Accessing Gender-Affirming Clinical Care in the Central Valley: An Exploration of Personal Experience

Abstract

This study delves into the necessity for gender-affirming practices, particularly focusing on the underrepresented transgender and non-binary communities in California’s Central Valley. Despite the recognized standards by the World Professional Association for Transgender Health (WPATH) for best practices in mental health care, adequately trained professionals in this region remains a notable scarcity. The paper highlights the heightened risks these communities face, including discrimination and mental health challenges, underscoring the critical need for compassionate and competent care. The research aims to bridge the gap in education and training for practitioners on gender diversity and improve mental health services for transgender and non-binary individuals. Through thematic analysis of individual interviews, the study captures the experiences of gender diverse individuals with behavioral health care, emphasizing the importance of gender-affirming care, the dangers of pathologizing gender diversity, and the adverse impacts of gatekeeping and conversion therapy. Conclusively, the study advocates for an informed consent model for medical transitions, as per WPATH guidelines, and calls for a shift towards intersectional, inclusive practices. It stresses the need for ongoing education, policy reform, and advocacy to ensure equitable, affirming mental health care for gender diverse populations.

1. Introduction

According to the World Professional Association for Transgender Health (WPATH) standards, gender-affirming mental health care is the best practice for treating the transgender and non-binary community [1]. Yet, the number of professionals fully trained and willing to work with transgender and non-binary individuals is quite small, especially in the Central Valley of California, which, despite its diverse population, is severely lacking in culturally responsive care for many populations [2]. The US has a large and diverse population of trans and non-binary individuals, and although specific data on the trans and non-binary communities of the Central Valley of California does not exist, the state has an estimated 150,000 trans and non-binary individuals [3,4].

Considerable research has shown that transgender and non-binary individuals are at high risk for experiencing behavioral health concerns and are often targets of discrimination, harassment, and violence [5,6,7,8,9,10,11,12,13,14]. Therefore, competent, compassionate behavioral health care is vital for this community.

Practitioners seek to address the needs of diverse communities on multiple levels, in fighting for social justice, and in providing competent, culturally relevant care. Understanding how we can best meet the needs of this community and provide the most competent care possible is vital. Historically, most practitioners do not receive much education on treating gender diverse populations [3,15,16]. Additionally, little research has explored the experiences of transgender and non-binary individuals who seek behavioral health care. In the Central Valley, almost no research has examined the experiences of trans or non-binary individuals; while the region is diverse and unique, communities across the country have similarities, being comprised of a large urban area, surrounded by rural areas with a more conservative population. Therefore, this study has vital practice implications for practitioners by addressing a major gap and highlighting areas for necessary improvement needed in service provision for this understudied population.

2. Literature Review

Transgender is an umbrella term that describes any individual whose gender identity does not match the sex assigned at birth [17]. Similarly, the term non-binary is a term that describes those whose gender identity falls outside the binary categories of man or woman. Because language is important and evolving, within this paper, we have chosen to use “gender diverse” rather than terms like gender non-conforming because it represents a diversity of experience rather than a failure to conform to an arbitrary societal expectation around gender.

When seeking behavioral health care, gender diverse individuals need gender-affirming care. Gender-affirming behavioral health care addresses the “physical, mental, and social health needs” along with affirming gender identity [18]. While some research has explored gender-affirming care and best practices [1,19,20,21,22], published research that specifically addresses access to and the quality of gender-affirming behavioral health care for trans and non-binary individuals is lacking. What research has been published is focused on individuals living in large urban centers where the LGBTQ community is considerably larger. In the Central Valley, some academic research has been conducted on the experiences of this community, including a public report [23,24] and a couple of graduate theses [3,25]. Findings from this research support that gender diverse populations in the Central Valley lack service opportunities and often lag their peers in the LGBTQ community across social determinants of health.

2.1. Gender-Affirming Therapy

When gender diverse people seek behavioral health care, gender-affirming therapy is paramount. Establishing rapport and trust with the client leads to more successful therapeutic outcomes and decreased psychological distress for gender diverse clients [22,26]. One common reason for gender diverse individuals to seek service is gender dysphoria, which is discomfort or distress caused by the physical features they were born with not matching their gender identity [27]. This gender dysphoria is also connected to increased depression and anxiety among gender diverse individuals [28]; however, it is important to note that gender dysphoria is not something that all gender diverse individuals experience [29]. For many gender diverse individuals, a lack of diagnosis can inhibit access to gender-affirming care, as many insurance companies and government health plans in the United States require this diagnosis before care can be provided [30,31]. The American Medical Association [32] advocates against such restrictions on care access. Previous guidelines under the Affordable Care Act also prohibited restrictions on access to gender-affirming care but did not bar requirements for a gender dysphoria diagnosis; however, new guidelines under the current administration remove restrictions on the denial of gender-affirming care, further limiting access to individuals [31]. Additionally, not every transition is the same, and not all gender diverse individuals desire or pursue surgical transition and/or hormone replacement therapy. No “right” or uniform transition experience exists. Transnormativity (assuming that there is one right or normal way to be gender diverse) has historically played a significant role in pathologizing gender diverse individuals, forcing them to conform to rigid, stereotypical, binary concepts of gender to gain access to care [33]. This does not consider non-Western concepts of gender or gender identities and presentations outside this arbitrary binary.

