Clinical Practice with Trans and Gender Expansive Clients in Rural Settings

Overview: This session presents findings from 35 qualitative interviews with mental health clinicians serving trans and gender expansive clients in rural areas. Findings inform theoretical approaches, practice considerations, client-led resourcing, and clinical training gaps. Rural-based educators can also benefit from understanding students’ needs and strengths at this intersection of identities.Proposal text: Background
Within the last fifteen years, all the major mental health practice professions have all created special committees, task forces, and practice statements to support the unique needs of trangender and gender expansive (TGE) individuals (ACA, 2013; ALGBTIC, 2009; APA, 2009 & 2017; NASW, 2015; SAMHSA, 2015). Despite substantial efforts to ensure ethical practice with this population, research continues to indicate a lack of clinician competence (Cosgrove et al., 2021 ; McCullough et al., 2017; Timbers, 2022) and confidence in practice with TGE clients (Goldberg et al., 2019; GLSEN, 2019). Moreover, because research suggests unique needs at the intersection of TGE identity with other cultural and demographic factors (Gkiouleka et al, 2018; Meyer, 2003), it is essential to understand TGE clients amid their cultural environment. This study aims to equip social workers and social work educators with additional guidance for providing affirming mental healthcare to TGE clients in rural contexts.
Methods
Thirty-five clinicians of various licensure types participated in semi-structured interviews. Clinicians were recruited across the Appalachian region, which is known for its rural context. Snowball and purposive sampling was used to ensure a range in expertise with TGE clients, practice setting, and demographic characteristics. Coding was completed by two independent coders with different positionalities related to the topic. Using grounded theory, codes focused on the practices and processes of clinicians serving TGE clients in rural areas. Coders memoed and compared codes, agreeing on developing themes related to practice interventions and considerations. The process was audited by a third researcher for transparency and rigor.
Results
All participants noted gaps in resources related to medical and mental health care. Many who specialized said that there was still a need for more clinicians who are trained and willing to work with TGE clients. Clinicians often spent time helping TGE clients find medical gender-affirming resources and gender-affirming supports, suggesting a need for specific knowledge of TGE affirming resources in their particular region. Alongside this, clinicians also celebrated the mutual aid present in these communities. Those who specialized in this work were able to note specific trainings that supported their work. Clinicians that did not specialize in work with TGE clients expressed concerns about their own lack of training and worried about making mistakes. These clinicians often had basic knowledge related to gender identity but reported fewer or no specific trainings. Several theoretical approaches were mentioned and tailored to treatment with this population; however, critical perspectives were foundational for those specializing in this work.
Conclusions
TGE clients are often treated as a homogenous group; however, for clinicians in rural areas, there are unique considerations relevant to their work with clients. Specific training is important as well as intimate knowledge of community resources. This research shows that there are TGE individuals in rural areas who can and want to thrive where they live. Educators should include readings and content related to rural services for TGE clients and highlight specialized training for post-graduation specialization.