblings and the family's overall dynamics is also crucial.

Additionally, assessing the child's neurocognitive functioning and language skills is important. These factors can influence how accurately the child and their family report gender identity and expression. External pressures from family or school environments may compel a child to conform to certain gender expressions, and recognizing these influences is essential for accurate assessment and support.

Continuing education is imperative in this field. Professionals must stay informed about legislative changes, ongoing research, and evolving best practices. The recent introduction of the Standards of Care 8 underscores the importance of keeping knowledge current. In cases where it benefits the child and family, consultation or psychotherapy can be valuable, and it's crucial that this care coordinates with other aspects of the child’s life, such as school and faith communities.

Providing psychoeducation is a crucial element of working with transgender children and their families. Parents and children often require extensive information, especially as children approach puberty and begin considering their options regarding gender-affirming medical treatments. It is vital for healthcare providers to offer comprehensive details about available interventions, such as puberty blockers, ensuring that the family fully understands their effects and implications.

If a child expresses interest in exploring gender-affirming treatments, it is essential to discuss the potential impacts on fertility, as this is a common concern among families. Discussing fertility preservation options can help alleviate some anxieties about the future and aid families in making informed decisions. However, it's important to remember that if a child or their parents are not interested in these treatments, they should not be pressured or obligated to consider them.

Supporting a child's exploration of their gender identity is fundamental, whether or not they choose to socially transition. This support includes affirming the child's gender identity in a manner that respects their individuality and personal journey. It's also worth noting that a social transition can vary across different contexts. For example, a child might transition socially at home but not at school. Whether or not to disclose a social transition is a personal decision and should be guided by the child's comfort and safety, especially in environments where anti-trans legislation may affect their rights.

Additionally, it is crucial to address any concerns the family might have about sexual functioning, which can be a sensitive topic for some. While not all families will want to discuss this aspect, providing clear and age-appropriate information is essential for those who do. Furthermore, sex education should be introduced before puberty. This education should be inclusive, providing all children, including those who are transgender or gender-diverse, with the knowledge they need to understand their bodies and the changes they will undergo. This preparation concerns physical health and fosters a supportive environment that respects and affirms the child's developing identity.

When discussing social transition for transgender children, it is essential that the initiative for such a transition originates from the children themselves, not from assumptions made by their parents. For example, a parent should not deduce a child’s gender identity simply because they dislike traditionally gender-typed colors like pink and suggest the child might be a boy. Instead, the child should express their own desires and interests, and the transition should reflect their wishes.

Families can discuss with the child the advantages and disadvantages of social transitioning. It's important to note that social transition may occur in varying contexts; a child might transition at home but not at school, which is acceptable. Sometimes, a child may socially transition at a very young age, around 3 to 6 years old. In these cases, it's possible that neither their classmates nor their teachers are aware of the transition. This lack of disclosure is generally acceptable and often preferred to protect the child's privacy. This privacy should be respected unless external circumstances, such as anti-trans legislation, require disclosure. However, ideally, no one should be compelled to discuss their transgender identity involuntarily.

Exploring the risks and benefits of social transitioning is crucial. On the positive side, social transitioning can significantly enhance a child’s psychosocial adjustment and overall well-being. Research indicates that the mental health of socially transitioned children often parallels that of their cisgender siblings and peers, suggesting fewer mental health disparities than those observed in gender-diverse children and adolescents who have not transitioned socially. Supportive family environments frequently accompany these transitions and likely contribute to positive mental health outcomes.

However, there are potential downsides. Social transition may expose children to risks such as bullying or ostracism, particularly if they do not conform to established gender roles within their school or community. Additionally, the internal stress from experiencing gender incongruence can be a source of distress for gender-diverse children. 

Importantly, all children, including those who are transgender and gender-diverse, have the right to be supported and respected in their gender identities. They are a particularly vulnerable group, and the social determinants of health significantly impact their well-being. For these marginalized minorities, robust support from families and schools is crucial, playing a critical role in fostering their health and overall development.

WPATH Standards of Care 8: Adolescents

Let's switch our focus to adolescents. When discussing this age group, we refer to the Standards of Care 8 outlined by WPATH. It’s important to note that the numbers I mention correspond to specific standards within these guidelines.

• 6.1 - We recommend health care professionals working with gender-diverse adolescents:
  • 6.1.a - Are licensed by their statutory body and hold a postgraduate degree or its equivalent in a clinical field relevant to this role granted by a nationally accredited statutory institution.
  • 6.1.b - Receive theoretical and evidenced-based training and develop expertise in general child, adolescent, and family mental health across the developmental spectrum.
  • 6.1.c - Receive training and have expertise in gender identity development, gender diversity in children and adolescents, have the ability to assess capacity to assent/consent, and possess general knowledge of gender diversity across the life span.
  • 6.1.d - Receive training and develop expertise in autism spectrum disorders and other neurodevelopmental presentations or collaborate with a developmental disability expert when working with autistic/neurodivergent gender-diverse adolescents
  • 6.1.e - Continue engaging in professional development in all areas relevant to gender-diverse children, adolescents, and families.
• 6.2 - We recommend health care professionals working with gender-diverse adolescents facilitate the exploration and expression of gender openly and respectfully so that no one particular identity is favored.
• 6.3 - We recommend health care professionals working with gender-diverse adolescents undertake a comprehensive biopsychosocial assessment of adolescents who present with gender identity-related concerns and seek medical/surgical transition-related care, and that this be accomplished in a collaborative and supportive manner.
• 6.4 - We recommend health care professionals work with families, schools, and other relevant settings to promote acceptance of gender-diverse expressions of behavior and identities of the adolescent.
• 6.5 - We recommend against offering reparative and conversion therapy aimed at trying to change a person’s gender and lived gender expression to become more congruent with the sex assigned at birth.
• 6.6 - We suggest health care professionals provide transgender and gender-diverse adolescents with health education on chest binding and genital tucking, including a review of the benefits and risks.
• 6.7 - We recommend providers consider prescribing menstrual suppression agents for adolescents experiencing gender incongruence who may not desire testosterone therapy, who desire but have not yet begun testosterone therapy, or in conjunction with testosterone therapy for breakthrough bleeding.
• 6.8 - We recommend health care professionals maintain an ongoing relationship with the gender diverse and transgender adolescent and any relevant caregivers to support the adolescent in their decision-making throughout the duration of puberty suppression treatment, hormonal treatment, and gender-related surgery until the transition is made to adult care.
• 6.9 - We recommend health care professionals involve relevant disciplines, including mental health and medical professionals, to reach a decision about whether puberty suppression, hormone initiation, or gender-related surgery for gender-diverse and transgender adolescents are appropriate and remain indicated throughout the course of treatment until the transition is made to adult care.
• 6.10 - We recommend health care professionals working with transgender and gender-diverse adolescents requesting gender-affirming medical or surgical treatments inform them, prior to initiating treatment, of the reproductive effects, including the potential loss of fertility and available options to preserve fertility within the context of the youth's stage of pubertal development.
• 6.11 - We recommend when gender-affirming medical or surgical treatments are indicated for adolescents, health care professionals working with transgender and gender-diverse adolescents involve parent(s)/guardian(s) in the assessment and treatment process, unless their involvement is determined to be harmful to the adolescent or not feasible.

The first standard involves the requisite training, licensing, and credentials necessary when working with transgender adolescents. Importantly, while one does not need to be a mental health professional to assess a transgender-diverse adolescent, mental health professionals are generally best suited for this role. Typically, it is recommended that a mental health professional conduct assessments, especially those related to blockers, hormones, or surgery. However, a well-trained primary care physician could also competently perform this evaluation.

Additionally, those working with autistic or neurodivergent adolescents should seek ongoing training and professional development to ensure they are providing the most informed and effective care. It's crucial to facilitate the exploration and expression of gender in an open and respectful manner, ensuring that no specific identity is favored. This means avoiding any bias that might influence an adolescent either to embrace or reject a trans identity or to adhere strictly to the gender assigned at birth. The goal is to maintain a neutral, supportive space that allows youth to explore their identity at their own pace.

Conducting a comprehensive biopsychosocial assessment of adolescents is essential in a collaborative and supportive manner. It's important to recognize that not all children who are gender-diverse will continue to identify this way into adolescence. Similarly, adolescents may vary significantly in how quickly they consolidate their gender identity. This process occurs rapidly for some, while it evolves more slowly for others. This variability underscores the need to meet each youth where they are and proceed at a pace that respects their individual process.

Robust evidence supports the benefits of gender-affirming medical treatments in adolescents, but it's crucial to note that this evidence is based on clinical settings that incorporated detailed, comprehensive diagnostic assessments over time. There is no supportive evidence for making medical or surgical decisions without a thorough and prolonged assessment process. Therefore, the recommendation is clear: comprehensive diagnostic biopsychosocial assessments are necessary and represent the evidence-based approach for managing gender-diverse youth.

