When clients first come to consult with me, I recommend that we first reach a shared understanding of the gender and/or sexual concerns. I suggest that we discuss how gender and sexual issues emerged throughout your life from childhood to the present, so we can understand the path that your life has taken thus far. Then, we can agree on the goals for our work together. Clients often have specific goals, such as deciding whether to consider gender transition, learning how to develop a healthy and balanced self-concept as a transgender person, or obtaining referrals for hormones and gender affirming surgery, such as "top surgery", metiodioplasty, or vaginoplasty.
I also want to understand the psychological issues that might also be causing problems in your life. Sometimes clients have problems with depression, anxiety, obsessive or compulsive thoughts and behaviors, suicidal thoughts, shame, guilt, couples or marital conflict, and concerns about coming out to family, friends or at work.. Internalized negative beliefs about non-traditional gender and sexual expression, (internalized transphobia) can cause intense life long psychological suffering. Gender diversity, no matter what we may call it (e.g., transgender, transsexual, cross-dressing, androgyny, etc) is not a perversion, a psychological disorder nor a pathology.
I believe that the reason transgender persons struggle with gender and sexuality is because of the heterosexist beliefs in our culture which stigmatize gender diversity. As children, we are raised in a heterosexual culture with rigid beliefs about what is acceptable and normal for men and women. We learn at a young age what are acceptable gender roles and behaviors for our sex, and we internalize feelings of guilt and shame when we know we want to be and act like the other gender. The suppression of gender and sexual expression can cause prolonged depression and anxiety that can be resolved through therapy.
My experience has been that transgender persons are more susceptible to depression and anxiety than the average person. Transgender persons often experience multiple stressors that can increase the vulnerability to depression and anxiety. Depression and anxiety can be effectively resolved through transgender sensitive therapy, but sometimes medications are needed. However, many transgender persons do not have a psychological problems of this sort, such as depression, and do not need psychotherapy. I do not believe that people with transgender issues necessarily need therapy.
People who are transitioning and who would benefit from sex hormones and gender affirming surgery do not necessarily want or need psychotherapy. However, I do believe that counseling is an effective method to resolve the gender and sexual issues discussed above and as a tool for self-understanding that can improve the quality of life. When a client wants sex hormones and/or gender affirming surgery, and we conclude that there are no serious problems functioning in life, I do follow the WPATH (formerly Harry Benjamin International Gender Dysphoria Association) Standards of Care in making referrals to physicians and surgeons.
Many non-transgender providers of psychological and medical care assume that the desire to be the opposite sex is a psychological disorder. Unfortunately, the DSM-IV equates gender dysphoria and gendered diversity with a psychological disorder. Nevertheless, the SOC are a specific set of medical guidelines that psychologists, psychotherapists, physicians, and surgeons are expected to follow in providing healthcare, such as administering sex hormones and making decisions about genital surgery, to transgender people.
Clients who are transitioning from one gender to another often are unsure about what if anything to tell their employer and co-workers. There can be fears of discrimination and job loss.