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Psychotherapy (Chic). Author manuscript; available in PMC 2022 March 01.
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Longitudinal effects of psychotherapy with transgender and

nonbinary clients: A randomized controlled pilot trial
Stephanie L. Budge,
Department of Counseling Psychology, University of Wisconsin-Madison, 1000 Bascom Mall,
Education Building Rm 305, Madison, Wisconsin 53706

Morgan T. Sinnard,
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Department of Counseling Psychology, University of Wisconsin-Madison, 1000 Bascom Mall,

Education Building Rm 335, Madison, Wisconsin 53706

William T. Hoyt
Department of Counseling Psychology, University of Wisconsin-Madison, 1000 Bascom Mall,
Education Building Rm 304, Madison, Wisconsin 53706

Abstract
Minority stress has been determined to contribute to some mental health concerns for transgender,
nonbinary, and gender nonconforming (TNG) individuals, yet little is known regarding
interventions to decrease the effects of minority stress. The purpose of this pilot study was to
assess the feasibility and relative effectiveness of two interventions developed for work with
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transgender clients. Transgender individuals (N = 20) were recruited to participate in a randomized

controlled trial (RCT) comparing two psychotherapy interventions for transgender adults seeking
psychotherapy for a variety of concerns: a) Transgender Affirmative psychotherapy (TA) and b)
Building Awareness of Minority Stressors (BAMS) + TA. Gender-related stress and resilience
were assessed before, immediately after, and 6 months following the intervention; psychological
distress and working alliance were assessed at these three time points as well as weekly during the
intervention. Feasibility and acceptability of the study and psychotherapy interventions were
supported. Exploratory analyses indicate improvement in both groups based on general outcome
measures; targeted outcome measures indicate a trend of improvement for internalized stigma and
nonaffirmation experiences. Results from this study support further evaluation of both treatment
arms in a larger RCT.
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Keywords
transgender; RCT; minority stress; transgender affirmative psychotherapy; psychotherapy outcome

A large body of research has documented the tremendous minority stressors (Meyer, 2003)
that transgender, nonbinary, and gender-nonconforming (TNG) individuals face, ranging
from housing and employment discrimination to outright gender-based violence (Bockting,
Miner, Swinburne Romine, Hamilton, & Coleman, 2013; James et al., 2016). These

Corresponding author, [email protected], (608) 263-3753.

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interpersonal experiences of stigma are believed to have compounding and deleterious

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mental health consequences for TNG individuals (Hendricks & Testa, 2012), evidenced by
markedly high rates of psychological distress (Budge, Adelson, & Howard, 2013). Gender-
based adversity may also promote resilience among TNG individuals (Bockting et al., 2013;
Meyer, 2015), one form of which is seeking psychotherapy (Singh & McKleroy, 2011).

Psychotherapy for TNG Individuals

Interest in culturally adapted psychotherapy (Benish, Quintana, & Wampold, 2011; Grzanka
& Miles, 2016) has yielded a growing body of research examining psychotherapy processes
and outcomes with lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals
(Bidell & Stepleman, 2017; Hinrichs & Donaldson, 2017; Qushua & Ostler, 2018). While
certainly informative, this monolithic approach to gender and sexual diversity generally
involves small subsamples of TNG individuals and risks conflating sexual identity with
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gender identity. Furthermore, existing scholarship discussing culturally adapted

psychotherapy with TNG individuals typically employs binary gender descriptors (e.g., trans
man or trans woman), thereby eliminating potentially relevant findings for providers
working with nonbinary or gender nonconforming individuals. Such under- or non-
representation of TNG research participants is a pervasive issue in the field and has
potentially harmful implications at the public health level (Reisner et al., 2016). Moradi and
colleagues’ (2016) content analysis of the literature on transgender topics revealed that only
2.5% of articles published between 2002 and 2012 were focused on interventions.
Psychotherapy research that specifically addresses the needs and experiences of TNG
individuals is urgently needed to establish best practices and ultimately promote their vitality
in spite of chronic minority stressors (Pachankis, Hatzenbuehler, Rendina, Safren, &
Parsons, 2015).
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Psychotherapy and Gender Minority Stress: Source or Solution?

