Caring for Patients Who Question Their Gender or Sexuality

“Am I transgender?”

The first time a patient asked me this question, I was taken aback. I had been trained to take people at their word and to ask them to provide me with their labels and preferred pronouns. I had to ask myself: Why would a patient be asking me to define them? Wasn’t that inappropriate?

After some reflection, I realized that in my attempt to be open and accepting to any and all stated identities, I had unintentionally placed an entire group of individuals and experiences into my blind spot. I seemingly forgot that the Q in LGBTQ stands for questioning as well as queer.

PFLAG defines questioning as “a term used to describe those who are in a process of discovery and exploration about their sexual orientation, gender identity, gender expression, or a combination thereof.” It’s convenient for us if patients have already identified with a particular term or label, but this self-identification represents a certain amount of work already done. Sometimes our role as clinicians is to help patients while they identify how they identify–that is, to help patients who are questioning.

Sometimes our role as clinicians is to help patients while they identify how they identify.

The process of questioning one’s sexual orientation or gender identity can be confusing and empowering at the same time. On the one hand, it can be a relief to find a label that fits, but with a panoply of terms in common use, it can be difficult to plant a flag with one label and say, “Yes, that’s me!” Many patients may not know what labels are appropriate for their identity. In these instances, mental health practitioners can be an invaluable source of support, validation, and information for patients who identify as questioning.

When in doubt, practice culturally competent care

As with any other population, it is important to focus on the three components of cultural competency when working with patients who are questioning: awareness, knowledge, and skills.

Awareness

Awareness means understanding yourself and your attitudes towards a given population. Being culturally competent means consistently engaging in a dialogue with yourself, noticing your reactions or automatic thoughts and challenging them as appropriate. Working with patients who are questioning may challenge your understanding of sexuality and gender in ways that you don’t expect. Ask yourself:

• What do you know about patients who are questioning? (You may not know anything! Admitting that is okay. Doing nothing about it is not.)
• What training do you have in working with this population?
• How do your beliefs affect your willingness and desire to work with these patients?

Knowledge

Questioning is a state of being and a process.

Knowledge means going outside of yourself to learn what you can.

• Books, articles, podcasts, and trainings are excellent clinical resources. Consider accessing non-academic sources as well in order to hear from voices that might normally be excluded. When initiating or engaging in conversations about questioning, remember to listen more than you speak.
• Read and strive to demonstrate the ALGBTIC Competencies for Counseling LGBQQIA Individuals in your work. The group has also outlined Competencies for Counseling Transgender Clients.
• Attend a support group for patients who are questioning and listen to what they have to say. Being an ally does not always mean doing the talking.
• Seek non-clinical experiences where you can interact with people who may be questioning. Find out what events are going on in your area that provide a safe space for this community to gather. For instance, go to Pride in your city. Advocate for equality and affirmative policies at local, state, and federal levels.
• Get involved with organizations like The Trevor Project, It Gets Better, or your local Queer and/or Trans People of Color (QTPOC) group.

Skills

Using skills means finding techniques and strategies particularly suited to a given population. Identify theories and approaches that have been proven effective with patients who are questioning, and consider how to modify existing interventions to best suit their needs.

• Be explicitly affirmative in your approach. Don’t assume that patients will know that you are an affirmative clinician. Include patients who are questioning in your marketing materials to demonstrate unconditional positive regard from their very first interactions with you. Listen to and validate their experiences, even if they are unfamiliar to you.
• Share your knowledge with your patients. They may not know the terms that describe their experiences. Use the elicit-provide-elicit strategy to provide relevant information and process its meaning for your patient.
• Seek supervision and/or consultation with other practitioners who are experienced in working with patients who are questioning. No good clinician practices in a vacuum. Use your competent colleagues as resources to enhance quality of care for your patients, questioning or otherwise.

Cultural competency is a moving target, and working with patients who are questioning requires a commitment to ongoing learning. Terminology is always changing, so never stop seeking out resources and voices that reflect the terms of today. It’s our responsibility as clinicians to educate ourselves; it is not our patients’ job to do that. It’s okay to ask for clarification of what a term means to somebody; it’s not okay to ask somebody to speak for the entire questioning community.

To return to my original story, it took my patient more than a year to move from “Am I transgender?” to, “I am transgender.” Questioning is a state of being and a process. Some patients don’t want to pin down how they identify, and that’s OK too. Ultimately what is crucial is to meet patients where they are, use their goals to guide treatment, and provide the most affirmative experience we can.