Strategies for coming out

Sat in a cosy coupe, I cruise the Trans Siberian route. Leaning out the window, I take in the vastness of the landscape and its greenery. It has been an enthralling couple of days since arriving in Russia, where the human landscape is made up of homogenous and stern looks. At each end of the imaginary gender spectrum, you'll see cardboard cut-out versions of hyper feminine women and hyper masculine men. In this not-so-faraway land, women's beauty is showcased as capital and men's toughness is a medal to be worn. I inspect, scan and scrutinise my surroundings, unsure of what is missing and feel an uncomfortable void pinch my stomach. Oh, that's it! No camp, no butch, no twink, not even any bears to be seen. I wonder, where are all the LGBTQI+ people? Under what masks are they hiding? In a country of such intelligence and achievement, why is diversity so punished and prosecuted?

As I write these lines, I quickly become aware of what I'll call my 'clinical privilege': the ease with which I encourage my clients to be themselves in a country with embedded rights to afford equality and to punish discrimination. Here, 5,000 km away from London, there are no streets of Soho for gender- diverse people to walk in, there are no Tuesday support groups, and only those willing to risk their safety would march at Pride in Moscow. I often forget how limiting my job would be if I were to work with gender-diverse people in any other place in the world. Hence, in this chapter, where we will focus on strategies to come out, I would like to start by delineating the political terrain that will colour your work. Although we will concentrate on what it is like to work in the UK, I would also like to ask you and myself, 'What is the role of therapy when it is not safe to come out?'

'Coming out' is a term broadly used within the LGBTQI+ communities that refers to the act of disclosing one's gender or sexual identity. Interestingly, those who fall within the norm (i.e., heterosexual and cisgender people) are excluded from making such a disclosure. You are assumed to fall within the default setting and, if you don't, you need to make yourself known. Although recently, in an intended act of solidarity, some young heterosexual people have started to come out to their parents on social media platforms like TikTok.

Individuals can come out at any point in their lives; however, many people realise their identity during adolescence or early adulthood. Among other issues, the country of residence and cultural background will mediate in this process. As a point of reference, Tuite et al. (2021) gathered a sample of 106 lesbian, gay, bisexual, trans, and queer alumni from a residential gifted school in the US. On average, students came to terms with their identity at the age of 16.6 (which is similar to that found in the general population) and they waited an average of 2.1 years to share their identity with friends, and 3.4 years to share it with family. This, of course, refers to the first coming out experience. However, for a lot of gender and sexually diverse people, coming out is a process that continues throughout their life; for example, when making new friends, starting a new job and introducing one's partner, when dating someone and disclosing one's trans identity, or when being allocated a new healthcare provider.

Coming out to healthcare practitioners

Therapists and GPs hold a special place of responsibility, as often they are the first point of contact for gender-diverse clients – either to seek psychological support or referral to gender specialist services. So, what should you do if your client or patient comes out to you?

First, acknowledge how important this disclosure might be to your client, and try to put yourself in their position. Ask yourself, what would it be like for me to speak about the way I feel towards my body and identity when I have no way of proving it? By this I mean, there is no MRI or blood test that could help us diagnose Gender Incongruence (HA60). Consider, what hopes and fears might I project when coming out? Now that we have raised your natural levels of empathy and have tuned them towards this scenario, I would recommend using the following questions to explore the act of coming out with your client.

In the UK, GPs can change their client's name in their medical record without a formal name change (i.e., Deed Poll). It might be that, at the moment of the consultation, you do not have enough information, but you can research LGBTQI+ support organisations and specialist services and get back to your client. It is acceptable to acknowledge one's lack of training and to ask the client to guide the practitioner on what accommodations could be made to best support them. Consider that although some people might be sure about their identity, others might not have fully realised it and they might be still exploring it. Also, not everyone who is gender-diverse opts to medically or socially transition.

Preparing to come out

In my experience, clients often come to therapy having partially or fully realised their identity, seeking support in building up the courage to speak to their family, friends and work about it. And therefore part of our job can be to help our clients strategise. The act of coming out is infused with meaning, so do not waste the opportunity to explore it.