TNG individuals seek psychotherapy at markedly high rates. A nationwide survey of 27,714
TNG individuals revealed that 58% had ever accessed psychotherapy, compared to just 3%
of the general US population (James et al., 2016; Olfson & Marcus, 2010). They may seek
psychotherapy for a variety of reasons, including personal growth, navigating the coming out
process, accessing gender-affirming medical care, as well as common psychological
concerns found in the broader population (Keo-Meier & Labuski, 2013). Despite
comparatively high rates of psychotherapy utilization among TNG individuals, empirical
research on its processes and outcomes within this population is scarce—rendering the
provision of true evidence-based mental health care for this growing population inaccessible.
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A systematic review of the literature on psychotherapy with LGBTQ individuals revealed

the scarcity of research explicitly focused on TNG individuals’ experiences in
psychotherapy (Budge & Moradi, 2018). The small body of research on this topic indicates
that therapists frequently discriminate against, dehumanize, and refuse care to TNG
individuals (Mizock & Lundquist, 2016; Poteat, German, & Kerrigan, 2013; Shipherd,
Green, & Abramovitz, 2010; Xavier et al., 2013). Therapists are generally ill-equipped to
work with TNG clients due to insufficient training, stigmatizing beliefs, and a tendency to

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misattribute presenting concerns to TGN identity (American Psychological Association,

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2015; Mizock & Lundquist, 2016; O’Hara, Dispenza, Brack, & Blood, 2013). Indeed, TNG
individuals frequently report experiencing a unique type of minority stress in health care
settings—microaggressions (i.e., behaviors and statements that intentionally or
unintentionally communicate negative attitudes toward socially marginalized individuals)
(James et al., 2016).

Therapists generally receive insufficient training for working effectively with TNG clients
(American Psychological Association, 2015). This reality is particularly concerning due to
their roles as gatekeepers to gender-affirming medical care (Coleman et al., 2012) and the
intimate nature of the therapeutic relationship (Nadal, Whitman, Davis, Erazo, & Davidoff,
2016). The relationship between therapist preparedness to work with TNG clients and
treatment outcomes remains unknown. Qualitative research indicates that therapists who are
ill-prepared to work with LGBQ clients yield stunted treatment process and outcomes
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(Nadal et al., 2011; Shelton & Delgado-Romero, 2011). Although this phenomenon has not
been studied among TNG psychotherapy clients, the prevalence of health care provider
stigma toward TNG individuals is well-documented (James et al., 2016; White Hughto,
Reisner, & Pachankis, 2015). Poteat and colleagues (2013) posited that healthcare provider
stigma against TNG individuals serves to uphold systemic inequality, maintain power
hierarchies (with TNG individuals perpetually disempowered by providers), and ultimately
promote health disparities.

Guidelines and recommendations for providing affirmative care for TNG clients exist (see
American Psychological Association, 2015; Budge & Moradi, 2018), but presently there is
minimal evidence pertaining to their implementation. Attempts to meta-analyze
psychotherapy outcomes with transgender people have been stymied by the sheer lack of
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available data (Budge & Moradi, 2018). Quantitative data on psychotherapy processes with
TNG clients have been described in group (Heck, Croot, & Robohm, 2015; Yüksel,
Kulaksizoğlu, Türksoy, & Şahin, 2000) as well as individual contexts (Hunt, 2014; Rachlin,
2002). However, there are no reports of standard psychotherapy outcome measures for these
clients. Considering that TNG individuals access psychotherapy at comparatively high rates
(James et al., 2016), the lack of robust evidence pertaining to its process and outcomes in
this population is remarkable.

Researching Psychotherapy Processes and Outcomes with TNG

Individuals
Randomized controlled trials (RCTs) are often heralded as the benchmark of high quality
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psychotherapy research (Budge, Israel, & Merrill, 2017; Lilienfeld, McKay, & Hollon,
2018). Randomized controlled trials are theorized to minimize researcher bias and provide
robust evidence for treatment efficacy. However, scholars have critiqued this approach for its
limited generalizability, inability to explain mechanisms of action, and neglect of potential
confounding variables (Grossman & Mackenzie, 2005; Kaptchuk, 2001; Slade & Priebe,
2001). Nonetheless, RCTs provide one source of valuable information to guide clinical
practice—provided that their interpretation allows for flexibility in clinical application and

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acknowledgement of unobserved variables at play. Given this state of the art and the dearth
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of research on psychotherapy with TNG individuals, scholars have called for RCTs that
measure both process and outcomes. For example, conceptualizing outcomes not only as
symptom criteria but as growth-oriented features (e.g., resilience, pride, and quality of life)
may be well-suited for TNG individuals, whose lived experiences in psychotherapy are
insufficiently captured by traditional diagnostic criteria (Budge et al., 2017).

