TRANSGENDER AND GENDER DIVERSE PEOPLE IN PSYCHOTHERAPY: A SYSTEMATIC REVIEW OF QUANTITATIVE AND QUALITATIVE STUDIES

Introduction: “Transgender and gender diverse” (TGD) is an umbrella term that refers to individuals whose gender identity differs from their sex assigned at birth. At a population level, TGD people are more likely to experience greater distress compared to cisgender people. Reasons for seeking therapy that could relate to gender include experiences of discrimination, marginalization, and/or distress related to a person’s gender identity not aligning with their gendered body. Individuals may also seek therapy as part of a pathway to transition. The guidelines for ‘treatment pathways’ for people seeking medical gender reassignment suggest that psychological insight can support TGD individuals in a number of ways. These include exploring gender identity, coping with the negative consequences of gender dysphoria and stigma, alleviating internalized transphobia, improving body image and resilience, and strengthening social and peer support (Coleman et al., 2022). TGD individuals also naturally seek psychological therapy for the same reasons as cisgender individuals (Shipherd et al., 2010). Although it has been consistently demonstrated that the therapeutic relationship is the strongest predictor of psychological therapy outcomes, the therapy experiences of TGD individuals, aside from changes in a person’s social and relational context, are not well researched. The experiences of other oppressed or discriminated groups in therapy have received comparatively more attention, and the results deserve consideration. Therefore, the present study aims to systematically review studies that have addressed the experiences of TGD individuals in psychotherapy. Methods: A systematic search for quantitative and qualitative studies was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The Scopus, PubMed, and Web of Science databases were searched until June 1, 2024 for eligible records to include in the review. Boolean operators were used to combine terms related to the TGD population and their experiences in psychotherapeutic settings. Quality assessment was performed separately for quantitative and qualitative studies, each conducted independently by two authors. Disagreements were resolved by involving another reviewer. The National Institutes of Health’s Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies (2014) was used to rate the quality of the quantitative studies, whereas the quality of qualitative studies was assessed using the guidelines based on the article by Walsh and Downe (2006). Results: Sixteen articles were included in the current systematic review. Among these, 12 (75%) were qualitative, 3 (18.75%) used a mixed method design, and one (6.25%) was quantitative and cross-sectional. A two-step procedure (i.e., top-down and bottom-up) allowed us to group the findings of the included contributions into three main topics, respectively addressing microaggressions vs. microaffirmations in therapeutic settings (i.e., the therapist’s invalidation vs. acknowledgment of one’s affirmed gender), the therapeutic depathologization of gender diversity (i.e., moving beyond the societal cisnormativity), and the role of the therapeutic relationship (i.e., the alliance between patient and mental health provider). Overall, the findings of the current systematic review underscore the high frequency of microaggressions toward TGD individuals even in psychotherapeutic contexts, but also the help that these settings can provide to these people to get to know better themselves and their gender identity and expression. Conclusions: The literature reviewed in the current systematic review points to the significance for psychotherapeutic settings to provide TGD individuals with a safe place where to work on their concerns, at times preparing them for the transition process. Gender-specific training should be provided to all psychotherapists in order for them to adequately be at service of TGD patients (American Psychological Association, 2015), as well as to be prepared on specific issues such as minority stress and resilience factors in the TGD population (Meyer, 2003; Testa et al., 2015). Finally, the fact that 75% of the included studies (n = 16) have been carried out in the U.S., thus widely overrepresenting this population, prompts the need for further investigations of the therapeutic experiences of transgender patients in other countries – and especially Europe.