Understanding Transgender and Non-binary Transition Goals, Experience, and Narratives

Transition is the self-actualizing process of aligning one’s external being with their internal sense of gender. This includes social transition like gender expression, legal transition like changing one’s name or pronouns on documentation, and physical transition like hormone replacement therapy (HRT) and Gender Confirmation Surgery (GCS).

For gender-diverse people these milestones can carry a lot of hope and positive excitement, as well as a lot of apprehension and nervous energy. While mental health counselors can help clients find safe and healthy routes to transition, a lot depends on context and circumstance. In other words, while organizations like the World Professional Association for Transgender Health (WPATH) provide their Standard of Care (8th edition), gender-affirmative therapy must be adapted to meet clients’ unique goals, experiences, and transition narratives.

Transition Goals

Transition goals are often shaped by internal factors, like how a client experiences their gender identity, and external factors like the safety in their social environment or their access to trans-affirmative healthcare. 

Since self-acceptance is a gestation process, only the client can determine when they’re ready to self-actualize. Even if a client seems to be “on pause” for many years, there can still be a lot of psychological preparation going on below the surface. It takes time to gather information, cultivate personal resilience, build a social support network, and collect the resources they’ll need to move forward. Likewise, some clients may be very transparent about their transition goals, whereas others may need to build rapport with their counselor before letting them in on the plan.

Linguistic identifiers, like a client’s name, labels, and pronouns, are often the first step. Not only do they communicate authenticity to others, but they also affirm the self. Experimentation is natural, as certain labels may fit for a time until the client resonates with a more accurate term. 

Some clients may have several labels as part of their multifaceted identity or as a way of codeswitching. For example, a non-binary genderflux demigirl may call themselves queer to simplify things for their cisgender coworkers who don’t know the lingo. Eventually, a client may wish to legally change their name or pronouns on their identification. This incredibly validating step ranges in difficulty depending on their state, country, or immigration status.

Gender expression like body language, fashion, hairstyles, makeup, and vocal range, also affirms the self via acts of personal agency. Learning how to express one’s gender is a mindful process that cultivates self-acceptance, self-appreciation, and even gender euphoria. 

That said, there can be some steep learning curves! Self-monitoring thoughts may wonder: “Am I doing this right?” or “Does this look good on me?” Social anxiety may arise: “Will I pass as a man/woman?” or “Will people be able to tell I’m transgender/non-binary?” And safety concerns may worry: “Will I be accepted or targeted for the way I look?” 

In response, Gender Affirmative Therapy encourages clients to establish a social safety net comprised of kind, compassionate, and accepting people and role models who can provide guidance.

Counselors can highlight the therapeutic container as a safe space for authenticity, especially if the client can’t yet express their gender at home or at work. An hour-long session may not seem like much, but letting one’s hair down, either literally or figuratively, can be both relaxing and cathartic. 

It can also be helpful to set aside talk therapy in favor of experiential therapy, like practicing makeup tutorials, translating the complicated world of clothing sizes, looking online for well-made binders, or even teaching a client how to shave. Role modeling of this kind is both reparative and rapport-building, especially for clients who feel delayed in their gender development. Some counselors even go on to become gender specialists and even voice coaches to help clients practice their body language and vocal range in session.

When it comes to HRT and GCS, counselors can support their clients by processing their feelings around medical transition and by helping them form an action plan to procure and afford treatment. Actual consultation must be left to trained medical professionals who can monitor their bloodwork, titrate hormone regimens as needed, and discuss surgical options as requested. 

Goals around medical transition may vary greatly depending on how much a client wants to masculinize, feminize, or androgynize their body. It’s important to keep in mind that a client’s “transition status” or “passability” does not define their gender; that some clients aren’t transitioning into men or women but are, instead, actualizing a distinct trans or non-binary identity; and that some trans and non-binary people do not feel HRT or GCS is a necessary part of their journey. 

For those who do opt for HRT and/or GCS, there is a balance between accepting what is and is not in their control. For example, while a client can choose both the dosage and the route of application (subcutaneous, topical, ingested, etc.), how HRT affects their skin, hair, body fat, muscle tone, or vocal register may depend a lot on their unique physiology. 

For some, the results of HRT are subtle, and for others, they’re quite dramatic. For some there can be a number of unwanted side effects, for others, there are little to no side effects, or the side effects in question (like an increase or decrease in libido) were actually welcomed. 

Clients may also find themselves at an impasse with limited options. Like even if a client wants surgery, they may struggle to afford the procedure, doubt the quality of the outcome, or find themselves waiting for medical advancements in genital reconstruction, facial reconstruction, mastectomies, chest augmentation, and body contouring. Since some of these procedures may require a letter from a mental health counselor to either the surgeon or the client’s insurance company, WPATH provides a template.

With so many options, some clients may have clearly defined transition goals. Some may want to “pass” as a man or woman as much as possible, whereas others may proudly identify as a trans-man, trans-woman, or non-binary person and so challenge gender norms and expectations. 

In turn, some clients may not have a clear vision of who or what they’re becoming, and that’s okay too. Trying to determine if a client is “ready to transition” is a gatekeeping thought that limits a client’s agency. Transition isn’t instantaneous or impulsive. It takes years of consideration, evaluation, and intentional effort. 

