454 The Professional Counselor | Volume 11, Issue 4 Participants in this study praised the work of the professional counselors and other mental health professionals in their life when they (a) provided credible and affirming education about gender identity development; (b) worked in connection with support groups with which participants were involved; (c) recognized that the presenting concerns for the child and/or family may not necessarily be related to gender identity; and (d) completed gatekeeping responsibilities and tasks succinctly, efficiently, and without unexpected financial costs. These factors appear to be consistent with competencies for working with transgender clients developed by SAIGE (Burnes et al., 2010). Participants lamented their experiences with professional counselors and other health care professionals when (a) the above tasks were not completed within these guidelines, (b) the professionals were dismissive of the child’s gender identity or unwilling to provide care, and (c) clinic staff gave participants an unwelcoming or nonaffirming impression. The present study suggests that when presented with the opportunity to serve TGD adults, youth, and their families, professional counselors should familiarize themselves with and develop both the SAIGE competencies and the World Professional Association for Transgender Health (WPATH) Standards of Care (E. Coleman et al., 2012). Furthermore, professional counselors should follow established informed consent guidelines and be upfront and clear about fees for services when it comes to more specialized tasks like writing a GCEI referral letter. A growing body of resources also exists for developing TGD-affirming and inclusive cultures among non-clinical staff employed by counseling practices. For example, the guidelines developed by Morenz and colleagues (2020) for developing and implementing a transgender health program include suggestions for gaining buy-in from and training for reception and administrative staff. Finally, it appears that collegial support of counselors knowledgeable about the roles of clinicians in working with TGD individuals and families to develop competence among a wider network of providers may be necessary. This support is warranted, given the lack of access to TGD-affirming health care due to residential location, including counseling, cited as an inhibiting factor by this sample. This may support the reduction of referrals of TGD clients between counselors, a practice allowed by the ACA’s (2014) Code of Ethics in matters of limited competency but, as Kaplan (2018) has stated, is also a practice the clients may interpret as rejecting. Limitations and Future Directions As with all qualitative research, the results of this grounded theory study, despite the efforts made to maximize trustworthiness, need further testing using quantitative methodology to strengthen their applicability across a broader range of samples (Merriam & Tisdell, 2016). By its design, this was a study about how participants resolved their dilemma in an affirming way and therefore may not be as valuable for responding to research questions regarding dilemmas resolved in pathologizing or rejecting ways. This study was also limited demographically, with a sample heavily weighted toward the experiences of White (n = 16), cisgender women (n = 13), and married participants (n = 14). The majority of participants reported household incomes of more than $90,000, doubtlessly improving the odds that they could overcome some inhibiting factors because of greater financial ability. Finally, this research may have been limited by a sample that was heavily weighted toward participants who reside in the Mid-Atlantic region (n = 12); a sample that was more balanced across the United States may have produced different findings. These findings lend themselves to testing with quantitative methods such as pre-test/post-test program evaluation or randomized controlled trials (RCTs). Both methods have the potential to draw larger, more representative sample sizes, thus enhancing external validity to make greater
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