Sexuality Research and Social Policy

https://doi.org/10.1007/s13178-019-00382-4

Facing Transgender and Cisgender Patients: the Influence

of the Client’s Experienced Gender and Gender Identity on Clinical
Evaluation
Annalisa Anzani 1 & Antonio Prunas 1 & Simona Sacchi 1

# Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
The present study aims at investigating the role of anti-transgender bias in the psychological assessment of transgender (vs.
cisgender) patients. To this purpose, a female sample of licensed psychotherapists (N = 218) was presented with clinical vignettes
that described a transgender (vs. cisgender) man (vs. woman) reporting depressive symptoms or anger outbursts. Participants
were asked to evaluate the fictitious patient answering questions on their diagnostic impressions (e.g., psychopathological
severity). Moreover, the respondents’ individual variables (i.e., right-wing authoritarianism) were also assessed. Results revealed
that, for high levels of authoritarianism, psychotherapists evaluated cisgender women as more severe than transwomen and
cisgender men. Implications for clinical practice are discussed.

Keywords Transgender . Psychotherapy . Clinical assessment . Stereotypes . Right-wing authoritarianism

Transgender1 and gender non-conforming (TGNC) people are recent report from Transgender Europe (TGEU, 2016) has
frequently exposed to the effects of anti-transgender prejudice shown that, among European countries, Italy holds the sec-
(Pflum, Testa, Balsam, Goldblum, & Bongar, 2015). Prejudice ond highest rate of murders of trans people after Turkey. It
towards TGNC individuals may take the form of gender dis- has also been shown that Italian trans people face discrim-
crimination, harassment, or violence, and transgender people ination in the workplace or accessing the healthcare system,
are exposed to this kind of experiences more often than any and that 36% of them claim to be victims of violence
other sexual minority group (Browne & Lim, 2008). Scientific (Prunas et al., 2016).
studies have consistently been reporting that violence and The minority stress model (Meyer, 2003) provides a con-
overt forms of discrimination against transgender people are ceptual framework to explain the negative outcomes of dis-
a public health concern worldwide, in particular against crimination on physical and mental health in the TGNC pop-
transwomen (Bockting, Miner, Swinburne Romine, ulation (Hendricks & Testa, 2012). TGNC people are exposed
Hamilton, & Coleman, 2013; Fernández-Rouco, Fernández- to an additional amount of stress when compared to cisgender
Fuertes, Carcedo, Lázaro-Visa, & Gómez-Pérez, 2017; individuals; this stress is associated with discrimination and
Grant et al., 2011; Kosciw, Greytak, Bartkiewicz, Boesen, stigma that minority groups experience in everyday life, be-
& Palmer, 2011; Langenderfer-Magruder, Whitfield, Walls, cause of their gender-variant identity. Social norms, which are
Kattari, & Ramos, 2016; Rodríguez-Madera et al., 2017). A shaped within the relatively stable heteronormative paradigm,
provide the basis for minority stress. For instance, transgender
1 people have been shown to be at higher risk for mental disor-
BTransgender^ is often used as an umbrella term to refer to different groups
of people (including transsexuals, cross-dressers, and gender non-conforming ders, such as depression and anxiety (i.e., Bockting et al.,
people), who do not identify with their gender assigned at birth. 2013; Budge, Adelson & Howard, 2013), but also suicide risk
(Tebbe & Morandi, 2016).
* Annalisa Anzani Evidence exists of a direct connection between discrimina-
a.anzani7@campus.unimib.it tion and stigma against trans people and depression (Rotondi,
2012). Bockting et al. (2013) found, in a large sample of US
1
Department of Psychology, University of Milano - Bicocca, transgender participants from the community, that 49% of
Milan, Italy transwomen and 37% of transmen in the sample reported
 Sex Res Soc Policy