Much harm has been done to the gender diverse community through pathologizing by practitioners [29,34,35]. Gatekeeping, a widespread practice that has caused harm to the trans community, refers to processes by which practitioners determine when a gender diverse person is eligible to begin medical treatments for gender affirmation [36]. Clinicians engaged in gatekeeping often use “‘mental readiness’ as a prerequisite to medical transition, which contributes to patient distress and systemic discrimination”; this contrasts with WPATH guidelines, which state that clinicians must “shift from a gatekeeping model towards an informed consent model, which improves access to care” [36].

Another harm enacted on gender diverse individuals is conversion therapy. Conversion therapy, also known as gender identity change efforts or sexual orientation change efforts, refers to a practice that has the goal of making a gender diverse person cisgender or turning a sexual minority into a heterosexual. No person should experience this therapy, as the American Psychological Association [32] has stated, identification as trans or non-binary is not a mental disorder and conversion therapy is a damaging practice with no therapeutic benefit. The harm of these practices to people who have experienced increased risk for suicidal ideation and attempts [24].

2.2. Mental Health

Gender diverse individuals experience higher rates of anxiety and depression when compared to cisgender and heterosexual individuals [9]. Additionally, many gender diverse individuals score high on the Adverse Childhood Experiences scale [11]. Rates of post-traumatic stress disorder among gender diverse people are higher than other populations [6]. Many gender diverse individuals stay “closeted” or conceal their identity in certain situations to protect themselves, attempting to stay safe because of their experiences with discrimination and harassment. This high rate of self-concealment and discrimination increases depression and anxiety among gender diverse individuals [9].

While both transgender and non-binary individuals experience similar stressors as a minority population, non-binary individuals experience higher rates of co-occurring mental health and substance use disorders than transgender individuals do [12]. This is partly due to a high frequency of clinicians, physicians, and other individuals refusing to validate or accept their identities. Non-binary individuals often have their identities dismissed as fake, a mental illness, or a phase [12]. This has caused some non-binary people to feel discouraged, that they are not “trans enough,” and that they do not even have a place in trans communities [12]. A social support network, a sense of belonging, and a connection with the community are associated with better mental health outcomes [37].

2.3. Intersectionality

Intersectionality is a vital lens for understanding the unique experiences of gender diverse individuals. Coined by Crenshaw [38], the concept highlights how overlapping identities—such as race, class, gender, and sexuality—create compounded forms of oppression. Scholars caution against single-axis approaches, which obscure the realities of those facing multiple marginalizations [7,27,39]. Research shows that gender diverse individuals of color, immigrants, and those with disabilities often experience additional systemic barriers, yet these experiences remain underexplored in mental health research [9,22].

Collins’ matrix of domination expands this framework, emphasizing how power operates across structural, institutional, and interpersonal domains [40]. For gender diverse clients, oppression is felt not only in policy or service access, but also in everyday interactions—such as misgendering or microaggressions—that create chronic stress. Applying intersectionality to mental health practice requires acknowledging these layered inequities and designing culturally responsive, affirming services that meet clients at these crossroads, yet research in this area remains limited [39].

The history of psychiatry and mental healthcare is a history of disciplining gender diverse identities by first medicalizing gender nonconformity as a mental disorder, often conflating it with homosexuality, which was also classified as a mental disorder. The labeling of gender nonconformity as a mental disorder contributed to the further criminalization of gender diverse people. While the current DSM-5TR distinguishes gender nonconformity as not being a mental disorder, the stigma around gender diverse identities is still very much present in mental healthcare practices.

3. Methods

This research is situated within a larger study that explored the experiences of gender diverse individuals living in the Central Valley of California. While the “Central Valley” can be used to describe a large region of California from Sacramento in the North to Bakersfield in the south, this study focuses on the central region of the Valley from Merced County in the north to Kern County in the south, with Fresno County as a center point and regional hub.

3.1. Data Collection

We used individual interviews with participants to explore their use of mental health services. Through the interviews, we sought to better understand how licensed clinical social workers and other mental health practitioners were meeting the needs of gender diverse individuals and in what ways the service experiences for the population could be improved. Participants included gender diverse adults living in the Central Valley. They were provided with informed consent and their participation was voluntary. Data were collected using semi-structured interviews via Zoom. Recorded interviews lasted 45 min to an hour. Interview questions sought to understand the participant’s experiences seeking and utilizing mental health care services within the Central Valley region. Participants could decline to answer any questions they did not feel comfortable answering.