Budge and Moradi (2018) posed two overarching considerations to guide research on
psychotherapy with TNG individuals: is psychotherapy effective with this population, and if
so, how? These seemingly straightforward questions require careful attention to the complex
and intersecting aspects of psychotherapy process and outcomes. The reasons why TNG
adults seek psychotherapy, with what expectations, with what sorts of psychological distress,
and with what outcomes remain areas to be explored. Furthermore, the impact of therapist
attitudes and preparedness for working with TNG clients on psychotherapy outcomes is
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largely unknown (Budge & Moradi, 2018).

The present study is a pilot and feasibility randomized controlled psychotherapy trial with
19 transgender individuals. Method and results are described with the intent to inform future
research focused on conducting an RCT with transgender clients with a larger sample size.
There are three aims to the current study: (a) determine the feasibility and acceptability of
conducting a small randomized controlled trial with transgender clients, (b) longitudinally
investigate the impact of minority stress interventions (plus transgender affirmative
psychotherapy) versus transgender affirmative psychotherapy alone, and (c) explore level of
and trends in the working alliance for the two conditions, and whether alliance is predictive
of outcomes.
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Method
Participants
Clients.—The initial sample of clients consisted of 20 transgender psychotherapy-seeking
participants recruited from the community. Inclusion criteria consisted of a) being 18 years
or older, b) identifying as transgender, nonbinary, or gender nonconforming, c) English
fluency, and d) availability for weekly psychotherapy sessions on one specific night of the
week. Exclusion criteria were: a) presence of psychotic symptoms and b) ongoing
psychotherapy treatment outside of the study. To increase generalizability of findings, we
kept inclusion/exclusion criteria to a minimum. One client dropped out of the study at
session 5 due to a scheduling conflict; thus, the final participant sample was N = 19.
Demographic information of the clients is provided in Table 1.
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Therapists.—Therapists were included as participants in this study. There were four

therapists who were recruited to provide psychotherapy to five clients each. All therapists
were advanced doctoral students in a counseling psychology program who had completed at
least two years of formal psychotherapy training. Inclusion criteria for therapists included: a)
being 18 years or older, b) having at least one year of formalized training in psychotherapy
(having seen clients for at least one year), c) English fluency, d) availability to provide
psychotherapy to five clients on one specific night of the week, and e) availability to engage

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in 1 hour of supervision per week. Therapists reported that their theoretical orientation was
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either psychodynamic (n = 2) or person-centered (n = 2).

Procedure
Clients and therapists were recruited through emails and flyers advertising the study.
Potential participants (both clients and therapists) were instructed to call or email the
principal investigator to schedule a phone screening to determine eligibility. If clients met
inclusion criteria, they were asked to attend a 3-hour baseline assessment session prior to
starting the psychotherapy intervention. Clients provided written informed consent at the
beginning of the baseline assessment session. Therapists provided written informed consent
prior to engaging in their training sessions. Clients engaged in a structured diagnostic
interview based on the DSM-5 and were administered specific measures at the baseline,
termination, and follow-up sessions. They also completed the OQ-45 (Beckstead et al.,
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2003) and the WAI (Hatcher & Gillaspy, 2006) prior to engaging in each psychotherapy
session. Those who were randomized into the Building Awareness of Minority Stressors
(BAMS) group also filled out minority stress experiences prior to engaging in each
psychotherapy session. Therapists in the BAMS group were supervised by the first author
and therapists in the TA group were supervised by the director of the community clinic (a
licensed psychologist) where the sessions were held. Clients engaged in termination and 6-
month follow-up interviews regarding their experiences in the study. Therapists also engaged
in a follow-up interview regarding their training experiences and thoughts on the feasibility
of the study and acceptability of the interventions. This study was approved by the
Institutional Review Board at (masked for review) and was also registered at
Clinicaltrials.gov (identifier masked for submission). Participants were compensated for
filling out measures and engaging in interviews. Participants were also compensated at each
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psychotherapy session. The psychotherapy interventions were provided free of charge.