clinically significant levels of depression, and 33% of both or on the contrary, avoiding to talk about gender at all; some-
groups reported clinically significant anxiety. Both the expe- times TGNC patients may perceive that the therapist is trying
rience of stigma and that of perceived stigma were positively to fix their Bproblem^ with gender identity or that they ap-
correlated with psychological distress, with peer support act- proach it as a mental illness (Mizock & Lundquist, 2016).
ing as a protective factor that buffered the impact of stigma on In Western countries, overt forms of discrimination against
mental health. More recently, a study by Tebbe and Morandi TGCN people have increasingly become less accepted and so-
(2016) reports an even higher prevalence of depression, with cially desirable (Pettigrew & Meertens, 1995), leaving space for
68.5% of the sample meeting the diagnostic criteria for de- more subtle forms of discrimination. Nadal, Skolnik, and Wong
pression, and also high rates of suicidal ideation and attempts, (2012), Nadal (2013) introduced the construct of
reported respectively by nearly 72% and 28% of the respon- microaggression to explore the experiences of transgender peo-
dents. The model tested in the study suggests that the experi- ple. Although microaggressions may appear minimal and harm-
ence of minority stress is related to depression, which, in turn, less when compared to harassment or other direct forms of
mediates the relation between discrimination and suicide risk. discrimination, the cumulative effect of several microaggressive
It must be pointed out that, although a non-heterosexual experiences can lead to significant psychological distress (Sue,
sexual orientation can be kept undisclosed, transgender identity 2010). Also, when microaggressions are perpetrated by helping
is often clearly visible, which makes transgender people more professionals, whether in mental health, social, or healthcare
easily targeted. Dichotomic norms pertaining to gender and sex services, this can hinder the establishment of a therapeutic alli-
are highly internalized in Western societies (Tauches, 2006). ance (Sue, 2010). The studies on the attitudes of mental health
Sometimes these beliefs are so ingrained that they activate the practitioners towards TGCN people were recently reviewed by
perception of threat once they are challenged. Transgender peo- Brown, Kucharska, and Marczak (2018). Overall, the results of
ple are particularly vulnerable to discrimination and harassment the 13 reviewed studies seem to suggest positive attitudes to-
because transgender experience not only violates the sexual wards transgender clients (Brown et al., 2018). As for the de-
dichotomy (heterosexual–homosexual), but also gender norms, mographic variables that impact attitudes among therapists,
namely, social expectations about male and female roles and most studies report that women have significantly less negative
their gender expressions (Tauches, 2006). attitudes compared to men (Ali, Fleisher, & Erickson, 2016;
Research has shown that mental health professionals are Bowers, Lewandowski, Savage, & Woitaszewski, 2015;
not immune from negative attitudes towards sexual minorities Brown et al., 2018; Riggs & Sion, 2016). Furthermore, religi-
but, far from this, they clearly show a positive bias for hetero- osity and conservative political ideology are negatively correlat-
sexuals (Bartlett, Smith, & King, 2009; Capozzi & Lingiardi, ed with positive attitudes towards transgender clients (Ali et al.,
2003; Lingiardi & Capozzi, 2004). Among sexual minorities, 2016; Bowers et al., 2015; Brown et al., 2018). As noted by
trans people might be more exposed to prejudice than gay or Brown et al. (2018) in their review, if compared to colleagues
lesbians, even in mental health settings. European surveys from conservative regions, mental health practitioners living in
show that healthcare services might put trans people at risk progressive regions or holding liberal political ideology show
for experiences of discrimination, with about one quarter of more positive attitudes towards transgender minorities, they are
respondents reporting ever being discriminated against be- more prone to support their rights and to receive training on
cause of being trans (Prunas et al., 2016). A very large study transgender needs (Johnson & Federman, 2014).
across European countries that included over 6000 partici- The aforementioned recent strand of research mainly focused
pants shed light on another problem connected to healthcare on health practitioners’ explicit attitudes towards transgender
services: practitioners seem to lack information on transgen- people (for instance assessing bias through the Genderism
der experience (FRA - European Union Agency for Transphobia Scale, the Transgender Attitudes and Beliefs, the
Fundamental Rights, 2014). The EU-wide Transgender Attitude Towards Transgender Individual Scale; see Brown
Eurostudy reported that up to 30% of gender non- et al., 2018), thus leaving more subtle effects of prejudice and
conforming people found themselves in situations in which stereotypes unexplored. Filling this gap, the aim of the present
practitioners, in spite of their wish to help, lacked very basic study was to assess the extent to which mental health profes-
information about trans issues (Whittle, Turner, Coombs, & sionals are biased against transgender clients in the psycholog-
Rhodes, 2008). This lack of information might lead TGNC ical assessment process. To this end, a case description of a
people to have to educate providers about their own healthcare fictitious transgender (vs. cisgender) patient was proposed to a
needs (Grant et al., 2011; Mizock & Lundquist, 2016). large sample of licensed psychotherapists, whose right-wing
As pointed out in the study by Mizock and Lundquist authoritarianism (RWA; Altemeyer, 1981) was also assessed.
(2016), TGNC individuals often report other negative experi- The effects of the experimental manipulation on the therapists’
ences in clinical settings, beyond Beducation burdening.^ clinical evaluations were then investigated. To our knowledge,
They may feel that the main focus of ongoing therapy is on this approach has never been applied to investigate anti-
gender identity, neglecting other relevant aspects of their lives, transgender bias among mental health professionals.
Sex Res Soc Policy