Recruitment for the study used convenience and snowball sampling through local resource centers that cater to the LGBTQ+ community and through social media. Any adult gender diverse person living in the Central Valley could participate in the study with no exclusion criteria. To protect the identity of the participants, participants had the option of using their first name or a pseudonym. Before beginning, this research received human subjects approval from the Institutional Review Board at California State University, Fresno.

3.2. Data Analysis

Interviews were transcribed verbatim, with the transcript being checked against the recording for accuracy. Using a content analysis approach, we conducted a thematic analysis of the transcripts to find common themes and experiences of the participants [41]. The research team selected three transcripts to begin the analysis, reading and coding transcripts separately to identify key ideas and experiences from the participants. We then met to discuss coding and create labeling codes for these experiences. Using these codes, the remaining transcripts were analyzed. Key quotes and experiences were extracted from the transcripts based on these codes and placed into a coding table to assist in the thematic analysis and development [41]. As part of this process, we discussed our positionality and biases. A crucial step in qualitative analysis is positioning oneself in the research so that biases can be identified before beginning the analysis, known as reflexivity [42].

3.2.1. Jordan Fitzpatrick

I come to this research as a queer, nonbinary trans person who is living with a disability. This research is very personal to me as I have faced these barriers to mental health and medical care firsthand, especially in the Central Valley, where resources are limited, and few providers are trained or willing to provide gender-affirming care. I recognize that as a white person, I have privileges that a trans person of color does not have. As a social worker and advocate, I am called to speak out against inequality and continue to fight for liberation for all marginalized people.

3.2.2. Marcus Crawford

As a gay white male, this author has experienced the discrimination faced by the LGBTQ+ community; however, as a cisgender male, these experiences differ profoundly from those who are gender diverse. I come to this research from the lens of someone who has seen a renewed and increasing hatred toward members of the LGBTQ+ community, particularly focused on gender diverse people. As a social worker, I am compelled to seek justice and equity for all individuals, and I recognize that an attack on the most marginalized makes all of us less safe.

3.2.3. Katherine Fobear

I come to this research as a queer white cisgender female who has worked for LGBTQ+ nonprofits for twenty years. My experience around oppression, especially around mental healthcare, greatly differs from transgender and nonbinary communities. I recognize my privilege in advocating for gender-affirming healthcare in which I am not the primary recipient. As an advocate and researcher, I have witnessed and worked with transgender and nonbinary communities for greater gender-affirming healthcare access in the Central Valley.

4. Results

We conducted interviews with 43 gender diverse adults living in the Central Valley. In a study such as this, gender is an important variable with considerable variation across participants. While studies often report male and female with everyone else grouped under “other,” we chose not to erase that identity because it is a central characteristic for our participants. A full accounting of the genders and other demographic information is in Table 1. Analysis of the data resulted in a concentration on the experiences of participants with therapy. For many, these experiences were related to gender transition, but for others, the experiences were unrelated to gender. Despite this, their gender identity often played a significant role in the experience they had with therapists. We will begin by exploring the positive, affirming experiences that participants reported, followed by a deeper exploration of the negative experiences.

Table 1. Participant demographics.

Variable		N (%)
Gender	Genderfluid	4 (9.3%)
	Genderfluid and non-binary	2 (4.7%)
	Non-binary	6 (14.0%)
	Questioning	2 (4.7%)
	Trans man	11 (25.6%)
	Trans woman	6 (14.0%)
	Another option *	11 (25.6%)
Race/Ethnicity	African American/Black	1 (2.3%)
	Asian	1 (2.3%)
	Hispanic/Latinx	11 (25.6%)
	White/Caucasian	19 (44.2%)
	Multiple race/ethnicities	10 (23.3%)
	Not provided	1 (2.3%)
Sexual Orientation	Asexual	2 (4.7%)
	Bisexual	8 (18.6%)
	Demisexual	1 (2.3%)
	Gay	3 (7.0%)
	Heterosexual	2 (4.7%)
	Lesbian	2 (4.7)
	Pansexual	10 (23.3%)
	Multiple orientations	7 (16.3%)
Insurance **	Private insurance	32 (74.4%)
	Public insurance	16 (37.2%)
	No insurance	1 (2.7%)
Insurance created barriers to accessing care	Yes	31 (72.1%)
	No	12 (27.9%)
Sought care outside the Central Valley to find affirming care	Yes	23 (53.5%)
	No	20 (46.5%)
Therapist who provided gender-affirming care	Yes	18 (41.9%)
	No	25 (58.1%)
Involuntary hospitalization	Yes	16 (37.2%)
	No	27 (62.8%)
Age	R = 18–53	M = 32 (SD = 9)

* Genders listed by only one person: genderqueer; genderqueer and woman queer; intersex, non-binary, and agender; trans man and demi boy; trans, non-binary, and genderqueer; non-binary and trans femme; non-binary and autigender; trans masculine; trans woman and two spirit; gender nonconforming male; and third gender. ** Totals more than 100% because some participants had both private and public insurance coverage.