Treatment Conditions
Trans Affirmative psychotherapy (TA).—This intervention was initially
conceptualized as “treatment as usual (TAU)” with training provided to therapists to ensure
cultural competence in working with transgender clients. Clients were informed that they
would receive 12 sessions of psychotherapy focused on the clients’ individual presenting
concerns. Therapists were not proscribed from providing any specific type of psychotherapy
and were provided with instructions to follow typical guidelines for providing psychotherapy
within their theoretical framework (one therapist provided psychodynamic psychotherapy
and one therapist provided person-centered psychotherapy). Therapists received weekly
supervision to assist with case conceptualization and to discuss the course of treatment for
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each of the clients. The supervisor was a licensed psychologist who has extensive experience
supervising therapists in their clinical work with transgender clients. To better represent the
nature of the between-group comparison, we reconceptualized this group as TA rather than
TAU. Both therapists in this condition received specific training in transgender affirmative
psychotherapy techniques, such as ways to ask about pronouns, discuss therapist gender
identity with client, and basic education about transgender health. This treatment condition
label was changed from TAU to TA, due to the fact that both of the therapists received
specific training in transgender affirmative psychotherapy techniques. Prior to the initial

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psychotherapy session, all client participants attended an individual assessment session with
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a member of the research team during which they received psychoeducation about what to
expect from psychotherapy (Fende Guajardo & Anderson, 2007) to provide a control
condition to the psychoeducation received in the Building Awareness of Minority-related
Stressors (BAMS) group.

Building Awareness of Minority-related Stressors (BAMS + TA).—The BAMS

component included (a) psychoeducation regarding the reasons for increased mental health
concerns in transgender populations (minority stress) and (b) prompts to clients each week
to recall and discuss recent minority stress experiences. We hypothesized that the BAMS
module, when added to TA, would lead to increased improvement in generic distress and in
minority-related stress and resilience for this population. For this condition, clients were
instructed that they would receive 12 sessions of psychotherapy where they were able to
discuss any presenting concern of their choice. Prior to engaging in their first session of
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psychotherapy, each client received a standardized psychoeducational training (created for

this study) that focused on minority stress in transgender populations. Clients were also
instructed that they would be prompted to provide up to 3 minority stress experiences they
had noticed over the previous week (prior to starting their session that day) and that they
could discuss these in psychotherapy, if they wished. Clients in this condition also received
the same handout as the TA group regarding expectations for psychotherapy.

Beyond the psychoeducation and prompting for discussing minority stress experiences,
clients and therapists could structure their sessions based on the client’s presenting concerns
or goals for that particular day. Therapists were instructed to provide psychotherapy within
their own theoretical orientations (one therapist used psychodynamic psychotherapy and one
therapist used person-centered psychotherapy) and were instructed to not push discussions
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of minority stress experiences if the client indicated a desire to discuss a different topic in
psychotherapy. Therapists received weekly supervision from the first author of this study, a
licensed psychodynamic psychologist with extensive experience providing supervision and
psychotherapy focused on transgender clients. Supervision was provided with a minority
stress framework in mind, with therapists considering how proximal and distal stressors may
be impacting the clients and framing client concerns within this theoretical understanding.
Therapists were provided with a specific training on minority stress theory prior to the start
of psychotherapy to orient them to the psychoeducation module that the clients would
receive and to provide contextual information to situate how minority stress may be
considered within the context of psychotherapy. Therapists also received the same
transgender affirmative psychotherapy (TA) training that was provided to the therapists in
the control condition.
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Measures
Measures were either filled out at one of three major assessment time points (e.g., baseline,
termination, follow-up) or prior to each psychotherapy session. Most measures were slightly
adapted to better fit the needs of transgender participants. Specifically, the language of
measures was changed from binary pronouns (i.e., “he/she”) to gender neutral pronouns
(i.e., “they”).

