Counseling Trans Folks in the Immediate Aftermath of Skrmetti
Guidance for Psychotherapists
I have started calling my therapist colleagues “comrades-in-care.” This is not just to be cute. It is adapted from comrades-in-arms and is meant to signify both solidarity and that the provision of care is a critical part of the fight we are in.
So my dear Comrades-in-Care, this substack post is for you. If you’re like me, you were in session with a client when the Skrmetti decision was released and had a day full of clinical work after the news broke. All my clients today were trans. All my clients tomorrow are trans.
I wanted to quickly share some guidance on how to show up for trans folks as they are processing this ruling and the impacts from it. This is largely adapted from my May training on on working with trans clients experiencing sociopolitical distress, but that costs money and I want as many therapists as possible to have access to this. And even if you attended that training, it’s good to be re-grounded in the approaches we discussed. [And a note here that I’m writing this in the evening after an intense day and not taking the time to review it. This is certainly going to be imperfect, but I am hopeful it will be helpful to others.]
First, take care of yourself. Your trans clients need a therapist who is able to be present with their difficult feelings about this and myriad reactions to it. You can only do that if you’re managing your own emotions and wellbeing. Of course it’s okay to be overwhelmed and upset right now, but if you’re too dysregulated to be an effective container for clients’ emotions, you need to resource yourself and/or reschedule sessions. Resourcing yourself may look like grounding before sessions with meditation or jumping jacks. It may look like non-distracting self-soothing (comfort tea, anyone?) during session or decompression after — I highly recommend uncensored journaling and a 2-minute dance party. It may look like calling your own therapist and trying to get an urgent session or utilizing prescribed psychopharmaceutical interventions. Or seeking hugs and care from loved ones. Resourcing yourself definitely looks like eating and hydrating in ways that sustain your energy throughout the day and prioritizing helpful sleeping behaviors (and thus hopefully good sleep).
Take care of yourself because your trans clients need you to show up.
Here’s what trans clients need you to do in the coming week especially:
Be consistent.
Many trans people feel abandoned by their country right now. You can help them experientially remember that there are people invested in their wellbeing by showing up on time, following up promptly, and keeping your appointments when possible. I know all to well this isn’t always possible and I just said above that it’s important that therapists can take time to re-regulate, so when you can’t be consistent, be communicative.
Display your commitment to the trans community.
I want to see therapist offices and social media outfitted with visual indicators that trans people belong in those spaces. I want art and books and language that makes it clear that you support trans people and believe in (and celebrate) the naturalness of gender diversity. Like I said, a lot of trans folks feel abandoned by this country. If you’re not trans, remind the trans people in your life and your office that you’re still with us. And I think this messaging is especially important with regard to trans youth. When I see an adult wearing a “protect trans kids” shirt I want to cry with happiness. I will never forget the mother of a trans young person, who relocated to my area from Tennessee for their family’s safety and access to care, telling me she cried with relief and gratitude every time she got coffee because she saw queer and trans flags in every cafe.
Know your role and skill set.
When you’re sitting with a client, it’s really important to remember what we are best equipped to offer them. We are not news analysts and we are not friends they’re seeing to discuss politics with. Therapists are uniquely trained to help clients make sense of their emotions and then sometimes change their relationship with or experience of those emotions. Avoid the pull to discuss things solely at a political level. When a client is sharing their analysis of the Skrmetti decision, it’s generally not our job to chime in with our analysis. It is our job to listen for the client’s emotion and internal processes related to that political analysis. There are always exceptions to rules, and an important exception to this guidance for me is if clients are spinning out about misinformation about what this means. More on that below.
Be open to alternative methods of getting trans healthcare. Educate yourself about this.
I’m not going to write too much about this on a public platform. But our clients need to feel safe emotionally and legally to be honest with us about however they are preserving or pursuing access to care during this oppressive time.
Gently confront misinformation. (Which also means you need to stay informed.)
Follow legal and advocacy orgs expert analyses of the implications of the Skrmetti decision. ACLU and Lambda Legal are the primary sources I’ll be engaging with. In scary and uncertain times, we are desperate for someone to give us something we can know - something to be certain about. And our freaked out brains will also look for signs of danger to protect against. This makes us highly susceptible to internalize others’ confident worst-case-scenario perspectives in periods like this. I anticipate clients are going to be on TikTok and in discord servers and group chats hearing all kinds of terrifying claims about what this means. If you are equipped with up-to-date knowledge about this, and a client comes in upset because of a misinterpretation, you can tend to the emotion they’re arriving with and carefully share what you have learned. Always always engage with humility: you might be wrong, your sources might not be as up-to-date as you thought. And always engage with compassion: we do not want folks to feel shamed for believing something potentially inaccurate. And finally, be careful of your countertransference. Are you needing to feel safe and reassured so you are giving more credence to more hopeful interpretations than scarier ones?
Recognize the both/and.
