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Examining Cisgender Mental Health Practitioner Responses to Transgender and Nonbinary Clients: An Experimental Vignette Study

Emily Wilson, University of Nebraska - Lincoln


The American Psychological Association’s guidelines for practice with transgender and nonbinary (TNB) clients call on practitioners to develop competence in providing trans-affirming mental health care services (APA, 2015). However, transgender and nonbinary clients report frequent occurrence of unhelpful and harmful therapist behaviors, including misunderstanding and stereotyping transgender identity (Benson, 2013), perpetrating macroaggressions and microaggressions (Morris, et al., 2019), focusing too much or too little on gender identity concerns (Mizock & Lundquist, 2016), and assigning unnecessary diagnoses (Sennott, 2010). Using an experimental, vignette-based design, this study examined differences in practitioner clinical responses to cisgender and transgender clients and sought to identify factors associated with practitioner perceptions of TNB clients in clinical settings. The sample consisted of 82 mental health practitioners, who read two vignettes depicting either a cisgender client with anxiety or depression, a transgender client with anxiety or depression, or a gender-questioning client. Participants then assigned diagnoses, and rated the vignettes on measures of symptom severity, function, and interest in forming a therapeutic relationship with client. Self-reported attitudes toward TNB people and clinical knowledge and preparedness for working with TNB people were examined as predictors of participants’ responses to vignettes. Results indicated that there were no differences in number of diagnoses assigned, but that practitioners rated cisgender clients as having greater symptom severity and higher psycho-social functioning, relative to the vignettes depicting transgender clients and gender questioning clients. Greater stigma and lower clinical preparedness and knowledge significantly predicted lower interest in forming a therapeutic relationship with gender questioning clients. Future research should examine the role of practitioner attitudes and competence in the formation of a strong therapeutic relationship, particularly when clients are seeking counseling for gender identity concerns. Interventions to improve practitioner competence in trans-affirming care should include training in therapeutic relationship-building skills with TNB clients.

Subject Area

Counseling Psychology

Recommended Citation

Wilson, Emily, "Examining Cisgender Mental Health Practitioner Responses to Transgender and Nonbinary Clients: An Experimental Vignette Study" (2023). ETD collection for University of Nebraska - Lincoln. AAI29254760.