4.1. Positive, Affirming Experiences

Participants who had good experiences with therapists discussed what made that therapeutic experience effective and satisfactory in similar ways. For them, more than anything else, having a therapist who was competent in providing gender-affirming behavioral health care was the most crucial factor in creating a positive therapeutic experience. Unfortunately, fewer than half the participants had this experience (n = 18, 41.9%).

Participants sought therapists whom they did not have to educate about their gender identity to avoid the labor of teaching their therapist. Therapists who have knowledge of the needs of gender diverse people, understand community resources, and have connections to the local LGBTQ+ community and its organizations or events also benefited the participants. Carli (trans woman) said this of her therapist:

She knew a lot about transgender people. Like, at the time, a lot of my education about what being trans was, came from my sessions with her. So, she like, knew about the transition process. She knew about hormones. She knew that just because someone’s trans, it doesn’t mean that they have to undergo any kind of medical transition. There’s varying degrees of social, medical transition. She knew that being trans is a very individualized experience and that there’s no right way to be trans, there’s no wrong way to be trans, any way you want to be trans is the right way. She was always really affirming… So, it just seemed like she not only knew a lot about trans people, but she really cared a lot about trans people.

Many participants also shared that having a therapist who was also a member of the LGBTQ+ community was a relief and beneficial, making it easier to open up and develop rapport with the therapist. Deege (intersex, non-binary, and agender) shared this about their therapist:

I’m currently with [a therapist who] is a queer, non-binary person. That has helped a lot, in surprising ways, like, I don’t have to explain my sexuality, I don’t have to like, cover the gender of my exes and cover why I feel so [like the] black sheep in my family, because I’m the only queer person in my family.

Gilberto (genderfluid, drag queen) agreed, sharing how having an LGBTQ+ therapist who is also the same ethnic background was helpful for them to feel comfortable with the therapist:

It was such a relief to have someone who I could identify with, you know, we shared a similar background. She was also, you know, Mexican, Native American. So, there were definitely a lot of things about like, you know, my family, my culture, and the things I was doing, you know, socially my extracurricular stuff, like all the drag shows and the [Imperial Dove] Court. So, it was really comfortable.

While being a part of the same racial or ethnic community and/or a member of the LGBTQ+ community was considered a plus, participants reflected that it was not a requirement to be an effective practitioner. For Alex (trans man, Hispanic), therapists needed to understand their positionality before working with him: “Having, like therapists that you know are open-minded if they’re not from that culture… So, like knowing their limitations was really helpful.”

Many of the participants mentioned that an important aspect of what made them feel safe and comfortable talking in therapy was nonjudgment and validation of their experiences without pathologizing them. As Eli (questioning gender identity) said, “I didn’t feel like [the therapist] judged me. It felt more like an opening and welcoming environment, and it felt like my concerns were heard, and that they were deemed valid.” D (queer) said, “It doesn’t feel as if [the therapist] is pathologizing me or that this person is analyzing every little word that comes out of my mouth and trying to, you know, psychoanalyze me.”

Going to an office or clinic that openly accepts and affirms gender diverse communities was found to be vital for creating a good experience as well. This includes office space and waiting areas that are inclusive, including front desk staff and other employees who were all accepting and informed on how to interact with gender diverse people. Micah (trans masculine) discussed avoiding therapy for years out of fear of non-acceptance until being referred to an office known to focus on gender-affirming practices. “So, just knowing that that was kind of like the basis of their office made me feel comfortable enough to open up to them.” Red (fluid) stated that the first question at their therapy office was confirming pronouns, which felt like such a simple affirming gesture. Others agreed. Ezra (non-binary) they can express themselves because of the atmosphere in the clinic, while Gabe (trans man) reported crying when he was told, “it’s okay to be myself” in their office. Overall, a good therapeutic experience included a therapist informed in gender-affirming behavioral health care working in a setting where all staff were also affirming of gender diverse individuals. Crucial to this was cultural responsiveness and recognition of individual intersectionality.

4.2. Negative Experiences with Therapists

While participants relayed positive experiences in seeking behavioral health care, many more had negative and even harmful experiences with therapeutic services. Four themes related to the negative experiences that participants had in accessing mental health care emerged as we analyzed the data: (1) Transphobia, (2) Gatekeeping, (3) Conversion therapy, and (4) Uninformed, which are explored below.