Our capacity to simultaneously hold two truths that are seemingly at odds with each other is called dialectical capacity. I suspect many of you will be familiar with this, at least through its role in dialectical behavior therapy (DBT). Dialectics are critical to emotional wellbeing, because the world is messy and so are our brains. The reality is rarely either/or and is almost always both/and. I am devastated by this ruling and I just felt ecstatic pleasure at eating that pizza. I am practicing hope about the future for trans people and I’m scared that I’m wrong and my hope is dangerous. Clients need to be able to grieve and know that grief is not all there is. Clients need to experience belief in their capacity to survive this and not deny their suffering or hard survival might be.
Invite and receive clients’ devastation, hopelessness, rage, and terror.
The number one thing clients need from us right now is the ability to withstand their big emotions about this ruling. To be in it with them. Many trans folks are understandably exhausted and for a lot of people, this decision is adding to a feeling of being unable to take much more. I have witnessed four main fears in my clients this year: 1) that they are going to lose access to treatments that have saved them from incredibly distressing gender dysphoria; 2) that they are going to be further marginalized and harmed for being trans; 3) that these things are going to happen to fellow community members; and/or 4) that they can’t handle the emotional impact of all of this and will be destroyed by their despair and fear and anger. The latter, in particular, is where we come in. By tolerating emotional extremes in session, we help clients internalize that they can also tolerate these. When a client sobs in session, I do not do a grounding technique. I let them sob. I use my steady presence as some form of grounding and load-bearing, but otherwise I want them to experience extreme emotion and safety at the same time. [There are limits to this, but it’s important that your window of tolerance for difficult affect is very, very wide.]
A lot of well-meaning therapists rush to comfort when clients experience and express affect that feels unbearable. By doing this, we are reinforcing that the affect is unbearable, but it is not - at least not when held in relationship or community. The other thing therapists are at risk of doing here is (sometimes unwittingly) invalidating clients’ actually reasonable and appropriate responses to this ruling. Please, please, please do not try to reassure clients that things will be okay or that this won’t affect them. It is already affecting them even if not directly in regard to their access to care. Things are already not okay. We are helping trans clients live meaningfully in a world that is harming our communities and we do them a disservice if we ignore that harm or teach them they have to ignore it to be okay.
So yeah, let them rage. Let them cry. Create the space for this. Talk less.
And then help them not be alone in these feelings by being there with them. Steady presence.
Facilitate the naming of these emotions and understanding their multiple dimensions. Don’t assume you know what clients are feeling or that they are feeling similar to how you are.
The Skrmetti ruling has indirect and/or symbolic effects for most folks. Unless you are working with a young trans person from Tennessee or their family, this decision is not about them and does not directly affect their care. If you are working with young trans people and/or their families in other states with healthcare bans, this doesn’t bode well for the fights for their healthcare, but it is still more about what it represents than the direct impacts right now. I say all of this, because what this decision means to someone is going to affect how they are feeling about it. For some young people it will mean that the most easily accessed (by far) door to puberty suppression or affirming hormones is fully closed, and this will feel devastating and they may be terrified of experiencing worsening dysphoria. Some folks will experience this decision as yet another piece of bad news, and will feel a crushing sense of weight under the accumulation of all the bad news of the past years; they may feel hopeless. Some folks will experience it as a canary and be scared of what comes next. Some folks will experience it as further evidence of the incompetence and/or corruption of this Supreme Court and feel enraged at their illegitimacy. Some may feel vindicated that their lack of hope seemingly proved appropriate. More than likely, clients’ reactions will be combinations of multiple thoughts and feelings - some in seeming conflict with each other. We have the great honor of sitting with clients’ raw feelings and helping them make sense of them, put words to them, understand where they fit into their narrative of this moment and their lives. All of this helps the emotions become more bearable. So do that here. Encourage description or creative expression. Invite associations. Does this feeling seem familiar to them? Does it look or sound or feel familiar to you? Help them contextualize it. Normalize and validate. Of course they feel this way. Listen to them, draw from what they’ve already shared with you. “It makes sense you’d be so messed up by this - it’s scary and devastating. And it’s happening when you were just expressing how much you could use a victory to combat that feeling of hopelessness. I suspect it’s also exacerbated by the distress you’re feeling about the ICE raids.” Be careful to not insert your own feelings here and assume that their reactions mirror your own.
Hold potential space for working with and through these emotions. But don’t rush to fix.
If your clients are upset about the Skrmetti decision, I believe they need at least a session to just be in those feelings, especially in the immediate aftermath. And also, tolerating clients’ difficult emotions is just the first step of emotional work around this. We also need to help clients make sense of their reactions and figure out what their needs are around all of this. But you don’t want to move into that too quickly and shut down the space for feeling all these things. Still, it can be helpful for some clients to know that your plan isn’t just to swim in place in big feelings forever. In one of my sessions today, I messed up. I was worried about my client and hadn’t adequately recalibrated after my own reaction to the news, and so after some time helping them express their grief and fear, I said something encouraging reflection on how they’ve handled overwhelming political stress in the past year. I knew I’d messed up because I watched them move out of an open, exploratory, and emotionally expressive state. They were suddenly thinking hard, rather than emoting and sharing associatively, and their words didn’t come freely. I named my mistake. “I think I moved there too fast. Maybe today isn’t about coping with or managing. Maybe today just needs to be us being in it. We have room for the other stuff later. You’re really suffering right now and it’s important you’re not alone in that.” I think this was ultimately a good mistake, because in the recovery from it, I noted that I was preserving a pathway for working through the feelings and believed that could happen but didn’t need to happen now. [It doesn’t make sense to get into this here, but I do talk about how I help clients work through these emotional reactions in the larger training.]
