Feeling Competent isn’t Enough: The Social Worker’s Role in Creating Positive Space and Promoting Trans-Affirming Practices

Archives > Volume 20 (2023) > Issue 1 > Item 12

DOI: 10.55521/10-020-112

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Heffernan, K., Dauenhauer, J. & Cesnales, N. (2023). Feeling Competent isn’t Enough: The Social Worker’s Role in Creating Positive Space and Promoting Trans-Affirming Practices. International Journal of Social Work Values and Ethics, 20(1), 142-170. https://doi.org/ 10.55521/10-020-112

This text may be freely shared among individuals, but it may not be republished in any medium without express written consent from the authors and advance notification of IFSW.

Abstract

Both the physical environment and cultural climate of a human service agency can prevent individuals from obtaining services. As such, it is important for health and social care service agencies to develop positive spaces that affirm individuals’ identities. This cross-sectional study explores master’s-level social work (MSW) practitioners’ perceptions of competence and comfort in working with persons who identify as transgender and highlights ethical and cultural considerations that impact service participation for transgender and nonbinary persons. Surveying a national sample of MSW level practitioners, we explore practitioners’ 1) education, training, competence, and comfort of social workers when working with transgender persons; 2) perceptions of artifacts used as part of the culture of their agencies (e.g., language on intake forms, brochures, pamphlets, and wall art); and 3) awareness of organizational, state, and federal policy pertaining to persons who identify as transgender. Based on our findings, we suggest that social work agencies and the social workers within them need to take a leading role in assessing their agency’s culture to ensure that they are providing a safe space for transgender, nonconforming clients and employees. Additionally, social workers should continually assess their competence and ability to provide trans-affirming services and practices using validated standardized tools.

Keywords: Transgender, nonbinary, gender non-conforming, transgender nonbinary (TNB), environmental culture, trans-affirming social services, social work, positive space

Introduction

The term cisgender refers to individuals whose gender identity aligns with the social expectations associated with their sex assigned at birth, while the terms transgender and nonbinary refer to individuals whose gender identity does not align with the sex they were assigned at birth. Transgender, or “trans”, is an umbrella term encompassing an inclusive array of gender identities and expressions. It includes those who medically transition and identify within the masculine/feminine binary while also encompassing those with more fluid or expansive gender identities outside of this binary (Beemyn & Rankin, 2011; Budge et al., 2014; Davidson, 2007). While this paper has adopted the term transgender nonbinary (TNB) or transgender, this does not imply that this group is homogeneous. Persons who identify as TNB have many identities and ways of describing themselves. As such, one cannot make assumptions or believe they understand an individual or their needs based on the category they ascribe to or identify with. That said, we recognize that the population of people who identify as TNB in the United States is growing, as is the importance of understanding the knowledge and preparedness of social workers and agencies to serve this population.

Herman et al. (2017) found that between 0.6% to 3.0% of adults and approximately 0.7% to 3.2% of persons under 24 years of age identify with a TNB identity in the U.S. The 2015 Report of the United States Transgender Survey (USTS) found that over one-third of those who participated in the study embraced a nonbinary gender identity (James et al., 2016), and Flores et al. (2016) estimated that there are more than 1.3 million transgender people in the U.S., which accounts for approximately 0.58% of the population. What is important to understand is that as the number of individuals who identify as TNB increases, likely so will the number of those seeking transgender-related services, which range from case management to counseling from both social workers and mental health counselors (Austin, 2018). However, finding trans-affirmative services is not always easy.

According to Austin (2018), “affirmative care refers to a non-pathologizing approach to practice which accepts and validates all (binary and nonbinary) experiences of gender” (p. 75). The term affirmative care also appears to be the term of choice in the U.S. literature specific to social work, counseling, and some educational literature when referring to individual practitioner practices that help create positive and inclusive spaces for lesbian, gay, bisexual, transgender, and queer (LGBTQ) people (Biaggio et al., 2003; Bridges et al., 2003; Crisp, 2007; Mottet & Tanis, 2008). Leland and Stockwell (2019) also argue that affirmative practices encompass organizational policies and procedures that operate at the macro level. Yet, the term affirmative care is most often applied to individual practices and, as such, can miss the broader structural practices or overall organizational culture encompassed in the term positive space. The term positive space has been adapted in much of the Canadian literature. According to the Ontario Public Health Association (OPHA) (2011):