We predicted that transgender patients would be rated as negative attitudes towards groups perceived as threating the
more severe in psychopathology than their cisgender counter- values or violating mainstream ways of life (Duckitt, 2006;
parts. We also hypothesized that transgender women would be Rios, 2013). Since previous studies have shown that sexual
rated as more severe in psychopathology than transgender minorities are stereotyped in terms of threat to traditional mor-
men and cisgender patients, as they are subject to a double al standards and values (Cottrell & Neuberg, 2005; Madon,
bias: gender bias and transgender bias. As shown in previous 1997), the individual’s RWA can be considered a reliable pre-
studies, transwomen are more exposed to negative experi- dictor of prejudice towards transgender people.
ences of discrimination and harassment than transmen The second reason is that, in the present study, it was not
(Bockting et al., 2013; Grossman, D’Augelli, Salter, & possible to measure the participants’ explicit attitudes towards
Hubbard, 2005; Seelman, 2014). Nevertheless, there is no transgender people, as people working in helping professions
direct evidence of greater prejudice towards transwomen than might be guarded against openly expressing negative attitudes
transmen, as the assessment instruments available so far (i.e., towards minorities. Furthermore, it would have been pointless
Hill & Willoughby, 2005; Nagoshi et al., 2008; Walch, to measure explicit prejudice after participants were invited to
Ngamake, Francisco, Stitt, & Shingler, 2012) mainly focus read and discuss a clinical vignette about a fictitious patient
on trans people as a whole group (Worthen, 2013), not belonging to that target group.
allowing to specifically assess attitudes towards transmen
and transwomen. When confronted with a cisgender or trans-
gender patient, we expect that, as in every social interaction, The Study
therapists will automatically activate stereotypes based on
gender as a social category. Stereotype is defined as Ba fixed, Participants
over-generalized belief about a particular group or class of
people^ (Cardwell, 1996). Generally, these beliefs are stable An a-priori power analysis was conducted for sample size
over time and are culturally based (Cardwell, 1996). The au- estimation, using G*Power 3.1 (Faul, Erdfelder, Lang, &
tomatic activation of stereotypes could have an influence on Buchner, 2007). The power analysis (alpha = .05, power =
therapists’ clinical evaluation, which not only relies on the .90, medium effect size = .30) suggested a sample size of
overall clinical picture, but also on the stereotypical character- approximately N = 216 for a between-participants ANOVA
istics of the client’s social group. The pernicious and pervasive with eight groups. Thus, a total of 218 female licensed psy-
effects of stereotypes, automatically activated in the presence chotherapists aged 29 to 71 years (M = 46.04; SD = 11.26)
of relevant behavior or stereotyped-group features, are well- participated in the experiment. All the participants were self-
known. The detrimental effect of stereotypes on social percep- identified cisgender, White Italian citizens. To avoid the large
tion could trigger a stereotype-consistent behavioral response effects of respondents’ gender observed in previous studies,
that is not dependent on an individual’s level of prejudice and male psychotherapists were excluded from the study (Steffens
values (Devine, 1989; Devine & Elliot, 1995). In line with this & Wagner, 2004). All participants provided written informed
hypothesis, we expect that transgender women activate nega- consent to participate. The procedure was approved by the
tive beliefs about both women and transgender identities, and University Ethics Committee and was in accordance with
are thus evaluated more negatively in terms of the severity of the ethical standards of the 1964 Declaration of Helsinki.
their psychopathology. We are interested in a more subtle form Demographic characteristics of the study sample are summa-
of prejudice that cannot be assessed using explicit responses to rized in Table 1.
a questionnaire measuring anti-transgender attitudes but, rath-
er, could emerge in the biased rating of severity of a fictitious Material and Procedure
patient. Furthermore, we expect high levels of RWA to mod-
erate the effects of the patient’s assigned and experienced gen- Clinical Vignettes The vignettes described the clinical picture
der on the ratings of psychopathological severity. The ratio- of a fictitious patient, with symptoms ascribable to a mood
nale behind the use of RWA as a moderating variable lays on disorder (major depression) or an impulse control disorder
two reasons. First, the RWA has been shown to be one of the (intermittent explosive disorder), and included some bio-
main variables underlying prejudice against minorities, as it graphical information and clinical history. The two vignettes
measures the individuals’ moral values in general, rather than were adapted from the DSM-IV-TR casebook (Spitzer,
their attitudes towards a specific group (Whitley Jr, 1999; Gibbon, Skodol, Williams, & First, 2002). The disorders se-
Tsang & Rowatt, 2007). People high in RWA have a strong lected were previously pretested as stereotypical of women
preference for tradition and social order and are negatively (major depression) and men (intermittent explosive disorder).
inclined towards deviance and behavior that they consider For each of the two disorders, four clinical vignettes were
immoral (Altemeyer, 1981). Thus, RWA does not predict a elaborated, by varying the patient’s experienced gender (man
generic prejudice towards minorities but, specifically, vs. woman) and gender identity (cisgender vs. transgender).
 Sex Res Soc Policy