4.2.1. Transphobia

Transphobic experiences here represent overt acts of transphobia not borne from ignorance or linked to gatekeeping and conversion therapy, which also represent forms of transphobia. Unfortunately, transphobic experiences in therapy were common among our participants. Carli (trans woman) discussed her therapist ignoring her when she discussed her experiences being misgendered. Experiences of misgendering in the therapy office or by the therapist were common among the participants. Frank (trans man) was explicitly told by his therapist that he was not a man and was actually a woman. Melissa (trans female) said her therapist at the Veterans Administration said the goal was “to get me to stop being myself rather than aid me” in her journey.

Kaede (non-binary) shared how seeing a therapist not competent in providing gender-affirming care affected them when the therapist would not use correct pronouns. “I just feel like I was brushed aside… like I was [not] being seen. I felt like my gender was an afterthought to them.” For people like Sam (non-binary), consistently having experiences with therapists uninformed in providing gender-affirming mental health care led them to say, “I’ve given up on talking about my trans experiences and my problems as a trans person to my therapist.”

Misgendering was extremely common among the participants; less common, yet still notably shared among many, were experiences more overtly transphobic. Morgan (trans man) described spending a year trying to convince his therapist that he really was trans and being “forced to wear feminine clothing” before getting approval to transition. Kaede (non-binary) described the feeling that their “gender was an afterthought’ that was not important to the therapist so their experiences were ignored. K (trans, non-binary, genderqueer) went further, stating he had to “compartmentalize” his transness to receive services for his mental health that were not connected to his gender identity, effectively shutting off his identity because the therapist would not accept it. Bear (trans man) said every therapist he had ever used was an “utter asshole” who disregarded everything about his gender identity as made up.

Cassie (non-binary) reported their therapist invalidated their non-binary identity and insisted on using female pronouns. The therapist defined Cassie’s role as a woman. Cassie expanded on this, saying, “For most of my childhood, I was only allowed to go to Christian therapists and I never met anybody that either supported the LGBTQ community, was okay with the queer community, or had queer people in their circle.” Maggie (trans woman) and Mandy (non-binary) both also experienced their therapist bringing up religion in their sessions to encourage them to “change” their gender identity.

Alex (trans man) spoke about holding boundaries with therapists who wanted to ask him inappropriate things about his identity. Additionally, his therapist tried to suggest that the negative things he experienced were his fault because of his gender identity. “There were always comments about my transness or queerness being an issue or a barrier and using that as an excuse for certain things when I was literally experiencing discrimination outside of therapy.”

4.2.2. Gatekeeping

Even when participants had therapists who were less overtly transphobic, they often encountered therapists whose role became gatekeepers to the gender-affirming services that they needed. We note that gatekeeping is a specific act of transphobia; however, it was so common among participants that we identified it as its own theme. Because many gender diverse individuals must acquire a letter from a mental health clinician to gain access to medical care, such as surgeries, “we’re at their mercy” as Oscar (trans man) said. Oscar talked specifically about the power that the therapist had over his life, with a particularly horrible experience when trying to access “top surgery” (a surgical procedure in which a chest becomes flattened or more “masculinized”). He described the therapist’s requirements:

[The therapist] wanted me to uh, be on testosterone for a year before she would even consider getting me a letter. Which, you know, wasn’t the standard of care anymore. I tried to explain to her that it was dangerous for me because I was, you know getting facial hair pretty quickly, and changes were happening, and I had a really large chest, and it was something that I wanted to do sooner than later.

This therapist also refused to respect Oscar’s name and pronouns until he “passed” better. This had a negative effect on his mental health as he said that after sessions with this therapist, “I would leave there crying and call my partner to get therapy from the therapy.”

Oscar reported that he eventually offered to pay extra money to get the letter, and it worked. This, as Oscar said, “just kind of goes to show it wasn’t about me or my mental health, it was just a gatekeeping technique.” After finally receiving this letter, Oscar shared that, “I ended it with her, and she even called me and was like, ‘you shouldn’t be doing this, you’re gonna need me after top surgery!’ And kinda like, threatened me a little bit.” Because of this experience, he reported that he has been unable to be vulnerable with any therapist again. Oscar said he did not feel that he could report what he experienced from this therapist because, as far as he knew, “she was the only one writing letters.”

Oscar was unfortunately not alone in his experience. Morgan (trans man) described going to a gatekeeping therapist for a year, “trying to convince this therapist who had never met another trans person that I was trans.” Another experience with a gatekeeping therapist was shared by D (queer):

[The therapist] made you see him for like six months before he gives you a letter, to make sure that you saw him afterwards, to make sure you didn’t kill yourself. He brought that up multiple times. No trigger warning, he brought up like, a trans woman who like, killed herself after she transitioned medically. Just brought that up during our sessions as a way to make himself feel better, that it’s okay that he’s forcing people to wait this long before they get their letter. Because he literally said, he’s like, ‘I’m not a gatekeeper.’”

