Transgender Issues: A Guide for Therapists Working with Clients in Transition

transgender issues, a guide for therapistsPsych Central contributor Edie Weinstein interviewed Nicole and Lori Bray, a couple she met last year when Nicole was in the process of transitioning from male to female. Their story touched her heart particularly, since they defied the statistical odds and are exceedingly devoted to each other through this arduous process.

Their raw vulnerability in sharing their story is evident. The decision to transition is not one to take lightly. She also had the honor of interviewing them on the radio in 2014.

The purpose of this article is to provide helpful information for therapists who may encounter clients or family members of those embarking on the journey of transitioning from one gender to another.

In the case of Lori and Nicole, one therapist’s interaction with Nicole prior to coming out to Lori, a therapist herself who works with LGBTQ clients, exacerbated an already stress-filled situation. Nicole is a documentary film maker producing her story called “I’d Rather Be Girl.

Edie Weinstein: When did you meet with the therapist who advised you not to tell Lori?

Nicole Bray: I began meeting with that particular therapist in April of 2012. I found her after doing a thorough Internet search for a therapist who specialized in Transgender care who also lived in my region. You can only imagine how disappointed I was to discover there were only three therapists meeting these criteria at the point I was ready to initiate counseling. I chose to see the therapist who was regarded as the “Transgender Guru” since it seemed she would be the one with the most knowledge and experience.

However, I want to clarify that this therapist didn’t advise me not to tell Lori about me being Transgender. Instead, she wanted to focus on what my life was going to be like after Lori divorced me after I come out as Transgender, rather than focus on anything related to transition.

This idea alone immediately started my tailspin into depression and suicidal thoughts. My therapist automatically made the assumption that Lori would divorce me before she even met her! Granted, the statistics are particularly bleak for couples who stay together throughout transition. In fact, less than 20% of couples stay together.

Nevertheless, she never considered the possibility that Lori might stay. As it turned out, my therapist’s assumption was wrong and Lori did stay. Her assumption was incredibly damaging to my already fragile emotional functioning at the time.

EW: When did you actually tell her?

NB: My original intention was to come out to Lori at the end of September of 2012. The significance of this time is it was right after our planned trip to Disney World to celebrate our five-year wedding anniversary.

I recognized that my coming out as Transgender was big news and to tell her before the Disney trip risked ruining her vacation. Therefore, I planned to tell her afterward, but circumstances don’t always work out as we planned.

However, my therapist’s comment about Lori divorcing me quickly sunk me into a depression that didn’t go unnoticed by Lori. On repeated occasions, she asked me about my down mood, but I deflected the questions by telling her I had other things I was working through.

Lori, being a psychologist, continued to notice the pattern of my moods and was not willing to accept this as my answer as time marched on.

On July 29, 2012, I was having a particularly dysphoric day and I provided Lori with an irritable, short response to a simple question she asked.

As a result, she notified me that we needed to discuss what was really going on because my moods and behaviors were starting to affect the marriage. I spent the next three hours dropping hints about what the actual issue was while I mentally debated whether I was ready to tell her or not.

The moment I told her, I knew everything would change. I just wasn’t sure in what direction things would change for us. Even though I knew that my wife was a psychologist who specialized in working with the LGBT population, I was still uncertain how she would react to the news of knowing that her own spouse was Transgender.

To me, it seemed like an entirely different ballgame to have your spouse be Transgender as opposed to your clients.

Finally, at the three-hour mark, I stated, “I have a medical condition recognized by the APA and AMA and it’s a problem I was born with. It’s called Gender Identity Disorder. All my life I have felt like I am a woman. I think like a girl, I feel like a girl, yet I am a guy. I hate it.”

At the time, my gender dysphoria was so severe, I despised the condition and myself. Furthermore, I called it “Gender Identity Disorder” because this is what it was called at the time before it was appropriately renamed “Gender Dysphoria” via the American Psychiatric Association through the use of the DSM-5.

Amazingly, Lori responded with “I will stay with you and we will work our way through this together.” I was beyond shocked and could only utter back, “Will you?” She replied, “Yes, of course. I’m not going to leave you over something like this.”

