Questions 1. What steps might you take to help her? 2. How might Rachel’s needs differ from a non-transgender student who has been assaulted? 3. How much knowledge about the LGBTQ population is necessary before working with this client? Discussion The counselor should understand the distinction between sexual orientation and sexual identity. Sexual orientation and sexual identity, while related terms, have distinct meanings. Sexual orientation is determined by the gender to which an individual experiences sexual arousal and attraction. Sexual identity is a construct of personal analysis, generally based on sexual orientation, gender identity (sense of being male or female), and sometimes social factors. Lesbian, gay, and bisexual (LGB) people report greater dissatisfaction with counseling and psychotherapy services than their heterosexual counterparts (Bishop, Crisp, & Scholz, 2022). Greater dissatisfaction with counseling services may result from experiences of microaggressions resulting from a lack of service provider cultural competence. The counselor should also know about the discrimination, oppression, and violence plaguing transgender communities in this country. Having this foundation of knowledge would help them work with Rachel. Case Study 9: Kim Kim is a second-generation Vietnamese American woman in her early 20s who sought treatment for assistance with forming relationships. Kim was male-assigned and had transitioned several months before beginning treatment. Kim had undertaken hormone replacement therapy and was considering surgery at some point in the future. She had already taken care of many institutional matters: changing her Social Security card and driver’s license. Kim came out to her family. Her family was confused and distressed by her transition. While her father seemed angry and resentful, other family members seemed to be making a reasonable effort to reckon with the changes and the “loss” of their brother, son, and so on (from their point of view). Kim appreciated their try but felt sad and tense when she visited her family. She wished for more even though she did not expect it. She thought that some of her family’s difficulties stemmed from their adherence to their Christian religion. Kim was often lonely and wished to have friends and a partner. She was shy and seemed closed off. Kim felt isolated; she yearned for contact and help from other transgender individuals. Kim stated that she was not interested in attending a support group for transgender people because she imagined that most participants would be “freaks.” She acknowledged that some of her feelings were related to her difficulty feeling positive about herself as transgender. She spent several hours each day online, often playing video games and sometimes visiting online social sites. She had been very depressed before her transition; once she began, her symptoms lessened, only to return. She longed to have a family. She described a sense of at long last having things in order with her gender but of then having a sense of “now what?” with the rest of it. Her discomfort with her birth-assigned gender had felt like an impediment to forming friendships, finding a partner, and engaging with the world in an authentic and meaningful way. Now that the condition had been removed, Kim wondered how to realize these other desires and goals. Questions 1. The case references the sense on the part of Kim’s family that they have suffered a loss and that things have changed. 2. How might this formulation - Kim’s transition precipitated losses - be similar or different from Kim’s experience? 3. How can Kim’s experience of coming out help us understand her relational experiences with her family? How might this inform our understanding of Kim’s presenting concerns?
4. Kim describes a tension between her family’s religion and gender identity. What might be helpful to Kim in addressing this tension? 5. Are there other culturally salient matters? If so, how would you begin to talk with Kim about these matters? 6. Kim expressed some fear and revulsion at associating with other transgender people; how would you address this and work with Kim around this? 7. How might you conceptualize her original depression? How might this be impacted by issues related to gender identity? What does the reappearance of her depression during the transition indicate? Discussion This case suggests another important feature of working with transgender clients: Clients come to therapy for many things that have little to do with their gender. This client wants to focus on themes of intimacy and relationships. These issues cannot be fully understood without attention to Alice’s experiences with gender and being known or unknown by others. Still, these concerns are not the focus of the treatment. Transgender individuals are not immune to society’s messages about gender and often struggle with internalized transphobia, as evident in Kim’s avoidance of other transgender people in support groups. These feelings can emerge in clients’ feelings about their bodies as they transition and intensify the social isolation many transgender people feel. Although this client yearns for connection with people who understand her, she is ambivalent about being associated with other “freaks.” Working to understand her feelings while also helping her develop empathy and appreciation for herself and other transgender people became an essential aspect of the work. Some transgender individuals will present with a history of mental health issues. Many people experience a lessening or disappearance of symptoms when they internalize their gender identity and begin their transition, much like this client. Many people often find that their mental health issues return, as Kim’s depression did, once they experience some difficulties related to the physical and social transition. A therapist should be cautious about interpreting this to mean that the change is not healthy for the client or that the client is not it for surgery. It is essential to consider that Kim’s depression emerged as her transition impacted her social relationships and how society perceived her. It seems possible that her depression was related to the stress from prejudice and discrimination, being misread by others, fear of transphobia, and her family’s reaction. Thus, the conceptualization of transgender individuals’ symptoms must include understanding the influence of the external environment(s) on internal experiences (mood, sense of self, for example). Including societal impact in one’s conceptualization of the presenting concern does not necessarily mean this will be the focus of treatment (Sue et al., 2013). Case Study 10: Ana Ana was a 20-year-old, heterosexual, Croatian American female in her sophomore year at a predominantly White university in the eastern U.S. She appeared older than her stated age and was dressed in fashionable clothing with neat, long, straight hair. She presents for counseling for assistance with depression and suicidal ideation after the breakup of a one-year-long romantic relationship. However, her affect was restricted, revealing no evidence of depressed feelings. Ana tearfully reported that she was at fault for the breakup, as her boyfriend walked off after she had angrily lashed out at him for rejecting her. Ana grew up in one of the poorest communities in the south- central U.S. She was the only child of a single immigrant mother whose financial struggles led to numerous evictions, blackouts due to unpaid electric bills, and limited healthcare or childcare. Ana’s mother also worked as an overnight security guard. For that reason, Ana was often left unattended or with relatives or family friends. By the time Ana was seven years old, she had learned to care for herself by walking home from school alone
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