Like Oscar and other participants in this study, D’s gender presentation was also critiqued by the therapist, with questions about their clothing. “He asked me if that top made me dysphoric about my chest. Which then made me dysphoric. It was incredibly triggering, and it was really frustrating.”

Rachael (trans woman) spoke about how her therapist wanted to make sure she was a “true transsexual” before being able to get a letter for her medical transition:

There was a lot of testing that they wanted to do to determine if you were a what they—what had eventually become the term… a true transsexual, and a lot of that testing was out of my own pocket. And so, we’re talking hundreds of dollars, that on top of her regular hourly rate because you’re seeing, you know, a psychiatrist or a psychologist, and they’re charging their normal hourly rates and insurance doesn’t—isn’t covering that.

When asked what kind of tests were conducted on her, Rachael described personality tests like Meyers–Briggs. She recalled that the tests had several hundred questions, including detailed questions about sexual history and other items that did not seem related to assisting her. She found the experience frustrating. Rachel’s experience with additional fees was common among the participants. Carlos (trans man) recalled not wanting to pay someone to tell him he could have the surgery. Samuel’s (trans man) therapist told him that he had to meet certain weight requirements before his therapist would write him a letter. “And then, she charges too, which I didn’t really like that well.” Indeed, as Oscar found, charging an additional fee for the letter was a common gatekeeping technique.

4.2.3. Conversion Therapy

Four of the participants shared experiences with conversion therapies, which represent another form of overt and deeply troubling transphobia. Melissa (trans woman) said, “their goal was to get me to stop dressing, stop being myself rather than aid me [in] understanding my own path.” And Sophia (trans woman) spoke of how her therapist took advantage of her fear of living as her authentic self:

One of the reasons that I went to [the therapist] in particular, was because I had stated in the therapy, I want to be a woman but I would rather not want to be a woman. And he went with that as the treatment plan.

Morgan (trans man) spoke about being forced to go through this treatment when he was just 10 years old and did not realize at the time that it was conversion therapy; it was only after processing the experience as an adult that he realized what he had gone through. Because he was assigned female at birth, he was forced to wear feminine clothing that his mom picked out for him any time he went to his therapy sessions. He described the therapy as a “fundamentally harmful” practice from the 1980s, including electroshock therapy and medical sedation. He further recalled:

I remembered the feeling of unsafety with that and that carried through with me my whole lifetime, and it took me until I was in my mid-forties finally, to actually seek help from a therapist. It was an extraordinarily damaging experience for me personally, but also in terms of being able to trust anyone in the therapeutic profession.

Not all these experiences occurred decades ago though. For Cassie (genderfluid, non-binary) conversion therapy occurred in their teen years (in the 2000s and 2010s). Cassie reported that the therapists were members of their church and session information was shared with the pastor. One aspect of this therapy required Cassie to read books and write in a journal which was reviewed by the pastor. Cassie described an example of this:

Say I had one bad thought which would be, you know, I find that woman really attractive. I would have to write a more appropriate response. So, I actually am attracted to her partner. I’m just jealous that she’s got something I don’t have, which is why I must be attracted to her. And they called it reprogramming. So, I had to relearn what I was attracted to.

Cassie shared about the negative beliefs instilled in them by the therapists, such as “I was born evil and that that was something I had to atone for, and I had to earn my goodness back.” This had the effect of making Cassie believe that celibacy was the only option, which led to depression. “I really felt like there was nothing I could do to fix myself, and so I must be destined for evil. So, the only way I could see out of it was suicide.” In fact, Cassie shared that they had multiple suicide attempts “that only stopped happening when I finally came out of the closet in 2020.” Like Morgan, this had a negative impact on their ability to trust mental health professionals in the future, stating that, “I think my foundation for trusting people has been severely shaken.”

4.2.4. Therapist Not Informed in Providing Gender-Affirming Care

An even more common experience among the participants was having a therapist not informed in providing gender-affirming care. This ignorance may be based in a lack of training and experience, which can be mitigated with proper education. One example of this was shared by Mercy (trans woman), who spoke about how her therapist did not know how to write a letter for her to receive gender reassignment surgery and this meant that she had to seek assistance from another provider for this letter:

My therapist at the time was even willing to sign a letter for me, but he thought all he really had to do was just like sign the name at the bottom of a letter. He didn’t know he had to assemble a letter explaining my history and this and that. So, I had to start seeking outside of, and it didn’t have to be outside of the county.