Table 1 Demographic characteristics of the study sample N = 218 intermittent explosive disorder, or cisgender woman with in-
% N termittent explosive disorder.

Sexual orientation Procedure The regional boards of psychologists across the

Asexual 0.9 2 country were contacted to achieve the highest possible
Bisexual 1.8 4 visibility of this research project among their members.
Heterosexual/straight 83 181 Female psychotherapists were then contacted by an email
Lesbian 1.8 4 presenting the project and asking for their participation.
Sexual attraction After providing informed consent, participants received a
Exclusively men 72.5 158 link to an online platform to complete the study. After
Mostly men but also women 10.6 23 reading the clinical vignette carefully, they were asked
Equally men and women 0.9 2 to rate the psychopathological severity of the patient on
Mostly women but also men 1.4 3 a single item, a 10-point Likert scale ranging from 1 (not
Exclusively women 2.3 5 at all severe) to 10 (extremely severe). Psychopathology
Neither men nor women 0 0 severity was further measured by rating the patient’s cur-
Post-graduation rent level of overall functioning using the Global
Doctorate 5.5 12 Assessment of Functioning score (APA, 2000). The GAF
Master 33.6 73 consists of nine behavioral descriptors ranging from
Psychotherapy training 83.5 182 Babsent or minimal symptoms (e.g., mild anxiety before
Other 20.7 45 an exam) […] no more than everyday problems^ to
Theoretical orientation Bpersistent danger of severely hurting self or others […]
Cognitive–behavioral 19.3 42 or persistent inability to maintain minimal personal hy-
Cognitive 3.7 8
giene or serious suicidal act with clear expectation of
Systemic 15.6 34
death^ (APA, 2000). Patients were rated between 0 (most
Psychodynamic/psychoanalytic 32.6 71
severe) and 100 (least severe), with each descriptor hav-
ing a nine-point range.
Eclectic 6.4 14
A similar paradigm and experimental procedure were used
Other 17.9 39
in a previous study to investigate homophobic prejudice in a
Sexology education
sample of mental health professionals (Prunas, Sacchi, &
Yes 11.5 25
Brambilla, 2017).
Years of practice
Participants were then presented with the Right-wing
1–5 40.9 88
Authoritarianism Scale (RWA) (Altemeyer, 1981), which
6–10 19.1 41
measures the degree of willingness to submit to an authority,
11–20 13 28
adherence to societal conventions and norms, and hostility
21+ 9.3 20
towards people who do not adhere to them (e.g., BOur country
needs free thinkers who have the courage to defy traditional
ways, even if this upsets many people^). The scale showed
The clinical vignettes referring to transgender patients present- satisfactory internal coherence in the present study
ed the following final sentence: BMrs./Mr. P. was assigned (Cronbach’s α = .76). Each item was scored on a 9-point
male/female at birth, but she/he successfully underwent Likert scale. The RWA has shown high correlations with
gender-affirming surgery over 15 years ago.^ Apart from this transphobic attitudes in previous studies (Warriner, Nagoshi,
detail, the cisgender and transgender versions of the clinical & Nagoshi, 2013).
vignettes were identical. At the end of the procedure, participants were thanked and
Thus, the experimental design consisted of a 2 (experi- properly debriefed. The debriefing provided information
enced gender: man vs. woman) X 2 (gender identity: about the purpose of the study and phone number and email
cisgender vs. transgender) X 2 (disorder: depression vs. inter- address of the principal investigator for participants who had
mittent explosive disorder) between-participants design. Each further questions or concerns.
participant was randomly assigned to one of the following
eight clinical scenarios: transgender man with depression,
cisgender man with depression, transgender man with inter- Results
mittent explosive disorder, cisgender man with intermittent
explosive disorder, transgender woman with depression, Descriptive statistics and correlations are reported in
cisgender woman with depression, transgender woman with Table 2. We decided to exclude three participants from
Sex Res Soc Policy

