https://doi.org/10.4081/ripppo.2025.834
Trans in treatment: a mixed-method systematic review on the psychotherapeutic experiences of transgender and gender diverse people
Transgender people’s experiences of psychotherapy
Submitted: October 21, 2024
Accepted: January 27, 2025
Published: February 28, 2025
Accepted: January 27, 2025
Abstract Views: 1267
PDF: 566
SUPPLEMENTARY MATERIAL: 240
SUPPLEMENTARY MATERIAL: 240
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Authors
Transgender and/or non-binary (TNB) individuals encounter a variety of attitudes from mental healthcare professionals in therapeutic contexts, ranging from microaffirmations to the reinforcement of cis- and heteronormative stereotypes and even overtly invalidating behaviors or communications. Given the scarcity of literature addressing the therapeutic experiences of TNB individuals, the current mixed-method systematic review aimed at better understanding the factors that promote or adversely impact the therapeutic experiences of TNB individuals in clinical contexts. A comprehensive search for relevant records published before August 1, 2024, was conducted across four databases (i.e., Scopus, Web of Science, PubMed, PsycInfo), following PRISMA guidelines. The inclusion criteria specified that only peer-reviewed, indexed, English-language articles addressing the therapeutic experiences of TNB individuals would be selected. A total of 20 studies (both quantitative and qualitative) met these criteria. A meta-synthesis of the selected studies identified three main themes: (1) factors influencing therapist selection and reasons for seeking psychotherapy (e.g., quality of life, gender-specific concerns); (2) factors contributing to a positive therapeutic relationship (a nurturing therapeutic alliance that, e.g., acknowledges authentic gender and addresses intersectional stigma); and (3) factors contributing to negative encounters with mental healthcare providers (e.g., micro- and/or macroaggressions, inadequate trans-specific knowledge, pathologization of TNB identities). Recommendations for future research and clinical practice addressing the needs of TNB individuals in psychotherapy are provided.
*Articles included in the systematic review
American Psychological Association. (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70, 832–864. doi: 10.1037/a0039906
DOI: https://doi.org/10.1037/a0039906
American Psychological Association Task Force on Gender Identity and Gender Variance. (2009). Report of the task force on gender identity and gender variance. Available from: http://www.apa.org/pi/lgbt/resources/policy/gender-identity-report.pdf
*Anzani, A., Morris, E. R., & Galupo, M. P. (2019). From absence of microaggressions to seeing authentic gender: Transgender clients’ experiences with microaffirmations in therapy. Journal of LGBT Issues in Counseling, 13(4), 258–275. doi: 10.1080/15538605.2019.1662359
DOI: https://doi.org/10.1080/15538605.2019.1662359
*Applegarth, G., & Nuttall, J. (2016). The lived experience of transgender people of talking therapies. International Journal of Transgenderism, 17(2), 66–72. doi: 10.1080/15532739.2016.1149540
DOI: https://doi.org/10.1080/15532739.2016.1149540
*Arora, S., Gonzalez, K. A., Abreu, R. L., & Gloster, C. (2022). “Therapy can be restorative, but can also be really harmful”: Therapy experiences of QTBIPOC clients. Psychotherapy, 59(4), 498–510. doi: 10.1037/pst0000443
DOI: https://doi.org/10.1037/pst0000443