Kimica (non-binary trans femme) described finding a therapist or any other medical professional who had any knowledge of gender diversity was challenging. Mandy (non-binary) agreed, stating the whole process was “more laborious” because they had to educate the provider before treatment could begin. For Sam (trans, non-binary), he stopped seeking treatment after repeatedly experiencing a “deer in the headlights moment” after providers learned his gender identity, stating they “just don’t get it.” Unfortunately, for most of the participants, negative experiences with behavioral health care providers were more overt and less about ignorance. Overall, nearly every participant discussed some degree of needing to educate providers about what gender diversity meant. While we recognize that education and training may help to alleviate the concerns related to uniformed providers, the responsibility for this training should not lie with the client.

5. Discussion

Findings offer valuable insights into the experiences of gender diverse individuals seeking therapy and the implications for practitioners. Gender-affirming behavioral health care is beneficial for gender diverse clients to fully be their authentic selves and overcome obstacles [3,23,25]. Practitioners must be competent in culturally responsive gender-affirming care when treating gender diverse clients. Behavioral health care goes beyond just care from a practitioner, though. Services for eating disorders, crisis care, domestic violence, and substance abuse must also have gender-affirming practitioners and treatment models. A nuanced exploration of the needs and experiences of gender diverse people promotes therapeutic relationships.

Positive, affirming experiences in therapy were characterized by several key factors identified by participants. Foremost among these, as supported by Budge et al. [26] and Sloan and Shipard [22], was the significance of having a professional who demonstrated competence in providing gender-affirming care. Participants highlighted the importance of practitioners who were well-informed about transgender experiences, understood the diversity within the community, and were familiar with resources and support networks available to gender diverse individuals. This knowledge not only fostered a sense of validation for participants but also alleviated the burden of educating their therapists about gender identity, allowing them to focus on their therapeutic journey.

While receiving services from someone who was also a member of the LGBTQ+ community or who shared a racial, ethnic, or cultural community with the participant was beneficial, participants pointed out that other attributes are more important. Nonjudgmental attitudes and validation of experiences were also paramount in creating affirming therapeutic environments. Participants expressed the importance of feeling heard, understood, and respected by their care provider, without fear of judgment or pathologization of their identities [29,30,34,35]. This validation not only affirmed the legitimacy of their experiences but also empowered participants to explore their identities and emotions more freely within the therapeutic context. The facilitation of a deeper level of understanding, empathy, and rapport enhanced the therapeutic alliance and fostered a safe space for exploration and expression, which was seen as pivotal in their healing process.

Conversely, participants also recounted negative experiences that underscored significant challenges within behavioral health care for gender diverse individuals. Transphobia [33], gatekeeping practices [36], conversion therapy, and encounters with uninformed therapists [12] emerged as prominent themes that hindered access to affirming care and perpetuated harm for participants. These experiences caused participants to have less trust and hope in behavioral health providers, and some won’t trust another therapist again.

Transphobia, manifested through invalidation of identities, discriminatory attitudes, and lack of understanding, was a pervasive issue encountered by many participants. From being told that their identity was invalid to experiencing microaggressions and outright hostility from therapists, participants described the profound impact of transphobia on their health and well-being. These experiences not only invalidated their identities but also eroded trust in the therapeutic process and hindered their ability to seek support, which is supported by Budge et al. [37].

Gatekeeping practices posed significant barriers to accessing necessary medical interventions for many participants. These gatekeeping practices not only delayed essential medical care but also perpetuated power imbalances and eroded participants’ autonomy and agency over their own bodies. Conversion therapy also contributed to lasting impacts on their mental health, identity development, and trust in practitioners. These experiences underscored the urgent need for legislation and policy measures to prohibit conversion therapy and limit gatekeeping to protect gender diverse individuals.

Additionally, encounters with practitioners who lacked competence in providing gender-affirming care further compounded the challenges faced by participants. From practitioners who misgendered them or focused on irrelevant aspects of their identity to those who imposed their own beliefs or religious values onto therapy sessions, participants described feeling invalidated, marginalized, and dismissed by therapists who were ill-equipped to support them. These experiences not only undermined the therapeutic alliance but also perpetuated feelings of alienation and distrust in mental health professionals.

5.1. Intersectionality

Using an intersectional lens to examine the results supports Crenshaw’s [38] principle of compounded oppression. Of the 19 participants who identified as white, six (31.5%) reported experiencing transphobia while accessing behavioral health care; conversely, of the 23 participants who identified as not white, nine (39.1%) reported experiencing transphobia. Reports of professionals uninformed about the gender diverse community were similar, with five white participants (26.3%) and eight not white participants (34.7%) reporting it. Gatekeeping was experienced equally between white (n = 4, 21.1%) and not white participants (n = 5, 21.7%). Only conversion therapy was reported by white participants more, with both reports of this experience coming from white individuals. All four of the participants who reported therapists treating them negatively about their weight were not white. Thirteen percent (n = 3) of the participants who were not white reported experiencing racism in their behavioral health care settings.