When working with families and schools, similar to interactions with children, it's crucial to avoid any approaches akin to reparative or conversion therapy. Such practices, aimed at changing a child's experience of their gender or eliminating gender incongruence, are not only ineffective but also harmful and unethical. Extensive research indicates that these methods can have detrimental effects on adolescents' well-being.

Health education on tucking and binding is also essential. If patients are engaging in these practices or are interested in doing so, it is important to provide proper guidance. Many teens might be tucking and binding unsafely, using materials like ace bandages or excessively tight tape, which can disrupt circulation and lead to issues such as back and chest pain, shortness of breath, and overheating. For example, one patient reported wearing two to three binders simultaneously, keeping them on while sleeping and during exercise, which is highly inadvisable. Binders are not meant for prolonged wear, especially not during sleep or physical activity, and should not be substituted with ace bandages. There are binders specifically designed for safe use, and these should be recommended instead. Notably, 87% of transgender masculine individuals, those designated female at birth who are transitioning to a more masculine identity, have a history of binding.

Discussing tucking, which involves retracting the testes and penis for a smoother appearance at the groin, is also crucial. This practice can affect sperm production and fertility, necessitating thorough educational support on these topics. Menstrual suppression is another consideration; it can be managed with various agents, regardless of whether the patient is using testosterone or puberty blockers. Some individuals may opt only for menstrual suppression without pursuing hormone therapy. Just as some cisgender women choose not to menstruate for personal comfort, similar options should be accessible for transgender individuals. Options include estrogen and progestin medications, oral progestins, and IUDs.

Puberty blockers, or GnRH (Gonadotropin-releasing hormones) analogs, can also suppress menstruation. However, testosterone, while it can suppress menstruation, may not immediately stop uterine bleeding, and breakthrough bleeding can occur. Importantly, testosterone is not a form of birth control and is teratogenic, meaning it can cause harmful effects on a fetus if pregnancy occurs. Therefore, it is vital to provide sex education and discuss birth control options with sexually active patients who could become pregnant, even if they are not menstruating. Ovulation and the potential for pregnancy can still occur in individuals using testosterone or puberty blockers who do not menstruate.

Providing ongoing support throughout the duration of puberty suppression, hormone treatment, or surgical interventions is crucial until the transition to adult care is complete. This process should not be limited to a single evaluation, after which the adolescent is sent on their way with prescriptions for hormones or puberty blockers. Decision-making is an ongoing process that requires constant support, especially as adolescents experience changes that might affect them differently than anticipated.

All of the research and evidence supporting these interventions were conducted in settings that fostered ongoing clinical relationships between the adolescents, their families, and their providers. This continuous support within multidisciplinary settings, where medical and mental health professionals collaborate closely, is essential for effective treatment. It’s important to understand that the evidence base comes from these types of collaborative environments.

Both medical and mental health professionals should be involved in both the initial evaluation and the ongoing care concerning blockers, hormones, and surgery. It’s not sufficient to have only mental health support; medical professionals must also be involved. While only one letter from a professional is required to proceed with treatment, this letter should reflect the entire team's comprehensive assessment and consensus, encompassing medical and mental health perspectives.

The multidisciplinary team might include professionals from various fields, such as adolescent medicine or primary care, which is often needed to confirm the stage of puberty. Endocrinologists may be required to prescribe hormones or puberty blockers, while psychologists, psychiatrists, and social workers address mental health aspects. Speech-language pathologists might be involved in voice training, along with support staff and the surgical team.

Discussing fertility is crucial when considering gender-affirming treatments for adolescents. It is essential to address the potential for fertility loss associated with various treatments and explore options for fertility preservation.

Puberty blockers are fully reversible, meaning they do not typically impact long-term fertility. However, transitioning directly from puberty blockers to hormones could potentially result in fertility loss. Furthermore, genital surgeries, although less common among adolescents, can have an irreversible impact on fertility. Therefore, discussing fertility preservation options, such as egg retrieval or sperm preservation, is important. It is vital that both parents and the adolescent understand the pros and cons of these options thoroughly.

Differences in perspective between parents and adolescents regarding reproductive capacity can lead to disagreements. Parents might place a high value on the potential for grandchildren, whereas the adolescent may express a clear disinterest in having children. Such disparities underscore the importance of facilitated discussions that help both parties understand each other’s viewpoints and the implications of treatment decisions.

It is also crucial to consider the adolescent’s decision-making competency regarding their future reproductive choices. While many adolescents feel certain about not wanting children, their desires and life circumstances could change as they mature. Guidance from professionals experienced in adolescent development and family dynamics is essential in these discussions. These professionals should help set realistic expectations for fertility preservation outcomes and ensure that these discussions are informed and based on the adolescent’s and family’s needs and values. These conversations need to occur both before initiating any medical intervention and throughout transition.

Fertility counseling is often recommended, even if preservation is not pursued. However, it is important not to coerce adolescents into fertility preservation if it is not aligned with their or their parents’ wishes. Procedures like egg retrieval can be distressing and physically uncomfortable, particularly for transmasculine individuals, due to the highly gendered nature of most reproductive health environments.

I'm currently working with an adult patient who was going through the egg retrieval process prior to continuing on testosterone. They experienced significant anxiety, partly because they had previously undergone the procedure. The environment, heavily feminized with images of women, did not align with their transmasculine identity, adding to their discomfort. They also found the process physically uncomfortable and painful.

These considerations must be navigated sensitively, ensuring that discussions about fertility preservation are inclusive and respectful of the adolescent’s gender identity and personal preferences. The decision to undergo fertility preservation is complex and must balance medical possibilities with the psychological comfort and personal desires of the adolescent, making professional guidance and open communication essential throughout the process.

It's crucial not to make assumptions about an adolescent's goals, especially given the limited research in this area. There is existing research involving childhood cancer survivors, which suggests that some participants experienced regret and distress over missed opportunities for fertility preservation. However, the experiences of transgender individuals may differ significantly.

Involving parents or guardians in both assessment and treatment is generally standard practice, with the assessment often occurring over multiple sessions—individually with the child, with the parents, and then together. This process can be extensive. Exceptions may occur, such as in cases where the adolescent is in foster care, under Child Protective Services, or where parental involvement might be harmful due to issues like abuse. However, in the majority of cases, parental or guardian involvement is crucial. Depending on the institution’s policy, consent from one or both parents might be necessary.

Parents and caregivers can provide valuable insights into the adolescent's gender development, medical and mental health history, and overall level of functioning. Discrepancies in reports between the adolescent and their parents about mental health can also provide critical information for understanding the youth's needs.

Working closely with parents is vital. It is essential to educate them about the treatment process, follow-up care, and potential complications. It’s important to take parents' concerns seriously and address their questions thoroughly, which can help in assessing the influence of peers or social media on the adolescent's understanding of gender.

There may be instances where parents do not consent to treatment. While some may still be generally supportive of their child’s gender identity, others may hold unsupportive or even antagonistic views. These perspectives, while challenging, are important to engage with as part of the therapeutic process. Many parents, with appropriate support and psychoeducation, may become more accepting and supportive of their trans and gender-diverse children over time.

Thus, continuing to work with families remains critical regardless of their initial stance on medical care. Even if a parent does not consent to specific treatments, supporting them can still positively impact the family dynamics and the well-being of the adolescent.

The following recommendations are made regarding the requirements for gender-affirming medical and surgical treatment (All of them must be met):

• 6.12 - We recommend health care professionals assessing transgender and gender-diverse adolescents only recommend gender-affirming medical or surgical treatments requested by the patient when:
  • 6.12.a - The adolescent meets the diagnostic criteria of gender incongruence as per the ICD-11 in situations where a diagnosis is necessary to access health care. In countries that have not implemented the latest ICD, other taxonomies may be used, although efforts should be undertaken to utilize the latest ICD as soon as practicable.
  • 6.12.b - The experience of gender diversity/incongruence is marked and sustained over time.
  • 6.12.c - The adolescent demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment.
  • 6.12.d - The adolescent’s mental health concerns (if any) that may interfere with diagnostic clarity, capacity to consent, and gender-affirming medical treatments have been addressed.
  • 6.12.e - The adolescent has been informed of the reproductive effects, including the potential loss of fertility and the available options to preserve fertility, and these have been discussed in the context of the adolescent’s stage of pubertal development.
  • 6.12.f - The adolescent has reached Tanner stage 2 of puberty for pubertal suppression to be initiated.
  • 6.12.g - The adolescent had at least 12 months of gender-affirming hormone therapy or longer, if required, to achieve the desired surgical result for gender-affirming procedures, including breast augmentation, orchiectomy, vaginoplasty, hysterectomy, phalloplasty, metoidioplasty, and facial surgery as part of gender-affirming treatment unless hormone therapy is either not desired or is medically contraindicated.