Positive space refers to an agency that is open and welcoming, as well as equitable and accessible to persons of all sexual and gender diversities, both to clients and employees of the agency. The term also refers to an agency in which all staff have been trained to understand the issues around sexual and gender diversity and are familiar with human rights, diversity and resources. (p. 33)

From a social work perspective, creating positive spaces reflects the importance of affirming the human rights and self-determination of TNB people while also challenging organizational cultures that render TNB persons invisible (MacDonnell & Daley, 2015). This paper also argues that it is important for service agencies to develop positive spaces in which to develop affirmative practices because both the physical environment and cultural climate of a social service agency can prevent individuals from obtaining services (Stotzer et al., 2013).

Less research has looked at the physical environments of health and social care agencies and how environment can influence the wellbeing of persons who identify as TNB, with the exception of services set up directly to engage LGBTQ+ communities. These specialized agencies, by and large, pay attention not just to their physical location within the community, but to the physical space in which they operate and to the way they deliver gender-affirming care. Many of these agencies send clear messages of inclusivity through their mission statements, allowing persons to know in advance that they specialize in services for LGBTQ+ communities. They offer visual imaging through artwork, pictures on their brochures, reading material for guests to peruse and often use inclusive language in their materials for intakes and assessments as well as in signage and through verbal communication (McLain et al., 2016).

Challenges finding gender-affirming care

Persons who identify as TNB face many challenges to finding gender-affirming care provided in a positive space, other than with agencies specifically set up to serve these populations. While movements to rectify this issue have begun (see the Gay and Lesbian Medical Association [GLMA] and the Human Rights Campaign Foundation, 2014), much more work is needed as demonstrated via research that shows that persons who identify as transgender are at an increased risk of negative physical, emotional, and social health outcomes due to social stigma (Bradford et al., 2013; Fredriksen‑Goldsen, 2011; Grant et al., 2011; James et al., 2016; Testa et al., 2012). Additionally, Mongelli et al. (2019) found that persons who identify as a sexual minority face higher rates of mental health issues compared to those who identify as cisgender (a term often shortened to cis). Furthermore, Klien et al. (2018) found that services meant to dissipate the effects of transphobia, racism, and poverty may actually contribute to discrimination and the negative psychological, social, and health-related outcomes associated with minority stress. The theory of minority stress posits that higher rates of emotional and psychological stress among LGBTQ+ populations relative to their heterosexual peers is the result of stressors unique to sexual and gender minorities (Hendricks & Testa, 2012; Meyer, 1995, 2003).

Some of the stress affecting persons who identify as transgender stems directly from cisnormativity—the belief that cisgender identity is the norm or that all people are cisgender. Another form of minority stress has been linked to heteronormativity, a term “that describes the hegemonic normalizing of heterosexuality” (Buddel, 2011, p. 133). Such beliefs systematically marginalize transgender identities (Bauer et al., 2009), and perceived discrimination, along with underutilization of needed mental health care services, is a significant risk factor for mental health disorders (Burgess et al., 2007; Fredriksen-Goldsen et al., 2013). Such perceived discrimination has also been identified as a form of anticipated stigma, which refers to an individuals’ expectation of having a stigmatizing experience as well as the belief that others assign negative attributes to them (Teh et al., 2014). Persons who internalize transphobia may experience psychological distress and depression (Breslow et al, 2015), and high levels of internalized transphobia are associated with an increased likelihood of attempted suicide (Perez-Brumer et al., 2015).

Social work education

According to the Council on Social Work Education’s (CSWE, 2022) Competency 3 and the National Association of Social Workers’ (NASW) Code of Ethics Standard 1.05 (NASW, 2017), social workers are expected to be educated regarding the impact of marginalization related to gender identity and expression. But what happens when this information is not included in their formal education? There is a plethora of research suggesting that TNB issues are largely absent from social work education (Austin et al., 2016; Hoff & Camacho, 2019; Erich et al., 2007; Martin et al., 2009). This means that as social workers graduate with a master’s degree in social work (MSW), they may be uninformed or, worse, biased against persons who identify as TNB (Erich et al., 2007; Floyd & Gruber, 2011; Logie et al., 2007). Austin (2018) suggests there is a dearth of expertise specific to gender diversity and transgender issues among social workers, noting that associated content in MSW programs is lacking. A recent study found MSW students reported that their coursework and field placements did not prepare them for social work practice with persons identifying as transgender (Hoff & Comacho, 2019). Research has also found that a lack of trans-affirmative social work education and training negatively affects student attitudes toward members of the transgender community (Floyd & Gruber, 2011).