*Artime, T. M., Rosenfeld, E. A., Ong, L., Lisha, N. E., Dilley, J. W., Shumway, M., Edward, D., Ceja, A., Einhorn, L., Lubensky, M. E., Dastur, Z., Lunn, M. R., Obedin-Maliver, J., Cloitre, M., & Flentje, A. (2024). Mental health treatment experiences among sexual and gender minority individuals: Trauma exposure, barriers, microaggressions, and treatment satisfaction. Journal of Gay & Lesbian Mental Health. Advance online publication. doi: 10.1080/19359705.2024.2315976
DOI: https://doi.org/10.1080/19359705.2024.2315976
*Benson, K. E. (2013). Seeking support: Transgender client experiences with mental health services. Journal of Feminist Family Therapy: An International Forum, 25(1), 17–40. doi: 10.1080/08952833.2013.755081
DOI: https://doi.org/10.1080/08952833.2013.755081
*Bess, J. M., & Stabb, S. D. (2009). The experiences of transgendered persons in psychotherapy: Voices and recommendations. Journal of Mental Health Counseling, 31, 264–282. doi: 10.17744/MEHC.31.3.F62415468L133W50
DOI: https://doi.org/10.17744/mehc.31.3.f62415468l133w50
*Bockting, W., Robinson, B., Benner, A., & Scheltema, K. (2004). Patient satisfaction with transgender health services. Journal of Sex & Marital Therapy, 30, 277–294. doi: 10.1080/00926230490422467
DOI: https://doi.org/10.1080/00926230490422467
Bristowe, K., Hodson, M., Wee, B., Almack, K., Johnson, K., Daveson, B. A., Koffman, J., McEnhill, L., & Harding, R. (2018). Recommendations to reduce inequalities for LGBT people facing advanced illness: ACCESSCare national qualitative interview study. Palliative Medicine, 32(1), 23–35. doi: 10.1177/0269216317705102
DOI: https://doi.org/10.1177/0269216317705102
Carone, N., Innocenzi, E., & Lingiardi, V. (2023). Microaggressions and dropout when working with sexual minority parents in clinical settings: The working alliance as a mediating mechanism. Psychology of Sexual Orientation and Gender Diversity. Advance online publication. doi: 10.1037/sgd0000651
DOI: https://doi.org/10.1037/sgd0000651
Catelan, R. F., Costa, A. B., & Lisboa, C. S. d. M. (2017). Psychological interventions for transgender persons: A scoping review. International Journal of Sexual Health, 29(4), 325–337. doi: 10.1080/19317611.2017.1360432
DOI: https://doi.org/10.1080/19317611.2017.1360432
Cavanaugh, K. M., & Luke, M. M. (2021). Transgender college student identity development: A narratology of intermediating experiences. The Journal of Humanistic Counseling, 60(2), 137–156. doi: 10.1002/johc.12161
DOI: https://doi.org/10.1002/johc.12161
Cohen, J. (1960). A coefficient of agreement for nominal scales. Educational and Psychological Measurement, 20(1), 37–46. doi: 10.1177/001316446002000104
DOI: https://doi.org/10.1177/001316446002000104
Coleman, E., Radix, A. E., Bouman, W. P., Brown, G. R., De Vries, A. L. C., Deutsch, M. B., ... & Arcelus, J. (2022). Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health, 23(Suppl 1), S1–S259. doi: 10.1080/26895269.2022.2100644
DOI: https://doi.org/10.1080/26895269.2022.2100644
Compton, E., & Morgan, G. (2022). The experiences of psychological therapy amongst people who identify as transgender or gender non-conforming: A systematic review of qualitative research. Journal of Feminist Family Therapy: An International Forum, 34(3–4), 225–248. doi: 10.1080/08952833.2022.2068843
DOI: https://doi.org/10.1080/08952833.2022.2068843
Cruciani, G., Quintigliano, M., Mezzalira, S., Scandurra, C., & Carone, N. (2024). Attitudes and knowledge of mental health practitioners towards LGBTQ+ patients: A mixed-method systematic review. Clinical Psychology Review, 113, 102488. doi: 10.1016/j.cpr.2024.102488
DOI: https://doi.org/10.1016/j.cpr.2024.102488