When discussing gender-affirming medical and surgical treatments, it's imperative that the adolescent meets the diagnostic criteria for gender incongruence as outlined in the ICD-11. If the ICD-11 is not yet implemented within a specific healthcare system, an alternative classification, such as the DSM-5, may be used. However, the ICD-11 is generally preferred because it categorizes gender incongruence under conditions related to sexual health rather than mental and behavioral disorders. This shift is significant as it reflects a more current understanding that gender diversity is not a mental health condition, similar to historical changes in the classification of homosexuality.

The ICD-11 allows for diagnoses such as gender incongruence of adolescence or adulthood (HA60) for adolescents, gender incongruence of childhood (HA61) for children, or unspecified gender incongruence (HA6Z). This classification is less pathologizing and helps reduce stigma compared to the DSM-5’s diagnosis of gender dysphoria.

It's essential to recognize that adolescents may experience shifts in their gender-related experiences and needs. Therefore, they should ideally demonstrate several years of persistent gender diversity and incongruence before initiating less reversible treatments such as hormones or surgery. Puberty suppression is particularly beneficial as it can provide adolescents experiencing distress from the changes associated with puberty the time to decide if they want to undergo the typical changes of their biological puberty or pursue hormone therapy.

However, prolonged periods without hormones can impact bone health and density, making the extended use of puberty suppression treatments a complex decision. While several years of observation and assessment are ideal, practical considerations, including potential impacts on physical health, must also be taken into account. Social transition can provide significant relief and additional time for adolescents to explore their gender identity before making any medical decisions.

While we have already discussed reproduction and fertility, it is vital to reiterate the importance of these topics in the context of gender-affirming care.

A critical aspect of treating adolescents involves ensuring they have the emotional and cognitive maturity to consent to or assent to treatment. This typically requires both parental consent and the adolescent's assent. The adolescent must fully understand the treatment, including the ability to evaluate the risks and benefits. They must appreciate the nature of their decision, especially considering the long-term consequences of irreversible treatments such as hormone therapy or surgery.

To make an informed decision, adolescents need to clearly communicate their choices and understand the timelines for expected changes from treatments like hormones. They should be aware of what is reversible, partially reversible, and irreversible, weighing all the pros and cons to determine if the treatment aligns with their needs.

It's crucial to assess whether the adolescent can thoughtfully consider the future implications of partially or fully irreversible interventions. This includes evaluating if they have the self-reflective capacity to understand how their gender-related needs and priorities might evolve over time. Adolescents should consider their responses if their perspectives on gender identity change in the future.

Additionally, it's essential to determine if the adolescent can manage the day-to-day and long-term aspects of a medical treatment. This includes adhering to medication schedules, attending necessary medical follow-ups, and handling any associated responsibilities.

When considering the capacity to consent, it's essential to evaluate all aspects thoroughly, particularly mental health concerns, which are prevalent among transgender youth. This demographic may face a range of mental health issues, including depression, self-harm, suicidality, and eating disorders. When such concerns are present, the priority must be safety and stabilization. For instance, an adolescent grappling with suicidality or an active eating disorder may not be in a position to make informed decisions about gender-affirming medical or surgical treatments. Furthermore, these conditions could potentially destabilize them further, prompting careful consideration of whether they are ready for such treatments.

Mental health concerns can also complicate the assessment process. It may be challenging to distinguish between gender incongruence and other mental health issues, such as compulsions, special interests associated with autism, or symptoms stemming from trauma or psychosis. Such complexities necessitate a nuanced approach to evaluating the adolescent's true needs and readiness for transition-related care.

Moreover, if an adolescent is experiencing a depressive episode, it could impair their ability to engage in thoughtful decision-making. For autistic adolescents, persistent communication differences and a preference for concrete or rigid thinking can further complicate discussions around treatment options and future planning.

Treatment adherence is another critical consideration. An adolescent dealing with severe depression might struggle to consistently take prescribed medications or follow through with post-surgical care. While mental health issues do not need to be fully resolved before proceeding with gender-affirming treatment, they must be sufficiently managed to ensure the adolescent can safely participate in and benefit from treatment.

Regarding treatment timing, it's crucial that adolescents reach Tanner stage 2 before initiating puberty blockers. For hormones and surgery, the recommendation generally includes at least 12 months on hormones before considering surgical options. This duration allows for anatomical changes necessary for certain procedures, such as breast augmentation, and ensures that the adolescent has adequate time to psychologically adjust to the physical changes hormones induce.

Gender-Affirming Care: Outcomes

Let's discuss the outcomes associated with gender-affirming interventions. There is substantial evidence indicating that these interventions improve mental health outcomes. These interventions, which include puberty blockers, hormone therapy, and surgery, have been shown to lead to a resolution in gender dysphoria. This resolution is often associated with enhanced psychological functioning and increased satisfaction with body image.

It's important to note that trans adolescents generally exhibit poorer mental health compared to their cisgender peers. However, studies have shown that after undergoing puberty suppression, their mental health tends to improve significantly. Additionally, trans males who have undergone hormone therapy report lower levels of depression and anxiety compared to those who have not yet started hormone treatments. These findings underscore the potential benefits of gender-affirming interventions in improving mental health.

It's crucial to recognize that while these interventions can markedly enhance mental health, their impact varies. Not all adolescents will experience the same benefits, particularly if they have preexisting mental health issues. Gender-affirming treatments specifically address gender dysphoria; they do not directly treat other mental health conditions. Therefore, it is possible for an adolescent to continue experiencing mental health challenges even after undergoing hormone treatments, surgery, or puberty blockers. This highlights the importance of comprehensive mental health care that addresses all aspects of an adolescent’s well-being, not just those related to gender dysphoria.

What About Regret & Detransition?

Research concerning regret and detransition is a topic that garners significant attention, often highlighted in various articles due to public concern. However, studies indicate that the rates of adolescents choosing to cease puberty blockers are relatively low. For example, two Dutch studies from 2018 and 2019 found that only about 2% to 3.5% of adolescents chose to stop puberty suppression. It's crucial to note that puberty suppression is entirely reversible, so stopping these treatments does not result in long-term or sustained effects.

Regarding detransition, research shows that while some adolescents do detransition, they do not necessarily regret initiating treatment. For instance, an individual might have achieved the desired irreversible effects from hormone therapy, such as a lower voice, and choose to discontinue treatment while still feeling positive about the decision to start it.

A significant study conducted between 2014 and 2020 by a gender diversity service in Western Australia that provides gender-affirming care to children and adolescents up to 18 years tracked 552 closed referrals and provided insightful data. Out of the 548 patients included in the study, only a very small percentage, 5.3%, re-identified with their birth sex after being referred. Remarkably, only two patients, approximately 1% of those who received some form of treatment such as puberty suppression or hormones, later re-identified with their birth sex. The findings suggest that some individuals might re-identify during the assessment process and choose not to proceed with treatment.

It is essential to distinguish between detransition and regret. Detransition refers to the cessation of the medical transitioning process, which does not necessarily imply regret about the decision to start. Furthermore, the rates of re-identifying with the birth sex are exceedingly low, and stopping hormone therapy does not always mean re-identifying with one's birth sex. Individuals might continue to identify with the same or a different transgender identity but decide against continuing medical transition.

This complexity underscores the need for nuanced understanding and support in the realm of gender-affirming care, recognizing that the paths of gender identity and transition are highly individual and not uniformly linear.

Clinical Approaches

Let's briefly review some clinical approaches. Since we've covered these extensively, I'll quickly summarize the key points.

Supporting TGD Youth

• The role of advocacy
  • Join community organizations
  • Join with parents and families
• Provide psychoeducation and training
• Make your voice heard in schools, with medical providers, in politics/courts, and in the media
• Support youth in their families, schools, and communities
• Understand the role of multiple minority stress
• Address barriers to accessing care

Advocacy plays a crucial role in supporting transgender and gender-diverse youth. It is vital to engage with community organizations, collaborate with parents and families, and make one's voice heard in various settings, including schools, medical environments, political arenas, and the media.

Family Interventions

• Providing psychoeducation
• Allowing space for families to express reactions to their child's gender
• Emphasizing the protective power of family acceptance
• Utilizing multiple modalities of support, 
• Giving families opportunities for allyship and advocacy
• Connecting families to TGE community resources
• Centering intersectional approaches and concerns 
• Types of support:
  • Emotional
  • Instrumental 
  • Appraisal
  • Informational
• Parental support is essential!

In working with families, it is important to provide education and space for them to express their reactions to their child's gender identity, even if those reactions are not always positive. Emphasizing the protective power of family acceptance is crucial. Employ multiple modalities of support and provide opportunities for allyship and advocacy. For example, connecting families with advocacy organizations and community resources can help them support their children more effectively. It is also important to consider intersectional approaches, acknowledging that these families may face additional challenges related to other marginalized identities.

Studies have shown that family support can take various forms, including emotional support, such as expressions of love, empathy for mental health issues, and communication about emotions. Instrumental support might include financial assistance, help with healthcare, and support during social and legal transitions. Appraisal involves giving feedback and affirming the child’s gender, helping choose a name, or helping choose pronouns. Informational support includes providing advice and sexual health information. These elements are crucial in helping transgender children feel supported by their families.