Help clients understand the threat they are facing, their body’s threat response, and any incongruence between those.
As I said earlier, unless you are working with young people and their families in Tennessee, most of your clients are not going to be materially impacted by this ruling in the immediate or near-immediate future. Their bodies may still be reacting as though they are. There’s a meme from the first couple weeks of the second Trump presidency that read “My body doesn’t know the difference between reading a headline and being tied to a cement block in the bottom of a lake.” It can be useful when clients are really dysregulated to remember that feeling scared and panicking are two different things. Fear is an emotional experience. Panic on the other hand, is a full nervous system reaction, in which bodily processes not necessary for survival are under-resourced in order to prioritize our ability to GTFO, fight for our lives, or freeze and play dead. Panic is what helps us survive when the bear is charging at us, but it really gets in the way of what is needed to survive when the bear is somewhere out in the woods and we need to strategize on how to get to the other end of the woods. Panic gets in the way when we need to be figuring out how to access out-of-state care or how to manage dysphoria without medical intervention for an amount of time. It can be helpful to do some psychoeducation with clients about this and to help them develop ways of re-regulating their nervous system when panic starts to set in. We’re not trying to get clients to avoid feeling incredibly upset. We’re helping them avoid getting stuck in survival mode. And we’re helping them know the difference between the two, so they can honor their emotions and also down-regulate panic.
Nurture rootedness in history, community, and other sources of strength, connection, and empowerment.
Shortly after the ruling, ACLU lawyer Chase Strangio posted a reel expressing sadness and anger about the decision. He reaffirmed his own commitment to fighting for trans people and reminded young trans people that our community will continue to show up for them. He used a photograph of Pauli Murray as his background and said he was doing so because he wanted “to stay grounded in the fact that our histories stretch back decades and centuries.” (Pauli Murray was a trailblazing Black queer lawyer and social justice activist.) Help clients remember and/or develop their sources of strength to stay grounded in. For some clients, they may be like Strangio, and draw empowerment from reminders that we’ve always been here and we will always be here - by feeling connected to the transcestors who would be so proud to see us living our truths and continuing this fight. Other clients may feel more capable of facing the post-Skrmetti reality when they think of the people in their close community who have their back. Some will feel less alone when they listen to trans music or call to mind other trans art. Maybe community pride events or rallies will nourish your client’s resolve and energy. Maybe time in nature or physical movement.
Encourage rest. (Play and pleasure are also great.)
Today my city council is voting on a resolution affirming the city’s commitment to trans people’s safety and rights. A huge amount of support was expected, but so was some opposition. I decided that it was not a good use of my time and body to be present for the meeting and asked a non-trans friend who was attending to read a statement from me. I wanted to rest and play and work instead of sitting through even one anti-trans public comment. Especially today.
In my experience, many trans people don’t really want to be in this fight. They’re stuck in it because their lives and fellow community members’ lives depend on it. Big setbacks like this SCOTUS ruling are going to make people feel weary, overwhelmingly fatigued by a battle they were already tired of. Help your clients rest in the face of this weariness. Help them develop beliefs that they deserve rest. Help them find softness and even small doses of safety. I recently recommended a client try float therapy, not exactly for this reason, but I could see the practice applying here. Taking an hour and resting free of gravity and devices. And maybe even our clients can intentionally pursue playful activities, experience fun and pleasure.
Lastly, especially if you are not trans, your clients need you to show up for trans people outside of clinical work too.
Engage in effective advocacy & activism. And help trans people get hormones, surgeries, jobs, and money.
Historian Dr. Jules Gill-Peterson recently noted in an interview with them magazine that we’ve become overly focused on facilitating this nebulous immaterial “trans joy” that distracts us from the most critical avenues of positive change for trans people: hormones, surgeries, jobs, and money. While I am a big believer in the value of trans folks having access to joy, etc., Gill-Peterson’s words have inspired me to re-center the material in my advocacy.
Dr. Anna Marie LaChance put together an awesome guide for how cis folks can help trans people right now, and I’m posting it every chance I can get, because it’s really well done and thorough, and a lot of it speaks to helping trans folks access these material changes. So PLEASE READ THIS, share it, and choose some actions to take: https://www.thatannamarie.com/help
There’s more work for us to be doing in terms of sociopolitical distress and specifically in supporting young people and families in states with healthcare bans, but I think this guidance is good enough to get us through the first week or so of acute reactions to this. Again, I have an in-depth training on this work, with part 1 available as a recording (paid), and the expansion using clinical vignettes coming up live (and recorded) in July. The upcoming training’s registration is sliding scale and trans folks can register at an even further reduced cost or for free (see FAQ for current codes). All this info is available on my website: https://transpsychologist.com/trainings