Da Cruz Leal, G., Júnior, J. N. B. S., Ferreira, Q. R., Ballestero, J. G. A., & Palha, P. F. (2024). Institutional violence perpetrated against transgender individuals in health services: A systematic review of qualitative studies. International Journal of Environmental Research and Public Health, 21(8), 1106. doi: 10.3390/ijerph21081106
DOI: https://doi.org/10.3390/ijerph21081106
Dhejne, C., Van Vlerken, R., Heylens, G., & Arcelus, J. (2016). Mental health and gender dysphoria: A review of the literature. International Review of Psychiatry, 28(1), 44–57. doi: 10.3109/09540261.2015.1115753
DOI: https://doi.org/10.3109/09540261.2015.1115753
Egan, S. K., & Perry, D. G. (2001). Gender identity: A multidimensional analysis with implications for psychosocial adjustment. Developmental Psychology, 37(4), 451–463. doi: 10.1037//0012-1649.37.4.451
DOI: https://doi.org/10.1037//0012-1649.37.4.451
*Elder, A. (2015). Experiences of older transgender and gender nonconforming adults in psychotherapy: A qualitative study. Psychology of Sexual Orientation and Gender Diversity, 3(2), 180–186. doi: 10.1037/sgd0000154
DOI: https://doi.org/10.1037/sgd0000154
Esposito, G., Scandurra, C., Freda, M. F., Pepicelli, G., Valerio, P., & Vitelli, R. (2022). Qualities of mentalization and perception of parental mirroring in a group of Italian transgender people: An empirical study. Psychoanalytic Psychology, 39(1), 59–68. doi: 10.1037/pap0000388
DOI: https://doi.org/10.1037/pap0000388
Expósito-Campos, P., Pérez-Fernández, J. I., & Salaberria, K. (2023). Empirically supported affirmative psychological interventions for transgender and non-binary youth and adults: A systematic review. Clinical Psychology Review, 100, 102229. doi: 10.1016/j.cpr.2022.102229
DOI: https://doi.org/10.1016/j.cpr.2022.102229
European Union Agency for Fundamental Rights. (2024). LGBTIQ equality at a crossroads: Progress and challenges. Available from: https://fra.europa.eu/sites/default/files/fra_uploads/fra-2024-lgbtiq-equality_en.pdf
Giovanardi, G., Mundo, E., & Lingiardi, V. (2021). Paola on the couch: The quest for feminine identity in an empirically supported psychoanalytic psychotherapy of a trans woman. Psychoanalytic Psychology, 38(4), 239–253. doi: 10.1037/pap0000330
DOI: https://doi.org/10.1037/pap0000330
*Goldberg, A. E., Kuvalanka, K. A., Budge, S. L., Benz, M. B., & Smith, J. Z. (2019). Health care experiences of transgender binary and nonbinary university students. The Counseling Psychologist, 47(1), 59–97. doi: 10.1177/0011000019827568
DOI: https://doi.org/10.1177/0011000019827568
Goulding, R., Goodwin, J., O’Donovan, A., & Saab, M. M. (2023). Transgender and gender diverse youths’ experiences of healthcare: A systematic review of qualitative studies. Journal of Child Health Care. Advance online publication. doi: 10.1177/13674935231222054
DOI: https://doi.org/10.1177/13674935231222054
Hansbury, G. (2017). Unthinkable anxieties: Reading transphobic countertransferences in a century of psychoanalytic writing. Transgender Studies Quarterly, 4(3-4), 384–404. doi: 10.1215/23289252-4189883
DOI: https://doi.org/10.1215/23289252-4189883
Harris A. (2022). Transgender and analytic countertransference. Psychoanalytic Review, 109(3), 277–286. doi: 10.1521/prev.2022.109.3.277
DOI: https://doi.org/10.1521/prev.2022.109.3.277
*Hunt, J. (2014). An initial study of transgender people’s experiences of seeking and receiving counselling or psychotherapy in the UK. Counselling and Psychotherapy Research, 14(4), 288–296. doi: 10.1002/14733145.2013.838597
DOI: https://doi.org/10.1080/14733145.2013.838597
Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. National Academies Press.
James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The report of the 2015 U.S. transgender survey. National Center for Transgender Equality.