Guidelines for Schools

• Create a welcoming environment
• Create antibullying measures – and actually enforce them!
• Provide opportunities to explore medical transition options if indicated 
• Use the youth’s name and pronouns correctly
• Support the youth in connecting with LGBT groups, trusted staff, and peers

It is essential to help schools create a welcoming environment in the educational setting. This involves implementing and enforcing anti-bullying measures, using the youth’s chosen name and pronouns correctly, and providing opportunities for medical transition if indicated. Schools should also facilitate connections with LGBT groups, trusted staff, and LGBT peers. In one school, for example, affirming teachers displayed symbols on their doors to indicate their support, allowing LGBT students to identify allies.

Unfortunately, the risks of inadequate support are starkly highlighted by incidents like the case of Nex Benedict, a non-binary student in Oklahoma. Nex was reportedly bullied and attacked and tragically found dead the following day. This case underscores the severe impact that bullying and lack of support can have on the physical and mental health of transgender youth, emphasizing the importance of robust advocacy and protective measures in all environments that influence the lives of these young individuals.

Ethical Considerations

Ethical considerations are critical, especially when working with transgender youth. As we conclude today's discussion, it's important to emphasize the role of ethical guidelines in guiding professional conduct.

Ethics Codes

Always refer to the ethics codes specific to your profession. These codes provide a framework for addressing the complex situations you may encounter and ensure that you uphold the highest standards of practice. Additionally, be well-informed about the legal and ethical environment in your state. Local laws and regulations can significantly impact how services are provided to transgender youth, and staying informed ensures that your practice meets professional standards and regional legal requirements. Below are links to Ethics Codes for some of the major behavioral health professions. Please ensure you always refer to your own ethical code.

• AAMFT: https://www.aamft.org/Legal_Ethics/Code_of_Ethics.aspx 
• ACA: https://www.counseling.org/resources/ethics
• APA: https://www.apa.org/ethics/code 
• NBCC: https://nbcc.org/assets/ethics/nbcccodeofethics.pdf
• NAADAC: https://www.naadac.org/code-of-ethics
• NASW: https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English

The Ethics of Gender-Affirming Care

The ethics of gender-affirming care, particularly for transgender youth, involves navigating complex issues that require a nuanced understanding of medical ethics and human rights perspectives. The World Professional Association for Transgender Health (WPATH) and its Standards of Care emphasize the ethical principles of self-determination and the right to access healthcare.

When deemed capable, adolescents should have the autonomy to make decisions about their healthcare. This often involves dual consent—both from the adolescent and their parents. However, the ethical principle of self-determination supports an adolescent's right to choose their own treatment, assuming they have the capacity to consent. This principle is particularly poignant in cases where gender-affirming care is deemed medically necessary, as it is the only treatment known to effectively address gender incongruence and has been shown to lead to significantly positive outcomes.

However, it is crucial to ensure that adolescents receive appropriate education about their treatment options and a thorough and thoughtful assessment process. This ensures they truly understand and can consent to their treatment, safeguarding against potential harm that could arise from treatments they are not fully prepared to undertake.

It is also important to recognize that choosing not to intervene—allowing puberty to progress without interruption—is not a neutral act. For many transgender adolescents, this could lead to intense distress and negative psychological outcomes. Inaction, under the guise of avoiding harm, can itself be harmful.

For example, I am currently working with a 20-year-old who began hormone therapy at around 17 or 18, with parental consent. However, prior to this, there was a period of confusion and non-consent from the parents. During this time, she obtained hormones via the internet, stating that it was life-saving and that her friend, by facilitating access to hormones, literally saved her life. While it's not ideal to encourage unsupervised medical interventions, this situation underscores the lengths to which individuals may go to alleviate their distress.

Moreover, consider the patient who wore three binders to flatten their chest despite the physical pain it caused. This example highlights the severe distress associated with experiencing gender incongruence and the potential risks individuals might take to find relief.

Ethics and the Law

When ethics and law are in conflict, particularly in the realm of gender-affirming care for transgender youth, professionals face significant challenges. Instances where laws may label supportive parents as potential child abusers simply for consenting to gender-affirming care for their children highlight the stark contrasts between ethical medical practices and legal mandates. This was a proposed law in Texas, and a psychologist took that law to court. These situations are distressing, not only to the families affected but also to the professionals involved.

In states where gender-affirming care is restricted or banned, families sometimes resort to extreme measures, such as traveling to neighboring states or even countries where such care is accessible. For example, families in Texas might travel to New Mexico to receive the necessary treatments that are prohibited in their home state. This places a financial and emotional burden on the families and highlights the disparities in healthcare access based on geographical location.

For mental health professionals and psychologists, these conflicts between ethics and law underscore the importance of being actively involved in policymaking. Advocating for laws that reflect current scientific understanding and best practices in healthcare is crucial. Many policymakers may lack awareness of the latest research or the scientific consensus on issues related to gender identity, which can lead to legislation that is not only scientifically unsound but also harmful.

Professionals can leverage their expertise to educate policymakers, participate in legislative processes, and challenge unjust laws in court. The case of the psychologist who took such a law to court is a prime example of how professionals can actively defend ethical practices and support the rights of transgender individuals.

Conversion Therapy

Conversion therapy, often referred to as reparative therapy, attempts to change an individual's sexual orientation or gender identity. It is important to acknowledge that this practice is ineffective and unethical. Research and clinical consensus have demonstrated that gender incongruence cannot be "treated" or altered through such therapeutic approaches; they simply do not work.

Gender-affirming treatments are the only interventions that have been shown to alleviate the distress associated with gender dysphoria. These treatments support the individual’s gender identity rather than attempting to change it, which is crucial for improving mental health outcomes.

Moreover, it's worth noting that conversion therapy is illegal in several states, reflecting its disapproval within the professional community and its recognition as a harmful practice. Engaging in or endorsing conversion therapy goes against the ethical guidelines of most professional bodies in the mental health field. As such, it is vital for professionals to avoid any involvement in practices that attempt to change a person's sexual orientation or gender identity.

Confidentiality

Finally, confidentiality is a critical ethical consideration when working with transgender youth. It is imperative not to disclose a child's gender identity to their parents or family without the child's explicit permission. Often, a child may reveal their gender identity to a healthcare provider while still not being ready to come out to their family.

To manage expectations and protect confidentiality, it is advisable to include specific provisions in the consent forms that are discussed and agreed upon with the parents at the onset of treatment. These provisions should clearly state that while issues of significant risk will prompt a breach of confidentiality — for example, if the child is in danger — the details of the child's gender identity will remain confidential if sharing those details poses no immediate risk.

Furthermore, it is important to discuss with the child the potential mental health impacts of coming out to their family. This conversation can help prepare the child for various outcomes and ensure they are making informed decisions about their disclosure.

Additionally, be cautious about documentation. In large healthcare systems, where multiple providers may access a patient's records or where parents can view their child's medical information, it is crucial to document sensitively. If certain information, such as the child's discussed gender identity, needs to be kept confidential, ensure it is documented in a way that respects the child's privacy.

Overall, establishing clear guidelines about confidentiality from the start with both the child and their parents can prevent misunderstandings and protect the child's privacy while under your care.

Resources

• APA Guidelines for Treatment of Transgender & Gender Diverse Practice 
• WPATH Standards of Care, Version 8
• UCSF Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People

References

ACLU. (2024). The ACLU is Tracking 484 Anti-LGBTQ Bills in the U.S. Retrieved from https://www.aclu.org/legislative-attacks-on-lgbtq-rights-2024

Andrzejewski, J., Pampati, S., Steiner, R. J., Boyce, L., & Johns, M. M. (2021). Perspectives of transgender youth on parental support: Qualitative findings from the resilience and transgender youth study. Health Education & Behavior, 48(1),74-81.

Call, D. C., Challa, M., & Telingator, C. J. (2021). Providing affirmative care to transgender and gender diverse youth: disparities, interventions, and outcomes. Current Psychiatry Reports, 23, 1-10.

Cavve, B. S., Bickendorf, X., Ball, J., Saunders, L. A., Thomas, C. S., Strauss, P., & Moore, J. K. (2022). Reidentification with birth-registered sex in a Western Australian pediatric gender clinic cohort. JAMA pediatrics, 178(5), 446-453.

Coleman, E., et al. (2022). Standards of care for the health of transgender and gender diverse people, Version 8. International journal of transgender health, 23(Suppl 1), S1–S259. 

Dhanani, L. Y., & Totton, R. R. (2023). Have you heard the news? The effects of exposure to news about recent transgender legislation on transgender youth and young adults. Sexuality Research and Social Policy, 20(4), 1345-1359.

Hays, P. A. (2008). Entering another's world: Understanding clients' identities and contexts. In P. A. Hays, Addressing cultural complexities in practice: Assessment, diagnosis, and therapy (2nd ed., pp. 65–83). American Psychological Association.