Social service agency culture

While there is a scarcity of research on discrimination experienced within agencies that employ social workers, persons who identify as transgender have reported experiencing discrimination within social-service settings (Austin et al., 2016; Kenagy, 2005; Minter & Daley, 2003; Stotzer et al., 2013). Much more research, however, has been conducted on discrimination in the health care and medical fields. Health care research is inundated with examples of discrimination. Stotzer et al. (2013) reviewed the literature and found:

1) experiences with discrimination or outright rejection from services; 2) provider insensitivity or poor treatment while receiving services; 3) problems or concerns with physical environment or ‘climate’ of social service agencies; 4) difficulty with availability of and accessing appropriate services; and 5) a lack of cultural competence in regard to transgender issues. (p. 67)

In many instances, TNB people have to educate their providers about the medical and emotional needs specific to TNB individuals and to correct misinformation (Jaffee et al., 2016).

According to Kattari et al. (2019), in order to provide trans-affirming care, practitioners need to be able to critically assess the current resources available for TNB individuals within the agencies where they work and to understand any gaps in the resources and support available. With the growing number of persons identifying as TNB, social workers should be aware of the resources available to clients as well as the existence of policies specific to persons who identify as transgender both within their agency and in the larger community. A lack of knowledge about agency, local, or federal policy regarding persons who identify as transgender may be related to an absence of agency artifacts that display TNB persons or use TNB language.

The lack of such artifacts may demonstrate limited open dialogue at an agency with regard to TNB issues, which may further support cisnormativity. Bauer et al. (2009) have identified how cisnormativity fosters the erasure of TNB persons within health care settings, specifically in the domains of informational systems and institutional policies. Lack of provider knowledge about transgender peoples’ health needs and organizational policies that are not affirming of transgender identities is a form of structural stigma (Kcomt et al., 2020). A lack of trans-affirmative discourse at an agency as well as a lack of visibility of trans-identifying people within an agency can have negative effects for TNB persons. In a small qualitative study exploring the experience of 13 TNB youth and young adults, Austin (2016) describes that participants who saw their own lives represented in others often experienced this as liberating.

A cisnormative agency culture perpetuates the invisibility of transgender identities and experiences (Bauer et al., 2009) and often means that services are organized around the assumption of cis service use (Pyne, 2011). The artifacts at an agency produce knowledge and information about services while setting norms for an organization’s culture. Artifacts used to welcome clients and help them feel supported within an agency can reinforce cisnormative and heteronormative culture when they are not TNB inclusive. Such artifacts may include an agency’s mission statement, informational brochures or other reading material, and decorative art on waiting room walls. Reading materials, symbols, and signs that specifically spell out the organization’s attitude about the importance of respect for all people as displayed in their waiting room can help clients, their families, and employment applicants feel welcomed (Mallon, 1999).

Language used within an agency is another artifact that can systematically discriminate or make a person feel unsafe. Health research has demonstrated the importance of adjusting client intake forms at the systems level to incorporate gender neutral terminology and the use of preferred names and pronouns, which arguably applies equally to social and mental health settings (Baldwin et al., 2018). Using a person’s correct pronouns can help alleviate feelings of discomfort. Equipped with knowledge of the needs of persons who identify as transgender, social workers could play a pivotal role in advocating for trans-affirmative resources and supports (Collazo et al., 2013). Social workers working with TNB clients need to be familiar with local resources and policies (Kattari et al., 2019) and be up to date and comfortable using language that incorporates TNB persons.

Based on the available literature, current social work education programs may not be adequately preparing future social workers to work with TNB populations. Even less is known about the education and training that happens post-graduation. Are MSW practitioners getting training at their place of employment, and, if so, are they finding these trainings useful? If social workers do not have formal education or post-graduation training specific for working with persons who are transgender, they may not know how to engage with, advocate for, and refer persons to appropriate resources when needed. These questions and subsequent research findings coincide with the IJSWVE’s mission to examine social work practitioners’ decision-making in context of their agencies’ program development, which should always be guided by social work values and ethics.