Jones, S., & Patel, T. (2022). Inaccessible and stigmatizing: LGBTQ+ youth perspectives of services and sexual violence. Journal of LGBT Youth, 20(3), 632–657. doi: 10.1080/19361653.2022.2134253
DOI: https://doi.org/10.1080/19361653.2022.2134253
*Keating, L., Muller, R. T., & Wyers, C. (2021). LGBTQ+ people’s experiences of barriers and welcoming factors when accessing and attending intervention for psychological trauma. Journal of LGBTQ Issues in Counseling, 15(1), 77–92. doi: 10.1080/15538605.2021.1868376
DOI: https://doi.org/10.1080/15538605.2021.1868376
Kuvalanka, K. A., Weiner, J., & Mahan, D. (2014). Child, family, and community transformations: Findings from interviews with mothers of transgender girls. Journal of GLBT Family Studies, 10, 354–379. doi: 10.1080/1550428x.2013.834529
DOI: https://doi.org/10.1080/1550428X.2013.834529
Lemma, A. (2018). Trans-itory identities: Some psychoanalytic reflections on transgender identities. The International Journal of Psychoanalysis, 99(5), 1089–1106. doi: 10.1080/00207578.2018.1489710
DOI: https://doi.org/10.1080/00207578.2018.1489710
Livingston, N. A., Berke, D., Scholl, J., Ruben, M., & Shipherd, J. C. (2020). Addressing diversity in PTSD treatment: Clinical considerations and guidance for the treatment of PTSD in LGBTQ populations. Current Treatment Options in Psychiatry, 7, 53–69. doi: 10.1007/s40501-020-00204-0
DOI: https://doi.org/10.1007/s40501-020-00204-0
*Mackie, G., Patlamazoglou, L., & Lambert, K. (2023). The experiences of Australian transgender young people in school counseling: An interpretative phenomenological analysis. Psychology of Sexual Orientation and Gender Diversity, 10(2), 337–349. doi: 10.1037/sgd0000544
DOI: https://doi.org/10.1037/sgd0000544
Malpas, J., Pellicane, M. J., & Glaeser, E. (2022). Family-based interventions with transgender and gender expansive youth: Systematic review and best practice recommendations. Transgender Health, 7(1), 7–29. doi: 10.1089/trgh.2020.0165
DOI: https://doi.org/10.1089/trgh.2020.0165
Matsuno, E., & Budge, S. (2017). Non-binary/genderqueer identities: A critical review of the literature. Current Sexual Health Reports, 9, 116–120. doi: 10.1007/s11930-017-0111-8
DOI: https://doi.org/10.1007/s11930-017-0111-8
*McCullough, R., Dispenza, F., Parker, L., Viehl, C. J., Chang, C. Y., & Murphy, T. M. (2017). The counselling experiences of transgender and gender nonconforming clients. Journal of Counseling and Development, 95(4), 423–434. doi: 10.1002/jcad.12157
DOI: https://doi.org/10.1002/jcad.12157
Mezza, F., Mezzalira, S., Pizzo, R., Maldonato, N. M., Bochicchio, V., & Scandurra, C. (2024). Minority stress and mental health in European transgender and gender diverse people: A systematic review of quantitative studies. Clinical Psychology Review, 107, 102358. doi: 10.1016/j.cpr.2023.102358
DOI: https://doi.org/10.1016/j.cpr.2023.102358
Mezzalira, S., Carone, N., Bochicchio, V., Cruciani, G., Quintigliano, M., & Scandurra, C. (2024). The healthcare experiences of LGBT+ people in Europe: A systematic review. Sexuality Research and Social Policy. doi: 10.1007/s13178-024-01068-2
DOI: https://doi.org/10.1007/s13178-024-01068-2
Mezzalira, S., Pick, E., & Palmieri, A. (2023). Nachträglichkeit and après-coup in the psychological scientific literature: A systematic review and future perspectives. Psychoanalytic Psychology, 40(2), 82–89. doi: 10.1037/pap0000425
DOI: https://doi.org/10.1037/pap0000425