Johns, M. M., Zamantakis, A., Andrzejewski, J., Boyce, L., Rasberry, C. N., & Jayne, P. E. (2021). Minority stress, coping, andtransgender youth in schools—Results from the Resilience and Transgender Youth Study. Journal of School Health,91(11), 883-893.

Malpas, J., Pellicane, M. J., & Glaeser, E. (2022). Family-based interventions with transgender and gender expansive youth:Systematic review and best practice recommendations. Transgender Health, 7(1), 7-29.

Reed, E. (2024). Anti-Trans Legislative Risk Assessment Map – February Update. Retrieved from https://www.erininthemorning.com/p/anti-trans-legislative-risk-assessment-96f

Testa, R. J., Habarth, J., Peta, J., Balsam, K., & Bockting, W. (2015). Development of the gender minority stress and resilience measure. Psychology of Sexual Orientation and Gender Diversity, 2(1), 65.

Trans Legislation. (2024). What is Happening With Anti-Trans Bills in 2024? Retrieved from https://translegislation.com/

Additional Current References

Please Note: The following resources have been included for members to view additional resources associated with this topic area. These resources were not used by the presenter when creating this course. 

Georges, E., Brown, E. C. B., & Cohen, R. S. (2024). Prohibition of gender-affirming care as a form of child maltreatment: Reframing the discussion. Pediatrics, 153(1), 1–5.         https://doi.org/10.1542/peds.2023-064292

Handler, T., Merchant, M., Guzik, C., Chen, S., Kralik, N., Ojo, A., & Zaritsky, E. (2024). Diagnosis and time to treatment for pediatric patients with gender dysphoria. Journal of LGBT Youth, 21(1), 20–28. https://doi.org/10.1080/19361653.2022.2139788

Pomarico-Denino, V. (2024). Gender-affirming care for the adolescent patient. Nurse Practitioner, 49(3), 11–18.  https://doi.org/10.1097/01.NPR.0000000000000147

Rangi, S. K., Rehmer, J., & Ferrando, C. A. (2024). Prevalence of Polycystic Ovarian Syndrome in young and adolescent transmasculine patients presenting for gender-affirming care. Journal of Pediatric & Adolescent Gynecology, 37(1), 51–55. https://doi.org/10.1016/j.jpag.2023.09.003

Restar, A. J., Layland, E. K., Davis, B., Thompson, H., & Streed, C. (2024). The public health crisis state of transgender health care and policy. American Journal of Public Health, 114(2), 161–163. https://doi.org/10.2105/AJPH.2023.307523

Editor's Note: This text-based course is an edited transcript of the webinar, Providing Behavioral Health Treatment to LGBTQ+ Populations: Introductory Ethical and Clinical Considerations, presented by Andrew Arriaga, PsyD.

Learning Outcomes

After this course, participants will be able to:

• Identify key terms, concepts, and empirical findings relevant to the understanding of LGBTQ+ people and their experiences.
• Identify common issues often reported by LGBTQ+ people in psychotherapy.
• Identify therapeutic challenges that may arise in psychotherapy with LGBTQ+ people.

Risks and Limitations

Today, I’d like to begin by discussing some of the risks and limitations we face. First, it’s essential to explore individual and cultural considerations before pursuing any treatment plans or interventions. Much of this is likely covered in your training—whether through graduate programs or hands-on clinical work—but these factors should always be carefully examined, often with supervision, to address potential concerns ahead of time.

The availability of gender-affirming therapeutic or medical support can vary widely depending on agency policies, local laws, and federal guidelines. As many of you are probably aware, gender-affirming care laws differ significantly across the United States. Some of what we discuss today may not directly apply to your specific region. However, that doesn’t lessen the importance of these concepts. Laws and federal guidelines are constantly evolving, so it’s critical to stay informed. Continuing education and supervision are highly recommended when working with LGBTQ+ populations. For some, this is a core focus in their work—particularly in behavioral health—but others may not have had as much exposure to these communities in their training or practice.

In light of this, it’s always beneficial to seek out further courses, like this one, and connect with supervisors who can offer broader perspectives and open up space for discussion. This approach is invaluable when serving populations with whom you may have limited familiarity. Since this is an introductory course, we won’t be able to dive deeply into all the health disparities and interventions across the lifespan for LGBTQ+ individuals. I’m sure many of you anticipated this, given the nature of the course, but it’s worth reiterating. Hopefully, in the future, I’ll have the opportunity to return, and we can take a deeper dive into these disparities and the interventions designed to address them. As you move forward from this course, keep in mind the importance of continued education and supervision. These will ensure you develop a thorough understanding of the health disparities LGBTQ+ individuals face and the appropriate interventions for supporting them in clinical settings.

Ethics Codes

As you know, behavioral health providers come from diverse training backgrounds, so many of us have encountered some or all of these codes in one way or another throughout our education. I strongly encourage you to always refer back to your specific ethical code when faced with ethical questions or decisions. While we all generally receive training grounded in similar ethical principles, there may be nuanced differences depending on the field in which you work. 

Below are links to Ethics Codes for some of the major behavioral health professions. Please ensure you always refer to your own ethical code.

• AAMFT: https://www.aamft.org/Legal_Ethics/Code_of_Ethics.aspx 
• ACA: https://www.counseling.org/resources/aca-code-of-ethics.pdf
• APA: https://www.apa.org/ethics/code 
• NBCC: https://nbcc.org/assets/ethics/nbcccodeofethics.pdf
• NAADAC: https://www.naadac.org/code-of-ethics
• NASW: https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English

Ethical Considerations

I’d like to begin by focusing on some general ethical considerations when working with LGBTQ+ individuals. As I’ve mentioned, ethical codes across behavioral health professions share commonalities, and many of us are familiar with at least a few of them. These codes typically require that, as professionals, we remain competent in serving a diverse range of clients, regardless of specific backgrounds. This applies not only to LGBTQ+ individuals but to all clients we encounter. It’s a vital point to keep in mind.

It’s natural to feel overwhelmed when faced with clinical situations that are unfamiliar or outside our comfort zones. However, a key ethical consideration is recognizing that our role as behavioral health professionals is to hold space for clients from all walks of life. We have the foundational skills to do this. So, if you're considering working more with LGBTQ+ populations but feel uncertain about your level of competence or confidence, I encourage you to remember that these ethical principles are already a part of your professional training.

That said, we also acknowledge that working with LGBTQ+ clients can be challenging for clinicians who may hold biases or discomfort with certain identities. This issue isn’t limited to LGBTQ+ clients; it can also apply to individuals from different religious, racial, or ethnic backgrounds. However, I always remind colleagues that the core of this work is about adhering to the same ethical standards you would apply to any client. So, whenever you find yourself making clinical decisions, always refer back to the ethical codes of your profession.

Important Ethical Concepts

I’d like to focus on a few ethical concepts that I find particularly important when working with LGBTQ+ clients. Many of these terms, if not all, will likely be familiar to you, but let’s explore them in this context.

First, autonomy. It’s crucial to remember that, just like with any client, LGBTQ+ individuals know themselves best. Gatekeeping care can be a significant concern, especially when clients feel misunderstood or sense that a clinician is steering them in a direction misaligned with their experiences. At the end of the day, we must trust that our clients understand their own needs.

Next, beneficence and nonmaleficence—core values we’re all familiar with in behavioral health. These principles remind us to do right by our clients, to help them navigate challenges in ways that are both productive and safe. Above all, we must ensure we’re not causing harm. When facing ethical dilemmas, it can help to simplify the situation: Am I doing everything within my ability to serve this person? Is there any risk that my actions could harm them? Avoiding decisions that could cause harm is especially critical when working with LGBTQ+ individuals, as there are often additional nuances to consider, which we’ll dive into later.

Fidelity and veracity—respecting others' rights and dignity—may seem straightforward, but they are fundamental to our work. This includes ensuring confidentiality and creating a safe space for LGBTQ+ clients, whether they are currently identifying as such or not. It’s essential that they feel comfortable exploring their experiences and unique challenges in an environment that honors their dignity and listens without judgment.

Lastly, justice. A significant aspect of working with LGBTQ+ individuals often revolves around social justice. Some of us are engaged in anti-racist training, social equity efforts, or advocacy work within our communities, and these elements can also shape our clinical practice. For LGBTQ+ communities, social justice concerns frequently arise, given the ongoing legal and social barriers that impact access to care and equality. Recognizing and supporting clients on their journey toward justice, both in and outside of the therapy room, is invaluable. Our role as clinicians, from an ethical standpoint, is to align with and support those efforts, recognizing the broader social and legal issues that continue to affect these populations.

Key Terms

Let’s dive into some key terms and concepts. Some may be familiar, and a few might feel quite straightforward, but it’s useful for all of us to refresh our understanding, especially as some of these terms carry nuances that differ from how they’re often used in everyday language.