This present study explores master’s-level social work practitioners’ perceptions of competence and comfort when working with persons who identify as transgender. It also explores if, and when, practitioners received education and training to work with this population and their knowledge of policies specific to persons who are transgender. While there has been a surfeit of research exposing gaps in the social work higher education curriculum addressing TNB content (Hoff & Camacho, 2019; Martin et al., 2009), less is known about post-graduate training and how this may influence a person’s feelings of competence to work with TNB persons. What we do know is that even well-intentioned clinicians who seek to affirm persons who are transgender can unintentionally reinforce socially sanctioned cisgender norms and systems (Benson, 2013). This is why it is important to understand not only how confident and comfortable MSW practitioners are working with persons who identify as transgender, but also to understand if the agencies where they work provide affirming transgender cultures through the agency’s artifacts, such as the verbal and written language used or displayed within the agency.

Methods

A cross-sectional electronic survey collected information between September 2020 and February 2021from persons who work in mental health settings. This paper uses a subset of the data from those participants, specifically all those who identified as MSW practitioners. This study reports on data that explored 1) participants’ knowledge of working with persons who identify as transgender and 2) the culture of the agency in which they worked to understand if it cultivates a gender-affirming culture. The study was reviewed and approved by the authors’ institutional review board (IRB) prior to data collection.

Participants and procedure

Participants were recruited and sent an invitation to complete an electronic survey developed in Qualtrics. Participants were identified through two different sampling frames. The first contained a list of 2,000 randomly selected members of National Association of Social Work (NASW) who work in mental health. This list was obtained from InFocus Marketing, a data management company employed by NASW. In order to use this sampling frame, the study underwent a second independent review through NASW and paid a fee of $990 for one-time use. InFocus conducted the random selection of participants and sent out the survey on our behalf. Due to financial limitations, it was not feasible to send a second email. The InFocus invitation yielded 121 responses—77 responses from persons who declined and 44 responses from persons who agreed to participate. Due to the low response rate from emails sent by InFocus Marketing (2%), we also used a list of 1,743 social work alumni who had graduated from the authors’ institution between 1973 and 2019. This email yielded 128 responses, 46 of which indicated consent to participate. However, four of those who had agreed to participate never filled out the survey. This resulted in a total sample of 85 participants working in 21 different states within the U.S. 

Our sample included predominantly white (79%, n = 59), cisgender women (32%; n = 23) identifying as a Licensed Clinical Social Worker (LCSW) (n = 26) with 15 years in the field. Over half of the respondents reported working full time (n = 56) and 45 reported being married or in a domestic partnership.

Survey design & measures

The majority of the survey questions, outside of those specific to demographics, used a five-point Likert scale, asking respondents to indicate how strongly they agreed or disagreed with specific statements.

Education, training, competence, and comfort

We asked a series of questions to better understand if the participants had received training and, if so, when they had received it (i.e., during their MSW education, post qualifying at their agency, both, or never received training). We also asked them how helpful they thought the training was, if they felt competent to work with persons who identified as transgender, if they thought more training would be beneficial, and, finally, if they felt comfortable working with persons who identified as transgender.

Perceptions of agency artifacts

To better understand if the participant’s agency had a culture that affirmed transgender identity, we asked four questions with five-point Likert scale response options (strongly agree—strongly disagree). Specifically, we asked participants how strongly they would agree that 1) they regularly used gender-affirming language, such as pronouns, to introduce themselves; 2) the agency intake forms include TNB language; 3) the brochures and pamphlets used to disseminate information about the agency depict pictures of TNB persons; and 4) the décor or wall art at the agency is sensitive to TNB persons.

Policy awareness

We asked three questions to better understand participants’ awareness of policies specific to persons who identify as transgender. These questions were also answered using a five-point Likert scale indicating their level of familiarity (extremely familiar—not familiar at all). We asked about familiarity with their agency’s policies, local government policies, and federal policies. For example, to measure respondents’ familiarity with agency policy, we posed the statement: “I am familiar with any of my agency’s policies pertaining specifically to transgender persons.”

Data Analysis and Results

SPSS version 25 was used to analyze the data for this study. Descriptive statistics are reported in the sections that follow.