We spoke for the next 5 hours about everything transition entailed, how to come out to friends and family, ways they might react, and we shed lots of tears together. We are still happily married today.


EW: How long have you been married?

We were married as husband and wife for 5 years and as wife and wife for 3 ½ years for a grand total of 8 ½ years.

EW: How long did it take from start to finish initial consult to completed Gender Confirmation surgery?

Initial Phone Call to Schedule Consultation for GCS: May 6, 2013

Initial Consultation for GCS: March 3, 2014

Gender Confirmation Surgery: August 19, 2014

This is the timeline specifically for Gender Confirmation Surgery. Note the difference in time between initial phone call and scheduled consultation. This demonstrates how booked up my surgeon is. In fact, most GCS surgeons are booked out one to two years in advance. Furthermore, from consultation to surgery, my surgeon’s first available surgery date was 5 ½ months later!

EW: What are the various steps along the way? How did therapy play into the process?

NB: I entered therapy for two reasons. The first reason was that my gender dysphoria was pretty severe to the point that it was interfering with my life. It was important that I start talking to somebody about what I was experiencing before the dysphoria became uncontrollable.

The second reason that I entered into therapy revolved around the criteria from the World Professional Association for Transgender Health (WPATH) since most surgeons and hormone providers follow WPATH.

WPATH requires that you obtain a letter from your therapist in order to obtain hormones and to undergo Gender Confirmation Surgery. I wanted to make sure I was compliant with the criteria of WPATH and initiated counseling to begin the process.

This is just one of the many steps involved in transition—acquiring a competent gender therapist who follows WPATH Standards of Care. Some of the criteria required to undergo GCS include: well-documented gender dysphoria, medical and mental health concerns are well-controlled, 12 continuous months of hormone therapy, and 12 months living in the gender role that matches one’s gender identity. These are areas that must be documented by the therapist.


The following is a timeline of the steps that took place in my journey of transition from male-to-female. Keep in mind that not every Transgender person finds it necessary to follow all of the steps that I took.

The coming out process is generally a long one for most people and for me it was no different. The process began with coming out to my wife, Lori, followed several months later by coming out to my parents and Lori’s parents.

After talking with both sets of parents over the next few weeks, answering questions and providing resources, I moved on to coming out to my siblings and Lori’s siblings. Extended family came shortly after that. I started coming out to friends after all family was notified.

Sperm banking was another part of the process. Lori and I knew we wanted to have children in the future, but that Hormone Replacement Therapy would render me sterile. The prospect of having children was important to both of us, so we invested in sperm banking in order to make certain we could have our own biological children when the time was right.

Full facial electrolysis is the option I chose for facial hair removal versus laser treatments. I was interested in permanent hair removal as is the case with electrolysis compared to permanent hair reduction as is the case with laser treatment. I travel out of state for electrolysis in order to receive twilight sedation to reduce the severity of pain that comes with electrolysis.

Many Transgender individuals will initiate Hormone Replacement Therapy (HRT) as part of their transition. WPATH requires that you obtain a letter from your therapist to begin HRT. HRT is a lifelong process. My hormones are prescribed through an endocrinologist who specializes in working with Transgender individuals.

I chose to undergo Voice Therapy not only to learn how to raise the pitch of my voice, but also to practice other areas such as intonation, resonance, inflection, and linguistic style. My voice triggered my gender dysphoria. For Voice Therapy, I traveled across the state since there were not any services that were local.

Facial Feminization Surgery was one of the major surgeries that was part of my transition process. There are distinct differences between male faces and female faces that the mind can detect within the blink of an eye.

My surgeon and I decided together the changes that were necessary for my surgery. These included: hairline advancement, brow bone and orbital rim contouring, brow lift, rhinoplasty, cheek augmentation, chin augmentation, and tracheal shave. I traveled out of state to obtain this surgery.

In order to go through a name change, you must attend a court hearing. Fortunately, this process was pretty uneventful, but you do have to meet before a judge with other people in the courtroom listening to why you are having your name changed.