• gender identity: This refers to how a person perceives themselves—as a man, a woman, both, neither, or somewhere along the spectrum. Essentially, it’s about how individuals define themselves and what they choose to call themselves. You may hear terms like cisgender man, transgender woman, non-binary, or agender, all of which relate to gender identity.
• gender expression: This differs from gender identity. Here’s where we start to get into the nuances of language, as these terms are often used interchangeably in everyday conversation. However, from a clinical and research standpoint, it’s important to distinguish between them. Gender expression refers to how people outwardly communicate their gender identity through behavior, clothing, hairstyles, voice, and overall presentation. For example, you might hear someone described as presenting masculinely, femininely, or with an androgynous expression. These terms reflect aspects of gender expression, rather than gender identity itself.
• anatomical sex: This refers to physical attributes such as external genitalia, sex chromosomes, gonads, hormones, and internal reproductive structures. These are typically the biological markers used to assign sex at birth, which leads us to the next term.
• sex assigned at birth: This is determined by a medical professional based on the visible physical characteristics of a newborn. Typically, this assessment is made by visual examination of external genitalia, such as assigning male if a baby is born with a penis. However, like gender, sex is a complex concept, and this visual method of assigning sex can sometimes oversimplify the biological variations that exist.
• sexual/romantic attraction: Generally, this refers to a person’s emotional or sexual attraction to people of the same or different genders. You may also encounter the term sexual orientation, which is often used interchangeably in this context. While these terms overlap in casual conversation and even in some clinical spaces, it’s helpful to clarify that we’re talking about attraction in both romantic and sexual senses here.

The Genderbread Person

I want to take a moment to introduce the "Genderbread Person." There have been many versions of this circulating for over a decade, but it's a useful tool in clinical work to highlight the differences between these terms and delve into the nuances. It helps explain to clients—whether they are LGBTQ+ or simply exploring their identities—how gender identity, gender expression, and sex assigned at birth can intersect and diverge in unique ways.

Figure 1. The Genderbread Person. Image Source: genderbread.org – CC Universal Public Domain Dedication

When I work with clients using the Genderbread Person, it can also be helpful for parents or family members in therapy, especially those with LGBTQ+ loved ones or those trying to become more supportive. I usually begin with gender identity, as we discussed earlier. This refers to a person’s internal sense of self—how they see themselves and what they prefer to be called. Terms like man, woman, and non-binary are often associated with gender identity.

Next, I move to gender expression. The key point here is that gender expression is how we outwardly communicate our internal identity to the world. Clothing plays a big role in this, but so do other personal choices in style and behavior. For instance, some might assume that identifying as a woman means you should wear dresses and makeup, but that’s simply not the case. If you prefer sweatpants and don’t like makeup, that’s perfectly valid. The takeaway here is that gender identity and expression don’t necessarily predict one another. A feminine man or a masculine woman, whether LGBTQ+ or not, is entirely possible. These are separate constructs, and understanding this is crucial for psychoeducation.

When we talk about anatomical sex, we’re shifting into the more medicalized terminology—terms like male, female, and intersex, which refer to physical characteristics. This leads into sex assigned at birth, where a newborn’s sex—often labeled as male or female— is assigned by a medical professional based on external genitalia. However, as we’ll discuss, this can be more complex, especially in cases of intersex individuals.

Now, an important distinction to make is between gender identity and sexual orientation. Sexual or romantic attraction to others has no bearing on one’s gender identity. For instance, if a cisgender man—someone assigned male at birth who identifies as a man—is attracted to both men and women, that has no direct connection to his gender identity. Attraction, whether sexual or romantic, exists as a separate construct.

This distinction is especially important because, in public discourse and media, there’s often confusion between gender identity and sexual orientation. Trans and gender-diverse individuals are frequently lumped together with queer people, which can blur the lines between these concepts. The Genderbread Person graphic highlights this beautifully, illustrating that identity, expression, sex, and orientation are distinct elements.

Understanding these concepts allows clients to gain clarity about their own experiences: Is this about my gender? How I present myself? Or is it about who I’m attracted to? Each is its own construct, and recognizing this helps break down confusion and fosters deeper self-awareness.

Additional Key Terms

Let’s go over some additional key terms. I’ve included these because, especially in work with younger people or those who are more comfortable discussing LGBTQ+ issues, you may encounter terms that are unfamiliar or used in shorthand. Some of these may seem elementary, and you’ve likely heard them many times before.

• heterosexual: Most of us are familiar with this term or the shorthand “straight” or “hetero.” It refers to someone who experiences sexual, romantic, or emotional attraction to people of a different gender. Historically, it’s been defined as attraction to the "opposite" gender, but since gender is now understood as a spectrum, we try to move away from that language and be more mindful of gender diversity.
• bisexual: This term, with shorthand “bi,” refers to a person who experiences sexual, romantic, or emotional attraction to their own gender as well as to others. Some may assume this means attraction to men and women only, but bisexuality can also include attraction to non-binary or agender individuals. So, defining bisexuality strictly as attraction to men and women is exclusionary. Instead, we acknowledge that it means attraction to the same gender and others.
• pansexual: Shorthand “pan,” refers to sexual, romantic, or emotional attraction to individuals regardless of their gender identity or sex assigned at birth. This broader concept of attraction extends beyond specific gender categories and can include an openness to many, or all, gender identities.
• aromantic and asexual: Often shortened to “aro” and “ace,” these terms are frequently heard together, especially when working with younger clients. Someone who identifies as aro-ace experiences little to no romantic or sexual attraction. However, it’s important to note that individuals on these spectrums may still experience some attraction but don’t feel the need to act on it in the way others might.
• intersex: This refers to individuals born with chromosomal or physiological variances, including ambiguous genitalia. Sex assigned at birth is often based solely on external genitalia, but as we know from biology, sex involves more than just what is visible at birth. Hormones, chromosomes, and reproductive structures all play a role in defining sex, and these factors may not always align with the assigned label. Intersex people exist, and their experiences are distinct from those of individuals assigned male or female at birth. There’s a broader ethical conversation about the practice of assigning sex at birth based on genitalia alone, but that’s a topic for another day.
• transgender: Shortened to “trans,” is a term you’ve likely heard in many contexts—whether in the news, schools, or clinical practice. It’s often used as an umbrella term to describe individuals whose gender identity does not align with their sex assigned at birth. For example, a transgender man is someone who was assigned female at birth but identifies and lives as a man. A transgender woman is someone assigned male at birth who identifies as a woman. It’s important to recognize that within the trans community, individuals may use more specific terms for themselves, such as trans man, trans woman, or trans girl. Some may even prefer not to use the term "trans" at all and simply identify as a man or a woman. Checking in with clients about the language they prefer is crucial.
• gender binary: This is the social system that assigns everyone to be raised as a boy or girl based on their sex assigned at birth. This rigid perspective of gender assumes that male and female are the only two options. However, we know that non-binary or genderqueer individuals exist—people who don’t identify strictly as male or female. Gender fluidity, which refers to a flexible range of gender expression and identity, can be confusing for some who aren’t used to thinking of gender as fluid.

It’s common to hear even more unfamiliar terms when working with younger individuals. It’s important to remember that, ultimately, the client’s view of their own identity and the language they prefer is what matters most—regardless of what you may have learned in a class or even here. While we’ve covered some typical terms for familiarity’s sake, it’s crucial to let our clients lead the way in how they identify and express themselves.

Some people may feel different on different days, choosing to express themselves in a variety of ways. For example, one day they may enjoy wearing dresses, and another day they may prefer a more masculine presentation with jeans and sneakers. This doesn’t necessarily reflect their gender identity but could simply be an expression of their fluid identity. With that said, the language around gender and sexual orientation is constantly evolving. It’s always important to follow the lead of your clients and ask directly if you’re unsure. Simple questions like “What would you like me to call you?” or “Do you have a preferred pronoun, name, or gender identity?” can make an LGBTQ+ client feel truly seen and heard.

Why is This Topic Important

Why is this topic important? I’m sure many of you could think of several reasons off the top of your head, but I’d like to highlight a few key ones that I’ve found particularly motivating in this field. These reasons underscore why we should be competent in this work—or at least work toward that goal.

As clinicians, we have an ethical duty to be prepared to serve individuals from all backgrounds. This means being aware of terms and concepts that are central to LGBTQ+ experiences, so we can create a welcoming and inclusive space for these clients. Familiarizing ourselves with these terms ensures that we are ethically prepared to support them.

Additionally, awareness of LGBTQ+ identities and the social issues within these communities continues to grow. You’ve probably noticed this yourself—there’s increasing visibility around queer and trans people. By “queer,” I’m referring to those who identify as sexual minorities, such as gay, lesbian, bisexual individuals, and more. As society becomes more knowledgeable, we often see an increase in the presentation of these identities in clinical spaces, as people feel more comfortable bringing these aspects of themselves into therapy.