Education and post-graduation training

Analyses revealed that 26% (n = 22) of our sample reported that they only received education and training to work with TNB individuals during their MSW studies and 20% (n = 17) of participants indicated that they had received education during their program and post-graduation at their agencies. There were 42 (51%) respondents who indicated that they only received training after they graduated from their MSW program while the remaining respondents indicated that they had never received any formal education or training to work with this population (8%, n = 8). Of those who reported having received training specific to TNB persons, 35 indicated that their education and/or training was only moderately (n = 12), slightly (n = 14), or not useful at all (n = 9).

When asked if they felt adequately trained to work with persons who identify as transgender, of those that responded (n = 79), a small percentage felt extremely adequately trained (20%, n = 16). Most participants indicated that they felt somewhat adequately trained (39%, n = 35) though some indicated indifference about the effectiveness of their training, feeling neither adequately or inadequately trained (15%, n = 13). There were also three participants who felt they were somewhat inadequately prepared and one who felt extremely unprepared.

When asked if they would benefit from further training, the majority of the respondents felt that they would either strongly benefit (36%, n = 32) or somewhat benefit (33%, n = 29). There were three people who did not believe that they would benefit from training on how to work with persons who identify as transgender.

Comfort and competence

Most participants reported feeling confident in their professional competence to work with persons who are transgender. The majority of the respondents answered positively; 21% (n = 19) reported feeling strongly that they were competent or somewhat confident (52%, n = 46). In terms of comfort level, however, the majority reported they did not feel comfortable working with persons who identify as transgender. Over half indicated that they were extremely uncomfortable (60%, n = 54), while 17% (n = 15) indicated that they were somewhat uncomfortable. No one answered that they were extremely comfortable working with persons who identify as transgender.

As displayed in Table 1, when asked how frequently they worked with or saw clients who identified as transgender, nearly one-third responded “never” (31%, n = 24), while 26% (n = 20) reported “at least once a month.”

To better understand these findings, we also ran a correlation coefficient to see if there was a relationship between how frequently a social worker sees or meets with a persons who identify as TNB, their comfort to work with, and their feelings of competence to work with persons who are TNB. Confidence in one’s competence to work with persons who identify as TNB was positively correlated with comfort r(75)=.571, p = .000 while frequency of seeing persons who identify as TNB was positively correlated with comfort r(75) = .239, p=.38. So the more often a practitioner saw TNB clients, the more comfortable they reported begin when working with these clients.

	%	n
1. In your practice, how often do you work with or see transgender clients?
Never	32	24
Less than once every 3 months	21	16
At least once every 3 months	7	5
At least once a month	26	20
At least once a week	15	11

gency artifacts: language, forms, and decorations

Regarding transgender-affirming language, the majority of practitioners stated that they did not regularly use language such as introducing themselves using their pronouns to allow their client to know that they are transgender friendly (53%; n = 40). Gender-friendly language in practice was regularly used by 23% (n = 18) of the practitioners.

Respondents were asked if they agreed that their intake forms used gender-affirming language. The majority strongly disagreed (22%, n = 20) or somewhat disagreed (28%, n = 25) with this statement. Only 6% (n = 5) of the respondents strongly agreed that their agency’s intake form used gender-affirmative language.

When asked if they agreed that their agency’s pamphlets or brochures were TNB representative and if the pictures or images displayed at the agency represented TNB persons, most respondents neither agreed nor disagreed with this statement (40%, n = 36), fewer strongly disagreed (8%, n = 7) or somewhat disagreed (15%, n = 13). Ten percent (n = 9) strongly agreed with this statement. The results regarding the question about the agency’s wall décor representing images of TNB persons was very similar. Nearly half of the respondents neither agreed nor disagreed with this statement (45%, n = 40), while a smaller number strongly disagreed (11%, n = 10) or strongly agreed (10%, n = 9).

Policy

When asked about their familiarity with policies specific to TBN identities at the agency where they work, only 9% (n = 8) of our sample were extremely familiar, while 25% (n = 22) indicated that they were not familiar at all. Other participants’ knowledge of policy ranged from very familiar (7%, n = 5) to moderately familiar (19%, n = 17) to just slightly familiar (23%, n = 20). There were 17 respondents who did not answer this question. Slightly more practitioners said they were familiar with state and federal laws pertaining to transgender persons (see Table 2).