Mezzalira, S., Scandurra, C., Mezza, F., Miscioscia, M., Innamorati, M., Bochicchio, V. (2023). Gender felt pressure, affective domains, and mental health outcomes among transgender and gender diverse (TGD) children and adolescents: A systematic review with developmental and clinical implications. International Journal of Environmental Research and Public Health, 20, 785. doi: 10.3390/ijerph20010785
DOI: https://doi.org/10.3390/ijerph20010785
*Mizock, L., & Lundquist, C. (2016). Missteps in psychotherapy with transgender clients: Promoting gender sensitivity in counseling and psychological practice. Psychology of Sexual Orientation and Gender Diversity, 3(2), 148–155. doi: 10.1037/sgd0000177
DOI: https://doi.org/10.1037/sgd0000177
Mkhize, S. P., & Maharaj, P. (2020). Structural violence on the margins of society: LGBT student access to health services. Agenda, 34(2), 104–114. doi: 10.1080/10130950.2019.1707000
DOI: https://doi.org/10.1080/10130950.2019.1707000
* Morris, E. R., Lindley, L., & Galupo, M. P. (2020). “Better issues to focus on”: Transgender microaggressions as ethical violations in therapy. The Counseling Psychologist, 48(6), 883–915. doi: 10.1177/0011000020924391
DOI: https://doi.org/10.1177/0011000020924391
National Heart, Lung, and Blood Institute. (2014). Quality assessment tool for observational cohort and cross-sectional studies. National Institutes of Health, Department of Health and Human Services.
Pachankis, J. E., Clark, K. A., Jackson, S. D., Pereira, K., & Levine, D. (2021). Current capacity and future implementation of mental health services in U.S. LGBTQ community centers. Psychiatric Services, 72(6), 669–676. doi: 10.1176/appi.ps.202000575
DOI: https://doi.org/10.1176/appi.ps.202000575
Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., … Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372, 71. doi: 10.1136/bmj.n71
DOI: https://doi.org/10.1136/bmj.n71
*Puckett, J. A., Kimball, D., Glozier, W. K., Wertz, M., Dunn, T., Lash, B. R., … DuBois, L. Z. (2023). Transgender and gender diverse clients’ experiences in therapy: Responses to sociopolitical events and helpful and unhelpful experiences. Professional Psychology: Research and Practice, 54(4), 265–274. doi: 10.1037/pro0000513
DOI: https://doi.org/10.1037/pro0000513
*Rachlin, K. (2002). Transgender individuals’ experiences of psychotherapy. International Journal of Transgenderism, 6, 1–19.
*Rosati, F., Lorusso, M. M., Pistella, J., Giovanardi, G., Di Giannantonio, B., Mirabella, M., Williams, R., Lingiardi, V., & Baiocco, R. (2022). Non-binary clients’ experiences of psychotherapy: Uncomfortable and affirmative approaches. International Journal of Environmental Research and Public Health, 19(22), 15339. doi: 10.3390/ijerph192215339
DOI: https://doi.org/10.3390/ijerph192215339
Saketopoulou, A. (2014). Mourning the body as bedrock. Journal of the American Psychoanalytic Association, 62, 773–806. doi: 10 .1177/0003065114553102
DOI: https://doi.org/10.1177/0003065114553102
Saketopoulou, A. (2020). Thinking psychoanalytically, thinking better: Reflections on transgender. The International Journal of Psychoanalysis, 101(5), 1019–1030. doi: 10.1080/00207578.2020.1810884
DOI: https://doi.org/10.1080/00207578.2020.1810884
Santamaria, F., Scandurra, C., Mezzalira, S., Bochicchio, V., Salerno, M., Di Mase, R., & Capalbo, D. (2024). Unmet needs of pediatricians in transgender-specific care: Results of a short-term training. Hormone Research in Paediatrics, 97(3), 254–260. doi: 10.1159/000533551
DOI: https://doi.org/10.1159/000533551
Scandurra, C., Mezza, F., Valerio, P., & Vitelli, R. (2019). Affirmative approaches and relevance of minority stress in psychological counseling with LGBT people: A review of the international literature. Psicoterapia e Scienze Umane, 53(1), 67–92. doi: 10.3280/PU2019-001004