Ways of coming out

Markowe (2006) said that 'coming out to family must be seen from the perspective of the individual, interpersonal, intergroup, cultural and societal viewpoint'. Considering this principle, you can support your client in deciding the best way to inform their loved ones about their identity. There is no right or wrong way of doing it. Some people write a letter or an email, and later meet with their families to discuss its content. Some set themselves up by sending a text saying, 'During lunch I would like to talk to you about something.' Some invite a friend or sibling (who is already aware of their diversity) to be present as a source of emotional support, or in the case of risk of violence, to prevent escalation or to help them escape. To frame the conversation, I find it particularly helpful to use a Mentalisation Based Model, which supports clear boundaries in interactions. The individual determines the amount of time needed, the topic of the conversation and expectations about the listening party. For example, 'I would like to speak to you for the next hour about my gender identity. I know that it might be hard, but I would like you to try and listen. You might have many questions about it, and I feel it is best if I give you a bit of time to process, so that we can meet tomorrow and discuss any questions you may have.'

One of my clients used an analogy to explain their expectations which has stuck with me. They said, 'My gender feelings are like a dish that I have been cooking at a high temperature for years. It's hot and heavy, and I am about to hand it to my parents without any warning. I expect them to get burnt initially, but hopefully time will cool it down.' Whether loved ones already suspect it or not, and as this breaks their known sense of normality, many can react as if they were receiving a life-changing diagnosis. Some might struggle to hear whatever comes after 'I am trans', and this is not because they are not interested, but rather that they are trying to assimilate what this means for them and their life. For this reason, I tend to discourage clients from sharing to much information too soon, particularly around accessing gender-affirming interventions.

So, what should your client talk about? If your client's friends or family are not particularly LGBTQI+ savvy, they might not even know what is means to be transgender or non-binary. Some might confuse it with being a drag queen, enjoying cross-dressing, or even with some kind of fetish. Therefore, the first step is to explain, making an emphasis on the concept of diversity as proposed in Chapter 1, Arriving at the world of gender. I tend to ask my clients to provide a broad description of their experience, focusing on elements that their family might be most likely to connect with. They might split it into their sense of dysphoria (i.e., how I am struggling with the way I feel, and its impact on my life); and euphoria (i.e., the positive effect gained from realising and expressing my identity). Also, it can help to bring up plans and expectations. Some gender- diverse people feel pressured, as soon as they come out, to immediately start presenting in a gender-affirming manner or accessing treatment to make their identity recognisable and tangible to others. In other words, they feel like they need to prove themselves. To help your client avoid feeling pressured to make changes that perhaps they are not ready to make, you might want to help them to clarify what coming out means in practical teams. For example, 'I wanted to make you aware of my feelings, but I am not yet ready to present in public. However, I would like to start presenting in female role at home once a week until I build the confidence to go out.'

In their own words: therapy

'In their own words' is a collection of interviews of community members.

Alice (she/her) and Dylan (they/he) were interviewed about their experiences of therapy. Alice is a 37-year-old trans woman and Dylan is a 40-year-old trans- masculine non-binary person. Both had had therapy prior to and following transition.

Finding a balance between offering affirmation and information

Dylan: I think an affirming approach is important, but if the client is coming to you and isn't sure, then it can be useful for the therapist to have that information. Not to push them into any one label, but say these are some options which might suit you.

Alice: The therapist was okay with me not knowing, but it was difficult for me within myself to feel like it was okay not to know. I actually would've been okay with her being more directive. Like Dylan was saying, having someone throw some identities at me and being like, 'Why don't you try this on? How does this feel?' That might also help as well. I think that's part of a therapist's job, to feel the way with the client and finding a middle ground.

- This article is adapted from Gender Affirming Therapy: A Guide to What Transgender and Non-Binary Clients Can Teach Us, by Laura Scarrone Bonhomme, Skye Davies, Michael Beattie.

Want to read more? You can purchase the book with 20% discount using the code OPENUP20 at checkout.

See also Affirm, the Home of Gender Affirming Therapy.

References

Markowe, L. (2006). Coming out as lesbian. In A. Coyle & C. C. Kitzinger (Eds.), Lesbian and gay psychology: New perspectives (pp. 66–80). British Psychological Society.

Tuite, J., Rubenstein, L. D., & Salloum, S. J. (2021). The Coming Out Experiences of Gifted, LGBTQ Students: When, to Whom, and Why Not? Journal for the Education of the Gifted, 44(4), 366–397.