	%	n
1. How familiar are you with state laws pertaining specifically to transgender persons?
Extremely familiar	13	10
Very familiar	21	16
Moderately familiar	39	29
Slightly familiar	21	16
Not at all familiar	5	4
2. How familiar are you with federal laws pertaining specifically to transgender persons?
Extremely familiar	15	11
Very familiar	20	15
Moderately familiar	43	32
Slightly familiar	15	11
Not at all familiar	7	5

Discussion

As in previous research, a large number of respondents indicated that they had not received education specific to transgender identities while studying for their MSW (Hoff & Camacho, 2019; Martin et al., 2009). Many, however, had received some sort of post-qualifying training at their agencies. A small number of participants felt indifferent about their training—neither adequately, nor inadequately trained; an even smaller number said they felt inadequately trained. Over half of the respondents indicated that they felt they were adequately or somewhat adequately trained to work with persons who identify as transgender, yet the majority felt they would benefit from additional training. One of the most perplexing findings in this study is the number of persons who felt competent, but uncomfortable working with TNB persons. Over half indicated that they were extremely uncomfortable working with persons who identify as transgender. This finding is very concerning, and more research is needed to better understand this result. If someone is uncomfortable working with a person who identifies as TNB, consciously or not, this could play out in how they interact with, and what services they offer, a person who identifies as TNB. Not surprising, the more a practitioner worked with transgender persons, the more comfortable they felt. However, there was not a statistically significant relationship between frequency of working with TNB clients and confidence in one’s competency to work with this population.

The U.S. social work profession is officially committed to advocating for social, economic, and environmental justice for persons who identify as TNB. Social workers cannot strive to build inclusive work settings if they themselves feel uncomfortable working with persons who identify as transgender. Additionally, CSWE’s 2022 Educational Practices and Accreditation Standards (EPAS) requires U.S. social work programs to teach students to recognize institutionalized oppression and to reflect on and correct the impact of personal bias (CSWE, 2022). Gaining a better understanding of why some social workers believe themselves to be competent to practice with TNB persons yet are uncomfortable doing so should be a priority moving forward.

Additionally, in order to normalize and create inclusive work settings, or positive spaces, social workers could adapt gender-affirming language and advocate that such language be incorporated as an artifact of the agency. In fact, social workers are in a prime position to educate their colleagues about the importance of incorporating artifacts that are representative of sexual minorities within the language and décor of the agencies in which they work. This would help to build positive spaces in which to practice trans-affirming social work methods. Ensuring that artifacts within an agency are representative of TNB persons will help to shape a safer climate or organizational culture through normalizing such representations. While social workers may not always be in administrative positions where they have the power to enforce institutional policies that reinforce trans-affirmative norms, they should be able to foster dialogues with their supervisors regarding the importance of developing such practices at their agency. It appears as if social workers may not necessarily be guilty of explicit oppressive behaviors or beliefs, but rather may be complicit in helping preserve cisnormativity via their indifference to trans representation within their agencies’ artifacts.

The respondents in this study showed indifference when asked if their agency used nonbinary or gender affirming language for themselves as well as on the agencies’ intake forms. When asked if they agreed that their agency had images representative of differing sexual orientations and gender identities on agency pamphlets and incorporated into the décor, many left this question blank or indicated that they neither agreed nor disagreed with the statement. Close to half indicated that they did not agree or disagree with these statements. So, either they are unable to assess whether the artifacts are representative, they were not willing to give a definitive answer to questions specific to the different artifacts used within their agencies, or it may be that they did not understand the questions asked.

There were also many participants who were unaware of policies within their own agency pertaining to persons who identify as transgender. Social workers have a responsibility to advocate for equal protections for persons who identify as TNB—not just at the state and federal level but within their own agency (Morrow, 2004; NASW, 2017). In order to advocate, they first need to be aware of current policy and practices. Interestingly, many of the respondents were more familiar with state and federal policies regarding TNB identities than agency policies.

Limitations

The results of this research study need to be considered in light of several important limitations, the first of which relates to the low response rate. While the NASW membership list is often considered a primary resource of master’s-level social workers, access to these members is cost prohibitive. While the authors would have preferred to send follow-up and reminder email requests to members to improve the response rate, we could not get institutional support to pay the nearly $1,000 fee to send emails to a selected portion of the membership list. This led us to contact social work alumni from our own institution, which resulted in a higher, but still limited, response rate. Thus, those who did participate in this study may not be representative of the NASW membership, most being alumni from one academic institution who work in mental health fields. A number of respondents who did agree to participate either did not answer any questions or skipped several questions; this could also be reflective of practitioners’ discomfort with, or lack of interest in, sharing perspectives on serving people who identify as transgender. Future research on this topic may benefit from smaller selective targeting of various agencies in a geographic area as well as from the use of qualitative methods (e.g., focus groups, interviews) to gain a deeper understanding of perspectives on education, training, and organizational culture as it relates to TNB service provision.