Within my state, you also have to publish in the local paper the reason for your name change, along with your old name. Following the name change, I had to notify the Social Security Administration, Secretary of State’s Office, and every other company or organization that contained my old name that there was a court order in place for the new name. This took quite a bit of time to accomplish.

My Facial Feminization Surgery qualified me for a Gender Marker Change on my birth certificate. The Medical Affidavit needed to be completed by my surgeon, notarized, and submitted to the State. Then, I waited for my new birth certificate to come in the mail with “female” listed on it. Coincidentally, it was quite a treat to have this arrive on my birthday! The new birth certificate allowed me to have the gender marker changed on my driver’s license.

To me, the Gender Confirmation Surgery was the most needed surgery. From the beginning, my gender dysphoria was pretty severe and I was anticipating this surgery for years. At this time, I decided to have a Breast Augmentation done as well. Gender Confirmation Surgery requires a letter from two different therapists. I traveled out of state to obtain this surgery.

Even with the Voice Therapy, I just could not get myself to a place where I was content with the sound of my voice. It bothered me that my voice dropped whenever I was tired or comfortable with certain groups of people.

Furthermore, my voice was always a reminder of the old me due to the amount of effort I had to use in order to keep my pitch raised. For these reasons and several more, I knew I was a good candidate for Vocal Cord Surgery (Voice Feminization Surgery). I traveled out of state for this surgery.

As you can see, I traveled out of state often in order to complete various aspects of transition. Unfortunately, transition-related services are far and few between and few are provided within the state where I reside. Therefore, I traveled quite a bit in order to receive the steps necessary for my personal transition.

EW: What would you want therapists to understand and how would you recommend they respond to a client?

  • Create a warm, inviting respectful environment. Interact with the Transgender client as you would any other client.
  • Determine if the individual has a preferred name and pronoun and use these accordingly. When legal name changes occur, make certain that these occur on paperwork and office materials as soon as possible.
  • Learn about the person’s unique story and journey. Avoid making assumptions about how things may or may not turn out. Statistics are merely guidelines and should not be used as the determining factor to direct treatment. Avoid judgment.
  • Listen to your client. Understand that the client likely knows their gender identity. If they tell you they are Transgender, they most likely are. Avoid looking for problems or identities that do not exist.
  • For many years, Transgender was an “invisible” condition” because nobody talked about it and Transgender individuals transitioned in secret. Today, more and more individuals feel comfortable coming out, are seeking out therapy, and people are discussing Transgender issues. As a result, therapists are much more likely to have a Transgender individual enter their counseling office, so it is necessary to have some background knowledge on what being Transgender is and isn’t all about so that therapists feel qualified to begin treatment or to refer to an appropriate gender therapist while allowing the client to feel respected and to get set up with services.
  • If you are going to work with Transgender clients, do your homework and get educated on Transgender issues, WPATH, surgeons, how to find community resources, etc. Do not expect your client to educate you on all aspects of Transgender-related care.

Part Two will focus on Lori’s perspective.


Transgender symbol image available from Shutterstock

Transgender Issues: A Guide for Therapists Working with Clients in Transition

Edie Weinstein Moser, MSW, LSW

Edie Weinstein, MSW, LSW is a journalist and interviewer, licensed social worker, interfaith minister, radio host and best-selling author. A free-lance journalist, her writing has been printed in publications and on sites such as The Huffington Post, Elephant Journal, Beliefnet, Identity, Inner Child Magazine, New Visions, Holistic Living, Conversations, Bellesprit, The Whirling Blog, The Doylestown Intelligencer, The Philadelphia Inquirer, YogaLiving, Wisdom, Mystic Pop, In Your Prime, the “What The Bleep Do We Know?” website and The Bucks County Writer. She has been interviewed by the Philadelphia Inquirer, Fox 29 news, CBS 3 news, WWDB 96.5 and National Public Radio as well as numerous blog talk stations. Check out her website at:


APA Reference
Weinstein Moser, E. (2016). Transgender Issues: A Guide for Therapists Working with Clients in Transition. Psych Central. Retrieved on August 10, 2020, from


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Last updated: 12 Apr 2016
Last reviewed: By John M. Grohol, Psy.D. on 12 Apr 2016
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