Overall, the findings of this study highlight the complex and multifaceted nature of experiences within behavioral health practices for gender diverse individuals. While positive, affirming experiences can foster healing, empowerment, and resilience, negative encounters underscore systemic barriers, discrimination, and harm perpetuated by uninformed clinical social workers. These findings have significant implications for practice, advocacy, and policy development.

The matrix of domination described by Collins [40] provides an opportunity to explore these intersectional experiences from a macro level. At an institutional level, the lack of respect for individuals’ gender identity was evident in the participants’ experience with misgendering on their documents. Reports of their gender identity not being recorded correctly or refusal to update pronouns were common. This was exacerbated for participants living outside of the major cities, as they had limited access to alternative providers, creating geographic oppression. Micah (trans masc) described the additional institutional barriers as adding to the cultural stigma against accessing care for people of color. Savun (gender fluid, non-binary) reported loss of programs through budget cuts, indicating a lack of institutional and structural support. Reports of insurance denial of services were common regardless of the insurance type the participants reported, with public insurance for the poor (Medi-Cal) often being described as inadequate in addressing the needs of gender diverse individuals.

Largely, however, the primary experience with oppression was structural within the healthcare system, coming through insurance companies. Nearly every participant discussed insurance as a barrier, hindrance, or obstacle, creating an oppressive force against their access to gender affirming care. These experiences ranged from changing insurance due to a new job or new provider at a current job to moving to a new city to aging out of their parents’ insurance plans to graduating from college and losing student insurance. These life changes created structural barriers that often result in starting over their behavioral health care experience and re-experiencing the traumas related to transphobia, gatekeeping, uninformed providers, and other concerns. Rachel (trans woman) described this succinctly: the health care system “did not want to help transgender people in any way.”

5.2. Recommendations

First and foremost, practitioners must prioritize cultural responsivity and affirming practices in their work with gender diverse clients. This entails ongoing education, training, and self-reflection to deepen understanding of diverse gender identities, experiences, and needs. Practitioners must actively challenge transphobia, discrimination, and bias within mental health settings, advocating for inclusive policies and practices that affirm the identities and experiences of gender diverse individuals within their agencies and practices. Moreover, practitioners must advocate for legislative and policy measures to prohibit conversion therapy and protect gender diverse individuals from harmful practices. This includes supporting efforts to pass laws that explicitly ban conversion therapy for minors and adults, as well as advocating for comprehensive behavioral health care services that prioritize affirming, evidence-based approaches to gender-affirming care.

Furthermore, practitioners must challenge gatekeeping practices within mental health care systems that obstruct access to necessary medical interventions for gender diverse individuals. This includes advocating for reforms to outdated standards of care, promoting informed consent models for accessing gender-affirming care, and empowering clients to make autonomous decisions about their bodies and identities. Additionally, practitioners must prioritize trauma-informed care and support for gender diverse individuals who have experienced discrimination, violence, or trauma within therapeutic settings, recognizing that gender diverse individuals may seek therapeutic services for many reasons not related to their gender identity. This entails creating safe, supportive spaces for clients to process their experiences, validate their identities, and rebuild trust in behavioral health professionals.

6. Limitations

Although there are several implications for this study, we would like to note several limitations. First, our sampling strategy was convenience and snowball, which limits the generalizability of our sample, as those who are engaged with LGBTQ+ networks may be more likely to participate. Second, our findings are limited to those in a single geographic area with unique political and cultural influences that may not be generalizable to other regions or countries. Third, although we attempted to diversify our sample to the greatest extent possible, some groups were likely not well represented in this study. Gender diverse individuals from smaller racial/ethnic communities or those not engaged with online-based platforms may not have had the opportunity to be recruited into our study. Fourth, while we discussed experiences with behavioral health care, we recognize that many different professionals provide these services, including social workers, psychologists, psychiatrists, marriage and family therapists, and professional counselors. Most participants could not identify the professional background of their care provider, and for some who did, they discussed different professional identities as one. These inhibit our ability to discuss nuances within the professional trainings and preparation across fields, which led us to discuss this broadly as “therapists” or “behavioral health care providers.” Finally, as with any qualitative study, these findings are limited by their temporal and contextual nature, as they only represent the lived experiences and opinions of our participants during this time and place.

7. Conclusions

The present study brings to light the critical need for affirming, competent, and intersectionally informed mental health services for gender diverse people in California’s Central Valley. Positive therapeutic experiences were frequently associated with being validated, culturally responsive, and working with a competent practitioner; however, too many study participants reported experiences with transphobia, gatekeeping, conversion therapy, or uninformed providers. These findings call for a continued shift towards informed consent, the elimination of harmful practices, and the integration of intersectionality in trainings and service provision. The study amplifies important lived experiences that can and should shape practice, education, and policy. By centering the voices and needs of gender diverse people and continuing to work towards inclusive clinical practice, practitioners can work to advance the field to an affirming and equitable space for all seeking mental health care.