Table 2 Descriptive statistics and variables correlation model tested with disorder type as additional moderator
Severity rating GAF score RWA did not yield any significant interaction effect. As showed
in Fig. 1, the interaction between gender identity, experi-
Severity rating – − .26* − .06 enced gender, and authoritarianism (RWA) on clinical se-
GAF score – – .07 verity ratings was significant (B = .53, SE = .24, t = 2.19,
M 6.30 57.59 2.33 p = .03, CI = LL .05, UL 1.01). In other words, the inter-
SD 1.28 10.22 1.49 action effect between gender identity and experienced
Cronbach’s α – – .77 gender on the ratings of severity was significant (B =
1.45, p = .007) only when therapists showed high levels
GAF global assessment functioning, RWA right-wing authoritarianism; of authoritarianism (3.82). With high level of authoritari-
*p < .01
anism, therapists rated a cisgender woman as more severe
the analyses, as they reported severity ratings over | ± 2.5| than a cisgender man (B = − .75, SE = .36, t = − 2.03,
standard deviations above the mean; thus, the final sample p = .04, CI = LL − 1.47, UL − .02). In addition, surprising-
comprised 215 participants. As shown in Table 2, severity ly, a cisgender woman was rated as more severe than a
rating and GAF scores are negatively correlated (r = transwoman patient (B = − 1.21, SE = .37, t = − 3.22,
− .26, p < .01), meaning that the more the patients is p = .002, CI = LL − 1.95, UL − .46); when the patient
judged as severe by the clinician, the lower their global was transgender, the difference between women and men
functioning, supporting the reliability of the scales. Then, did not reach significance (B = − .69, SE = .38, t = 1.80,
we computed a series of 2 (expressed gender: man vs. p = .07, CI = LL − .06, UL 1.46). The last comparison
woman) X 2 (gender identity: cisgender vs. transgender) showed no difference in psychopathological severity rat-
X 2 (disorder: depression vs. anger outbursts) between- ings between transmen and cisgender men (B = .23,
participants ANOVAs with the ratings of severity, and SE = .38, t = .62, p = .53, CI = LL − .50, UL .98). This
the GAF score as dependent variables. The analysis did interaction between gender identity and experienced gen-
not yield neither main effects nor interaction effects, Fs der is no longer significant (B = − .14, p = .77) for low
(1, 217) < 3.33, ps > .07. levels of the therapist’s RWA (1.00).
In order to ascertain whether right-wing authoritarian- We also controlled for the effect of the therapists’ training
ism influenced the severity ratings of transgender and and the number of years of experience in psychotherapy. We
cisgender patients, a series of moderation models was car- compared the severity ratings of therapist with different theo-
ried out through PROCESS (Hayes, 2013) (model 3, 5000 retical backgrounds (cognitive–behavioral, systemic, psycho-
bootstrap resampling). In all the models, we used gender dynamic/psychoanalytic, and others), using the RWA as co-
identity (cisgender = 0, transgender = 1) as independent variate in the model. We did not obtain any main effects, Fs (1,
variable (X), the patient’s experienced gender (female = 181) < .26, ps < .41, nor any interaction effect F (1, 181) = .63,
0, male = 1) as the first moderator (M), RWA as second p = .59. The same model carried out with the number of years
continuous moderator (W), and severity rating as the de- in psychotherapy did not yield any significant main effect, Fs
pendent variable (Y). The model did not consider the in- (1, 188) < .06, p < 61, nor any interaction, F (1, 188) = 1,
dependent variable disorder type, since the moderation p = .41.

Fig. 1 Interaction between psychotherapist’s RWA, patient’s gender identity, and patient’s expressed gender
 Sex Res Soc Policy