LGBTQ+ individuals also face a unique set of interpersonal and intrapersonal stressors, which need to be carefully considered in clinical work. I’ll walk through some of these stressors and the theoretical background that explains why they exist. Because of these increased stressors, LGBTQ+ people continue to experience disproportionately higher rates of health and wellness disparities—far exceeding those of majority populations.

LGBTQ+ Identity Statistics

Let’s go over a few statistics about identity and where things stand today based on the most recent data. Analyses conducted by the Williams Institute, using 2020-2021 data from the Behavioral Risk Factor Surveillance System—a major study conducted most years—revealed some notable findings about identity. Even I was a bit surprised by some of these, but it's heartening to see these shifts.

For example, 36% of respondents in the Southern U.S. identified as LGBTQ+, making it the largest regional population compared to the Northeast, Midwest, and Western states. This was unexpected for me, as someone from the South and Texas, but it’s encouraging to see more openness in this region, especially considering the political and cultural challenges that LGBTQ+ people often face in the Southern United States.

Additionally, almost one in six adults aged 18 to 24 identify as members of the LGBTQ+ community. I was pleasantly surprised by this as well. Of course, there are often heated discussions around this statistic—questions like, "Why are more young people identifying this way? Is there a rise in people becoming queer or trans?" In my opinion, much of this can be attributed to increased social acceptance and visibility for Gen Z and Gen Alpha, leading to greater comfort in openly identifying as LGBTQ+.

As for state-level data, California has the largest number of LGBTQ+ adults, with about 1.5 million. It’s also worth noting that, currently, the U.S. Census does not include questions about sexual orientation or gender identity, despite various proposals over the years. As a result, we rely heavily on studies conducted by universities and research institutes to provide this data.

Minority Stress Theory

Let’s start with a bit of theory. Ilan Meyer’s Minority Stress Theory is a framework you’ll often encounter in research and work with LGBTQ+ people. It posits that these populations face unique intra- and interpersonal stressors, which contribute to poorer health and wellness outcomes, beyond what is typically experienced by majority populations. When I talk about intrapersonal and interpersonal stressors, I’m referring to the stress that arises from interactions with others or from being in negative environments.

Interpersonal stressors include experiences like discrimination, microaggressions at work, or being denied services. This can be explicit or policy-driven and doesn’t always involve direct one-on-one discrimination. Intrapersonal stress, on the other hand, may be less familiar, especially to those who haven’t struggled with issues like shame or identity. LGBTQ+ individuals often face stress from internal conflicts, fear, or confusion when acknowledging their identities.

One common form of intrapersonal stress is internalized phobia, where an LGBTQ+ person begins to internalize negative messages from transphobic or homophobic encounters and directs that negativity toward themselves. This internalized negativity can be profoundly impactful and is unique to these populations. Meyer’s theory has been foundational in LGBTQ+ health and wellness research and is the basis for thousands of studies. The theory has also expanded to include other aspects of identity that compound stress, such as race, ethnicity, or socioeconomic background. Staying informed on the latest research and theoretical perspectives is crucial for engaging in this work, even if you’re not reading research articles all the time. Checking in occasionally can be helpful.

LGBTQ+ Barriers to Care

LGBTQ+ individuals often face significant barriers to care, sometimes even before measurable health impacts arise. Many postpone or avoid medical or behavioral healthcare altogether—even when dealing with serious issues like infections, suicidal ideation, or distressing mental health problems.

There are several reasons why LGBTQ+ individuals may avoid care. A major one is the fear of having their gender-diverse or sexual minority identity pathologized. The outdated view that being transgender or homosexual is something “wrong” still lingers in some spaces. Until recently, homosexuality was classified as a disorder in the DSM, and gender dysphoria remains in the current edition, largely for insurance purposes. Despite this, many still fear going into a hospital or therapy setting and being treated as though something is inherently wrong with them.

There are also more direct concerns, such as discrimination by healthcare providers. This discrimination doesn’t always manifest overtly; it can come in the form of microaggressions or comments rooted in heteronormative or cisnormative beliefs. Finally, past negative experiences with healthcare providers can deter people from seeking care. If a doctor made them uncomfortable when they disclosed their sexual orientation, it can discourage them from returning to that space—or to any medical provider. It’s common for clients to ask for lists of LGBTQ+-affirming providers, emphasizing their need to feel understood and cared for in the same way as cisgender and heterosexual individuals.

LGBTQ+ Health Disparities

Minority Stress Theory has sparked extensive research into why LGBTQ+ individuals face significant health disparities. Several large studies have shed light on these disparities. For example, the All of Us research project found that LGBTQ+ adults are more likely to experience tobacco use disorder than their heterosexual and cisgender counterparts. This pattern extends to other substances as well, with research showing elevated rates of alcohol and substance use among queer and trans people. The link between stress and tobacco use, in particular, highlights how these disparities may reflect the increased stress faced by these populations.

On a more positive note, a study by The Trevor Project found that higher levels of social support are associated with fewer suicide attempts among LGBTQ+ youth. This finding reminds us that social support—whether from family, friends, or school—can be protective against suicidality.

However, challenges remain. One in four transgender adults reported experiencing an issue with their insurance related to being transgender in the past year. As my previous work in the Gender Health Department with Kaiser Permanente illustrated, insurance coverage for gender-affirming care remains a significant barrier. While there’s a perception that greater visibility for trans issues means more equality, this is not always the case.

A Myriad of Presenting Issues

In therapy, queer and trans individuals often present with many of the same issues as other clients: depression, anxiety, social isolation, and marginalization. While these issues can affect anyone, the factors behind them—such as rejection by family or the broader community—can look different for LGBTQ+ individuals.

Family conflict, for example, is common across the board but may stem from lack of acceptance of a client’s identity. For clinicians experienced in addressing family conflict, those skills are just as valuable when working with LGBTQ+ clients. Similarly, issues like substance abuse and addiction are prominent among certain LGBTQ+ subcommunities, and licensed addiction specialists can bring their expertise to this work.

More severe concerns, such as complex trauma or physical and sexual violence, are also common. Transgender individuals, especially trans women of color, are often targets of violence due to prejudice and political discourse around their identities. While trauma can affect anyone, the targeted nature of violence against transgender people is a stark reality.

Finally, LGBTQ+ individuals may present with psychosis, though there’s no unique connection between this condition and their identity. Like all clients, they may face psychosis for a variety of reasons.

Other Unique Issues

There are some unique issues to consider when working with LGBTQ+ individuals. One common issue I’ve encountered is the questioning of identity. Someone may come to therapy without identifying under the LGBTQ+ umbrella, but they’re trying to figure out, “What does this mean for me? Am I gay? Am I transgender? Am I non-binary or sexually fluid?” You’ll hear all sorts of terms in these situations, and it can be a very confusing journey for the client. This is where psychoeducation around language, gender, sexual orientation, and birth sex can be incredibly valuable in helping clients clarify these questions.

Coming out, or informing others about one’s sexual orientation or gender identity, is a unique issue within the LGBTQ+ community. While not entirely exclusive to this group—people may “come out” regarding political ideologies or religious beliefs—coming out as LGBTQ+ often brings its own set of challenges. Even someone who feels secure in their identity might face difficulties when entering new spaces, especially if they haven’t had to come out in a while. The process of coming out is ongoing, as long as we are meeting new people, and the environment can impact whether it feels safe to do so.

Gender dysphoria is another major issue for individuals exploring their gender identity. This disconnect between one’s gender identity and their sex assigned at birth, or societal expectations based on appearance, can manifest as discomfort with secondary sex characteristics, pronouns, or even the name being used for them. Gender dysphoria is complex, and working through it often requires additional training and supervision to ensure you’re guiding clients in a helpful, non-harmful way.

Internalized homophobia and transphobia, as mentioned earlier, can also be deeply challenging in therapy. Some clients may not even recognize that they are acting out this internalized negativity toward their own identity.

Pointed discrimination—whether in medical, educational, or workplace settings—can be another major issue. LGBTQ+ individuals may face systemic or interpersonal discrimination that others do not. Acknowledging these struggles helps clients feel seen and validated in their day-to-day challenges.

A particularly unique issue is the why behind identity. When there’s shame associated with a minority identity, people often ask themselves, “Why me? Why do I feel different from my heterosexual siblings? How did I end up like this?” While research continues to explore the predictors of LGBTQ+ identity, there’s still much uncertainty. Holding space for this uncertainty, especially when clients are grappling with shame, can be an important part of the therapeutic process. Acceptance can play a key role in this work.

Even for Clinicians, Issues Arise!

Even for us as clinicians, issues can arise in therapy. One common issue discussed in supervisory meetings is identity disclosure by the therapist. There are strong arguments on both sides of this, and it can depend on your therapeutic orientation, setting, and personal beliefs about how a therapist should show up in the room. There is no definitive answer, which is why it’s helpful to acknowledge that this is a complex issue for many clinicians.