Implications for Social Work

In conclusion, ensuring inclusive and affirmative social and emotional health care environments means assessing service providers’ knowledge of and cultural competence to provide gender-affirming services as well as assessing the environment in which services are provided. Agencies’ artifacts should be welcoming and supportive of gender-diverse populations. Social workers need to be aware of their own personal beliefs about gender identities and to understand how the structural as well as procedural aspects of their agency can stigmatize TNB persons.

We recommend that in order to be culturally competent, social work practitioners need to adopt a policy of practicing cultural humility, which incorporates a lifelong commitment to self-evaluation and self-critique (Tervalon & Murray-Garcia, 1998). With regard to organizational culture, which includes observed language, customs, traditions, espoused values as well as agency artifacts (Schein, 1988), we argue that it is important for agencies to use a range of artifacts along with their policies and procedures to promote safe spaces and trans-affirming practices. It is important to remember that identities, in part, are shaped by environments that support, discourage or maintain them (Stewat & McDermott, 2004). Studies have shown that persons who are able to live according to their gender identity experience, via their transitioning experience, improved psychological well-being (Riggs et al., 2015; Verbeek et al., 2020). Having one’s gender affirmed by others may lead to lower rates of depression (Nuttbrock et al, 2012) and higher rates of well-being (Verbeek et al., 2020). Moreover, there is a growing body of knowledge to support the idea that immediate social environment factors most impact the health and well-being of persons who identify as transgender (Nuttbrock et al. 2012).

One possible strategy for normalizing TNB identities in non-specialized LGBTQ agencies is to borrow practices that have been found to be successful in these agencies. This means integrating TNB identities into the agency’s artifacts , such as mission statements, intake/assessment forms, informational brochures, pamphlets, and wall decorations. This integration should also permeate the language practitioners use to identify persons, such as the use of their preferred pronouns and preferred names. “Language, therefore, is central to the development of tactics that challenge cisnormativity” (Borba & Milani, 2017, p. 17). While it is important to remember that the person who speaks can carry power to persuade a person, it is equally important to remember that language and words in and of themselves have power. The words practitioners use within an organization to talk to or about people, their situations, and the services they need can perpetuate inequality, having stigmatizing effects (Heffernan, 2006; Vojak, 2009). Implementing procedures and policies that help in moving away from accepting cisgender as the norm is important to creating a safe space for clients.

Additionally, agencies need to be committed to helping their practitioners develop cultural competency. This requires continued commitment to self-assessment and extensive change in agency culture to encourage trans-affirming practices. One possible way to achieve this is to use a self-assessment tool to cultivate affirming practices with transgender and gender-nonconforming (TGNC) persons such as the TGNC Affirming Clinical Skills Self-Assessment (TGNC-ACSSA) (see Leland & Stockwell, 2019). This tool is designed for self-reflection, providing a clear representation of areas for growth “at both the individual and the organizational levels, specific to those who work in the field of applied behavior analysis” (Leland & Stockwell, 2019, p. 822). For those working in case management using a generalist approach to change, Leung and Cheung (2013) developed the Attitudes, Skills, Knowledge (ASK) scale to measure cultural competence. This scale has a long 97-item version and a short 24-item version, and was originally developed and tested for reliability and validity with child welfare case managers (see Leung & Cheung, 2013). More recently Cheung and Leung (2020) have proposed using this scale in broader social service settings as a self-assessment tool to help develop steps for helping workers develop cultural competence.

Social workers have an ethical responsibility to ensure that they are culturally competent (NASW, 2017). They are in a unique position to act as leaders, assessing and reflecting on their own cultural competence as well as that of their agencies and acting as change agents when necessary. Social workers have a duty to ensure that the availability of a full range of appropriate services, directly and indirectly, are being provided in a safe space. This should not be viewed as a static, “one-and-done” assessment; rather, procedures for continual assessment should be incorporated into an agency’s diversity statement, using measurable goals to assess progress toward providing positive spaces and using trans-affirmative practices.

References

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