General Discussion explanation of this unexpected and noteworthy result could

be that the psychological and psychopathological characteris-
The impact and consequences of prejudice against transgender tics ascribed to a trans person are both feminine and mascu-
people in mental health professionals are still largely line. According to our results, transwomen and transmen
understudied and unknown. Although we anticipated an were, in fact, located at an intermediate level of psychopatho-
anti-transgender bias in the assessment of a fictitious patient, logical severity, between cisgender women and cisgender
our data revealed an unexpected result. The moderation model men. A speculative hypothesis could be ascribed to social
showed that, for high levels of RWA, cisgender women were categorization: trans people may be not categorized in the
considered the most severely psychopathological group. This same boxes as cisgender men and women, but they could
finding would indicate the occurrence of a gender bias rather become part of new social categories that combine traits of
than an anti-transgender bias in the patients’ clinical evalua- the stereotypical female and the stereotypical male.
tion: despite the contents of the clinical vignettes being equal, This study suffers from some limitations that should be
cisgender women were judged more severely than transgender addressed in future research. First, our sample comprised only
patients (regardless of their experienced gender) and cisgender female psychotherapists. A large body of research on preju-
men. This difference was not significant for low levels of dice and negative attitudes towards minorities shows that
authoritarianism. As we mentioned before, high levels of women tend to have less heterosexist attitudes than men
RWA are associated with conservative beliefs and negative (Herek, 2002), but that they are more prone to self-
attitudes towards individuals belonging to groups deviating stereotyping (Cadinu, Latrofa, & Carnaghi, 2013). Thus, fur-
from social norms. In this perspective, RWA is one of the main ther studies are needed to analyze this bias in both male and
variables associated with prejudice towards minority groups, female clinicians. Future studies should also better character-
and it could explain the different attributions of severity rat- ize the sample in terms of clinical experience and supervision
ings based on the gender identity and expression of the ficti- (in particular with TGNC clients), and educational back-
tious patient. We grouped the possible explanations of this ground (i.e., specific training in gender diversity).
unexpected result into two main areas. A cognitive interpreta- Moreover, we did not include a non-binary identified pa-
tion could be supported by the evidence that women are, in tient among the transgender identities proposed in the vi-
general, more likely than men to report physical and psycho- gnettes that we presented to therapists. This issue could make
logical symptoms. Research shows that women are more our conclusions not directly applicable to the TGNC popula-
prone than men to report higher levels of anxiety, depression, tion at large. Again, this should be explored and addressed in
and poor health in general (Cauce et al., 2000; Myers et al., future studies, as non-binary people are a highly marginalized
1984; Nolen-Hoeksema, 1991; Verbrugge, 1989; Macintyre, group, at risk of victimization and discrimination (Richards