DOI: https://doi.org/10.3280/PU2019-001004
Scheim, A. I., & Bauer, G. R. (2015). Sex and gender diversity among transgender persons in Ontario, Canada: Results from a respondent-driven sampling survey. The Journal of Sex Research, 52(1), 1–14. doi: 10.1080/00224499.2014.893553
DOI: https://doi.org/10.1080/00224499.2014.893553
*Schofield, K., Dunnett, A., & Gabriel, L. (2024). Let me be me: Investigating transgender clients’ experiences of their therapeutic relationship with their counsellor. Counselling & Psychotherapy Research, 24(2), 582–590. doi: 10.1002/capr.12692
DOI: https://doi.org/10.1002/capr.12692
Schuster, M. A., Reisner, S. L., & Onorato, S. E. (2016). Beyond bathrooms – Meeting the health needs of transgender people. The New England Journal of Medicine, 375(2), 101–103. doi: 10.1056/NEJMp1605912
DOI: https://doi.org/10.1056/NEJMp1605912
Shelemy, L., Cotton, S., Crane, C., & Knight, M. (2024). Systematic review of prospective adult mental health outcomes following affirmative interventions for gender dysphoria. International Journal of Transgender Health. Advance online publication. doi: 10.1080/26895269.2024.2333525
DOI: https://doi.org/10.1080/26895269.2024.2333525
*Strauss, P., Lin, A., Winter, S., Waters, Z., Watson, V., Wright Toussaint, D., & Cook, A. (2021). Options and realities for trans and gender diverse young people receiving care in Australia’s mental health system: Findings from Trans Pathways. The Australian and New Zealand Journal of Psychiatry, 55(4), 391–399. doi: 10.1177/0004867420972766
DOI: https://doi.org/10.1177/0004867420972766
Vitelli, R., & Riccardi, E. (2011). Gender identity disorder and attachment theory: The influence of the patient's internal working models on psychotherapeutic engagement and objective. A study undertaken using the Adult Attachment Interview. International Journal of Transgenderism, 12(4), 241–253. doi: 10.1080/15532739.2010.551485
DOI: https://doi.org/10.1080/15532739.2010.551485
Walsh, D., & Downe, S. (2006). Appraising the quality of qualitative research. Midwifery, 22(2), 108–119. doi: 10.1016/j.midw.2005.05.004
DOI: https://doi.org/10.1016/j.midw.2005.05.004
Weir, C., & Piquette, N. (2018). Counselling transgender individuals: Issues and considerations. Canadian Psychology, 59(3), 252–261. doi: 10.1037/cap0000129
DOI: https://doi.org/10.1037/cap0000129
Winnicott, D. W. (1971). Playing and reality. London, UK: Tavistock.
Yang, Y., Ye, Z., Li, W., Sun, Y., & Dai, L. (2024). Efficacy of psychosocial interventions to reduce affective symptoms in sexual and gender minorities: A systematic review and meta-analysis of randomized controlled trials. BMC Psychiatry, 24(1), 4. doi: 10.1186/s12888-023-05451-y
DOI: https://doi.org/10.1186/s12888-023-05451-y
Supporting Agencies
This research was supported by funding from the Italian Ministry of University and Research (MUR) under the call Progetti di Rilevante Interesse Nazionale (PRIN) 2022.How to Cite
Mezzalira, S., Carone, N., Bochicchio, V., Villani, S., Cruciani, G., Quintigliano, M., & Scandurra, C. (2025). Trans in treatment: a mixed-method systematic review on the psychotherapeutic experiences of transgender and gender diverse people: Transgender people’s experiences of psychotherapy. Research in Psychotherapy: Psychopathology, Process and Outcome. https://doi.org/10.4081/ripppo.2025.834
Copyright (c) 2025 the Author(s)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
PAGEPress has chosen to apply the Creative Commons Attribution NonCommercial 4.0 International License (CC BY-NC 4.0) to all manuscripts to be published.