This includes whether to disclose your sexual orientation, gender identity, or even the pronouns you use. These days, with the push toward transparency, many clinicians include their pronouns in email signatures. This is often done to signal to prospective LGBTQ+ clients that their identities will be respected. However, some therapists believe that providing personal information could overshadow the client’s concerns or pressure them to be open about their own identity. If you’ve struggled with this, you’re not alone—it’s a topic of ongoing discourse in the field.

So What If I Make a Mistake?

What happens if you make a mistake? If you use the wrong pronouns, the wrong name, or an outdated term for someone’s sexual orientation?

The first thing to do is apologize. Acknowledge the mistake: “I’m so sorry, I didn’t use your correct pronouns.” Then, correct yourself and move on. It’s important to avoid over-apologizing, as this can shift the burden onto the client to comfort you. Even though the mistake was well-intentioned, repeated apologies can make the client feel like they need to take care of the therapist, when they’re the ones who were slighted.

It’s also important to keep updated on preferred terms, pronouns, and names, especially if you have a large caseload. Clients may experiment with different names or pronouns throughout the course of therapy, and that’s okay. Be patient with yourself—it does get easier with time. While some may feel frustrated by this fluidity, simplifying identity exploration in that way does a disservice to the complexity of the process.

If you work in a setting where medical charts or patient files are accessible to others—such as when working with adolescents—it’s important to be mindful of how you use pronouns and names. For example, if a client isn’t ready for their family to know about their identity, you may choose not to chart using the pronouns or name they use in session. The implications of when and where to use these terms are complex, but with practice and guidance, it becomes more manageable.

Case Study

All right, as we near the end, I’d like to present a case study for consideration. You’re halfway through your third session with Amos, a 16-year-old Mexican American who uses he/him pronouns, when he reveals that he’s been scratching himself deeply over the past week. When you ask why, he hesitantly admits that he’s trying to suppress “unnatural urges.” Eventually, he confides that he believes he’s developing a crush on a close male friend, but the thought terrifies him because he’s worried he might be gay. At this point, you also recall that during the intake, Amos’s mother expressed her desire to be informed if there were any safety concerns. So, my question is: How would you proceed with Amos, given what you now know about his self-harm, its potential link to his sexuality, and his mother’s request? I’m curious to hear your thoughts on possible first steps and how you might approach this.

I can imagine that you might have conflicting thoughts about how to handle this situation. Some of you might think, “I would consult my supervisor to talk this through before proceeding.” That’s completely understandable, as it’s not always easy to give an immediate response in cases like this.

I’ll give you a moment to think about it and share your approach if you have something in mind. Broadly speaking, I think the key here is to prioritize ethical and clinical considerations, focusing on protecting our clients from harm while providing the best possible care.

I don’t intend to provide a clear-cut answer because there isn’t one. How you approach this could vary depending on the nuances of the situation. For example, you might consider whether there’s a way to address the mother’s concerns without outing Amos or jeopardizing his trust. When working with teens, we often enter gray areas regarding confidentiality. Although Amos is 16, and his parents could access his charts in most states, navigating this ethically while maintaining the therapeutic relationship is critical.

This is a common ethical dilemma, particularly when working with younger clients. It requires careful thought—sometimes what seems like the obvious answer, such as disclosing everything to the parent, may not be the best approach. There are many ways this could play out, and each has its own set of considerations.

Limitations

Now, let’s consider some limitations when working with LGBTQ+ clients. It’s important to remember that queer and trans identities are not monolithic. No two LGBTQ+ individuals are the same, just as no two straight or cisgender individuals are the same. So, even if you’ve worked with a trans client before, it doesn’t mean the next trans client will share the same experiences. There may be overlap, but each person’s story is unique, and we must approach them as such. As cultural climates shift, so do language norms. It’s essential to stay current with the language your clients use to describe themselves and their identities. Additionally, it’s crucial to consider intersecting identities before making assumptions. For example, a queer person of color may have different experiences than a white queer person. These intersections play a vital role in shaping the client’s experiences and how they present in therapy.

Finally, it’s worth noting that there are still no major federal efforts to gather comprehensive national data on LGBTQ+ experiences. This is a significant limitation in understanding the full scope of these communities. As data collection evolves, hopefully, we will have more accurate and refined insights into LGBTQ+ populations in the future.

Summary

In summary, we are ethically bound to be competent in serving clients from all backgrounds, including LGBTQ+ individuals. These populations face unique social stressors that contribute to the health and wellness issues often highlighted in research. While LGBTQ+ clients may present with similar issues as cisgender and heterosexual clients, we must remain aware of the unique challenges they face. Lastly, when ruptures occur with LGBTQ+ clients, it’s most effective to apologize, correct the mistake, and move forward.

References

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct. https://www.apa.org/ethics/code

American Counseling Association. (2014). Code of ethics. https://www.counseling.org/resources/aca-code-of-ethics.pdf

Clay, R. A. (2015, April). Competence vs. conscience: ‘Conscience clause’ initiatives expand beyond psychology training into the practice arena. Monitor on Psychology. https://www.apa.org/monitor/2015/04/competence

Drescher, J., & Fadus, M. (2020). Issues arising in psychotherapy with lesbian, gay, bisexual, and transgender patients. FOCUS, 18(3), 262–267. https://doi.org/10.1176/appi.focus.20200001

Flores, A. R., & Conron, K. J. (2023). Adult LGBT population in the United States. https://williamsinstitute.law.ucla.edu/wp-content/uploads/LGBT-Adult-US-Pop-Dec-2023.pdf

Hailes, H. P., Ceccolini, C. J., Gutowski, E., & Liang, B. (2020). Ethical guidelines for social justice in psychology. Professional Psychology: Research and Practice, 2(1), 1-11. https://doi.org/10.1037/pro0000291

James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The report of the 2015 U.S. transgender survey. National Center for Transgender Equality. https://doi.org/10.1038/064604a0

Leitch, J., & McGeough, B. L. (2023). A proposed stage model of LGBTQ people’s selection of and engagement with therapists. Families in Society, 104(3), 372–383. https://doi.org/10.1177/10443894221150667

McLemore, K. A. (2018). A minority stress perspective on transgender individuals’ experiences with misgendering. Stigma and Health, 3(1), 53–64. https://doi.org/10.1037/sah0000070

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://doi.org/10.1037/0033-2909.129.5.674

Meyer, I. H. (2010). Identity, stress, and resilience in lesbians, gay men, and bisexuals of color. The Counseling Psychologist, 38(3), 442–454. https://doi.org/10.1177/0011000009351601

Tran, N. K., Lunn, M. R., Schulkey, C. E., Tesfaye, S., Nambiar, S., Chatterjee, S., Kozlowski, D., Lozano, P., Randal, F. T., Mo, Y., Qi, S., Hundertmark, E., Eastburn, C., Pho, A. T., Dastur, Z., Lubensky, M. E., Flentje, A., & Obedin-Maliver, J. (2023). Prevalence of 12 common health conditions in sexual and gender minority participants in the All of Us research program. JAMA Network Open, 6(7), e2324969. https://doi.org/10.1001/jamanetworkopen.2023.24969

The Trevor Project. (2022). 2022 National Survey on LGBTQ Youth Mental Health. https://www.thetrevorproject.org/survey-2022/

Additional Current References

Please Note: The following resources have been included for members to view additional resources associated with this topic area. These resources were not used by the presenter when creating this course. 

Chu, T. L. (A.), Treacy, A., Moore, E. W. G., Petrie, T. A., Albert, E., & Zhang, T. (2024). Intersectionality matters: Gender, race/ethnicity, and sport level differentiate perceived coach-created motivational climates and psychological needs. Sport, Exercise, and Performance Psychology, 13(1), 59–75. https://doi.org/10.1037/spy0000331

Dorrell, K. D., Benjamin, I., Dyar, C., Davila, J., & Feinstein, B. A. (2024). Minority stress and relationship satisfaction among bi+ individuals: The roles of partner gender and sexual orientation. Psychology of Sexual Orientation and Gender Diversity. Advance online publication. https://doi.org/10.1037/sgd0000711

Jeon, M. E., Udupa, N. S., Potter, M. R., Robison, M., Robertson, L., Rogers, M. L., & Joiner, T. E. (2024). Measurement invariance of the Depressive Symptom Inventory–Suicidality Scale across race, ethnicity, sexual orientation, and plurality of minoritized identities. Psychological Assessment. Advance online publication. https://doi.org/10.1037/pas0001306

Kim, H. J., Romanelli, M., & Fredriksen-Goldsen, K. (2024). Multidimensional social connectedness of sexual and gender minority midlife and older adults: Findings from the National Health, Aging, and Sexuality/Gender Study (NHAS). American Journal of Orthopsychiatry. Advance online publication. https://doi.org/10.1037/ort0000726

Lloyd, A., Granot, Y., Rovegno, E., Bazin, A., Bryant, A., & Richards, M. (2024). How schools can bolster belonging among Black lesbian, gay, bisexual, and queer youth. Translational Issues in Psychological Science. Advance online publication. https://doi.org/10.1037/tps0000039