Hunt, & Sweeting, 1996). In that sense, it could be that ther- et al., 2016).
apists are more exposed to female patients reporting symp- The evaluation of anti-transgender bias in a sample of pro-
toms than to males, thus biasing their clinical judgment. The fessionals with high psychological competence might have
second cognitive-motivational interpretation could be as- induced a mechanism of social desirability: when confronted
cribed to the activation of a stereotype, according to which with a transgender patient, psychotherapists are likely to sup-
women are more pathological than men. The literature reports press their transphobic response. For this reason, future stud-
that at least some psychiatric diagnoses suffer from a gender ies should assess attitudes towards transgender patients using
bias, according to which women are described as more path- implicit measures (e.g., the Implicit Association Test).
ological than men under the same symptomatic descriptions Moreover, future studies should focus on stereotypical symp-
(i.e., depression, histrionic personality disorder; see Garb, toms for transgender people, rather than neutral ones. In a
1997). It has also been suggested that the Global previous study on male psychotherapists evaluating a ficti-
Assessment of Functioning Scale (GAF) could provide a bi- tious gay client (Prunas et al., 2017), the authors found that
ased assessment of women’s functioning, even when men the stereotypicality of the disorder played a crucial role in
report deficient living skills (Hintikka, Saarinen, Tanskanen, treatment efficacy expectations. In particular, psychotherapists
Koivumaa-Honkanen, & Viinamäki, 1999). In some way, the anticipated fewer benefits from psychotherapy when a gay
internalization of this stereotype could explain the proneness patient reported a sexual disorder rather than a rage disorder.
of women to express more symptoms. Another explanation Exploratory studies are needed to identify psychopathological
could comprise a combination of the previous two; on the one conditions and disorders that mental health professionals
hand, therapists are more exposed to female patients, and, on stereotipically associate to being trans and gender non-
the other, a female sample of psychotherapists might demon- conforming.
strate internalization of the stereotype. Overall, these findings have relevant implications for clin-
No difference was observed between the ratings of severity ical practice (Sue, 2010): minorities already experience a rel-
for transmen and transwomen patients. One possible atively high level of stress, higher than that experienced by the
Sex Res Soc Policy

average straight white man. Practitioners should keep that in online sample of the US transgender population. American Journal
of Public Health, 103, 943–951. https://doi.org/10.2105/AJPH.
mind and try to control their biases and microaggressions
2013.301241.
towards this vulnerable population, ensuring a safe and trust- Bowers, S., Lewandowski, J., Savage, T. A., & Woitaszewski, S. A.
worthy environment for everyone. Research shows that com- (2015). School psychologists’ attitudes toward transgender students.
petence and knowledge about transgender health and issues, Journal of LGBT Youth, 12, 1–18. https://doi.org/10.1080/
along with familiarity and contact with gender-variant individ- 19361653.2014.930370.
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