To encourage a client’s intrinsic growth, remember that they are the driving force in their own lives. Like any client entering therapy, gender-diverse people may know it’s time for a change, even if they’re uncertain about the outcomes or how to proceed. Therapeutically, counselors can help their clients go beyond their presenting need to “end gender dysphoria” to explore, expand, and empower their sense of self.

Transition Experiences

Manualized, cookie-cutter approaches to transition neglect context, since each unique client will have their own unique experience. Consider their age, and how a young client on puberty blockers will have a very different journey than a client who begins HRT when they’re 50. 

Now consider culture. Exploring self-concept, Mattias de Vries and Sojka (2020) found that a client’s race and ethnicity make up a powerful dimension of how they understand themselves, especially as they transition. Culturally empowered role models can positively impact a person’s self-concept, yet vacuums in representation can lead to a pervasive sense of isolation and alienation. 

To make things worse, racism, sexism, and cissexism intersect, creating dynamic forms of oppression for trans and non-binary Black and Indigenous People of Color (BIPOC) including exclusion and discrimination within the LGBTQ+ community. For many, acceptance can begin to sound like a buzzword, and just because a client accepts themselves, it can take time to find or foster a safe social environment. How often does acceptance from a client’s family or community hinge on political ideology, religious morality, or rigid gender norms? 

And even if a client can work through any transphobia they or their family has internalized, their geographic location or socioeconomic status may also factor into their personal safety, upward mobility, and access to trans-affirmative healthcare.

Indeed, a client’s social environment can influence a lot of their locus of control, responsibility, and self-acceptance. Counselors can help clients by challenging negative self-talk and self-limiting mantras while affirming their ability to know themselves and make healthy decisions. Connecting clients to trans-positive communities can also help to process shame, guilt, and anxiety while validating their difficulties, normalizing their existence, and supporting their resilience and personal growth. 

This will be instrumental as clients work to afford transition costs and navigate the world of modern medicine. Some may have great doctors and a trans-inclusive healthcare plan. Others may have transphobic doctors and must pay for everything out of pocket. And after all the hard-won battles to procure HRT and GCS, results can vary, and there can be medical complications to recover from and new forms of self-care to learn. 

Transition Narratives

Transition isn’t just about transitioning how one looks or behaves, it’s also about transitioning one’s relationship to the self. For some transgender and non-binary clients, their pre-transition life is often spent in survival mode, ducking and weaving between social interactions to present a cisgender persona—often to their own psychological detriment. For others, their pre-transition life may have been so entrenched in a gender role that they didn’t realize they were trans or non-binary for a long time. 

As such, part of the transition process shifts the locus of care back to the self, by increasing self-awareness, self-compassion, and self-acceptance. This often involves the client adjusting their narrative (i.e., how they tell their story).

Personal narratives don’t just explain the facts, they detail a client’s self-concept via symbols, archetypes, metaphors, themes, and recurring life lessons. These narratives are typically retrospective, yet they also exist in the present and project into the future, in the same way that one may try to guess the end of a movie or the moral of a story. 

Because of this, such narratives can be empowering or limiting, depending on how a client views themselves and their situation. This is why many forms of therapy, including narrative therapy, cognitive processing therapy, acceptance and commitment therapy, and even Jungian therapy explore not just the events and characters in a person’s life story, but how they tell the story itself. Do they label themselves, or do they describe themselves? Do they judge themselves, or do they empathize with themselves? Were they at the mercy of fate, or did they blaze their own trail?

A transition narrative is the story of one’s transition process, which can evolve the more a client reflects on their identity. The term “transnormative” is often used to describe the stereotypical expectations of a linear trans experience from female-to-male (FtM) or male-to-female (MtF). Because of the expectations associated with this story, which many trans and non-binary people do not meet, clients may enter therapy feeling like they’re not “doing it right” or like they’re not “trans enough” or “non-binary enough.” 

Given the full diversity of human beings in the world, there is no penultimate transition narrative— no singular story or allegory to epitomize transition or how “it’s supposed to be.”

To explore this, Alex Stitt’s (2023) Accepting Gender: An ACT workbook for Tran and Non-binary people contains several fun and creative exercises to help clients express their own transition symbols and personal narratives. The goal, of course, is not to change how a client thinks about themselves or their process, but to deepen their self-knowledge, and differentiate who they are from the gender roles or stereotypes that just don’t fit. Essentially, return the pen to the author so they can write their own life story.

After all, not everyone connects with the metamorphosis imagery ofa caterpillar to a butterfly. For some, transition is a slow growth process like a tree expanding over a lifetime. For some, it’s a tale of shedding, like a hermit crab outgrowing its shell, or a snake shaking off its old skin. For others, it’s a hatching process, with an egg phase and a cracking phase. For others, it’s a story of severance, grief, and release, complete with deadnames and death imagery. For others, it’s a phoenix story of rebirth and reformation. For others, it’s a great unveiling, like removing a mask or raising a curtain. For some, transition is a journey of independence and rebellion; for others, it’s a journey of connection and community support. For some, it’s a clear path from one gender to another; for others, it’s a lifetime of shape-shifting.

Alex Stitt, LMHC

Alex Stitt, LMHC

Writer & Contributing Expert

Alex Stitt is a nonbinary author, queer theorist, and licensed mental health counselor living in Hawaii. As a proud Queer Counselor, they work to educate professionals in the mental health field interested in working with LGBTQ+ populations. Their textbook, ACT for Gender Identity: The Comprehensive Guide, demonstrates how to apply Acceptance and Commitment Therapy to gender self-actualization.