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Gender Minority Stress and Resilience Measure (GMSRM; Testa, Habarth, Peta, Balsam, &
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Bockting, 2014).
The GMSRM was considered the primary target outcome measure and was assessed at three
time points: baseline, termination, follow-up. Although this measure assesses many aspects
of minority stress, for this study we assessed the following targeted outcomes of minority
stress experiences: non-affirmation, internalized transphobia, pride, and community
connectedness. The subscales are scored on 5-point likert scales, with options ranging from
strongly disagree to strongly agree. Reliability scores for previous studies indicate the
following ranges from: (nonaffirmation: α = .88–.93; internalized transphobia: α = .91–.93;
transgender identity pride: α = .88–.90; community connectedness: α = .78;) (Kolp et al,
2019; Testa et al., 2014). Coefficients alpha for the current study at baseline were:
(nonaffirmation: α = .69; internalized transphobia: α = .91; transgender identity pride: α
= .84; community connectedness: α = .86).
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Outcome Questionnaire (OQ-45; Beckstead et al., 2003).

The OQ-45 was considered a secondary outcome measure and was assessed at baseline,
termination, follow-up, and prior to each psychotherapy session (up to 15 administrations).
The OQ-45 is comprised of 45 questions that determine an overall distress score (ranging
from 0–180), with a clinical cut-off of 63 or greater. All questions are assessed using a 5-
point likert scale (0 = strongly disagree to 4 = strongly agree). Reliable change occurs when
a score changes by 14 points or more. A high score suggests that the client is admitting to a
large number of symptoms of distress (mainly anxiety, depression, somatic problems and
stress) as well as difficulties in interpersonal relationships, social role (such as work or
school), and in their general quality of life. Previous studies have reported a coefficient alpha
of: .90–.93 (De Jong et al, 2014; Johansson et al., 2019). Coefficient alpha at baseline for the
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current study was: .89.

Working Alliance Inventory – Short Form C (WAI-C; Tracey & Kokotovic, 1989).
Prior to sessions 2–12, all client participants completed the WAI-C to report on working
alliance during the previous session. The WAI-C is comprised of 12 questions that focus on
the tasks, bond, and goals in psychotherapy and how well the client perceives the therapist to
be facilitating these components in psychotherapy. Questions are assessed on a 7-point likert
scale, ranging from 1 (never) to 7 (always), with a total score ranging from 7–84. Higher
scores indicate a better perceived working alliance between the client and therapist. Previous
studies have noted a coefficient alpha of overall working alliance of .93 (Mahon et al., 2015)
and .97 (Garner, Godley, & Funk, 2008). Coefficient alpha for the current study at Session 3
was: .96.
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Feasibility and Change Interviews.

Clients were asked a series of questions that focused on the feasibility of the study at
baseline, termination, and follow-up. At baseline, participants were asked questions about
how they heard about the study, why they wanted to participate, reasons for uncertainty to
participate, and anticipated barriers to participation. At termination and follow-up,
participants were asked questions that focused on participants’ overall experiences with the

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study, accessibility of the study/clinic space, timing of sessions, filling out measures,
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perceptions of study procedures, and if they would participate in the study again.

Results
Random assignment can result in non-equivalent groups, especially when sample sizes are
small (Hsu, 1989). Table 1 shows demographic and baseline symptom data for the two
treatment groups. There were no significant differences at baseline on age, gender, race/
ethnicity, or measures of stress and resilience.

Feasibility and Acceptability

Feasibility was assessed using the definition by Eldridge and colleagues (2016), which
included: client willingness to be randomized, ease of recruitment, number of eligible clients
and therapists, if there were suitable outcome measures, if clients would respond to take
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follow-up assessments, and time needed to collect and analyze data. To determine
acceptability of the interventions and study procedures, qualitative interviews were recorded
and transcribed. Transcripts were analyzed using a content analysis approach (Elo &
Kyngäs, 2008).

For therapist feasibility, we needed 6 therapists to meet a desired goal of 30 clients for the
study, but only 4 therapists (66.6%) were successfully recruited. As we only had capacity
(room space and timing at the clinic) for therapists to see 5 clients each, that determined our
final total sample size to be 20. For client feasibility, 100% (20/20) of all of the initially
screened clients were eligible and recruitment was closed after 10 days of initially opening
up the call. All 20 potential participants who responded to study invitations were randomly
assigned to one of the two treatment conditions, and all started treatment as scheduled.
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Clients were included in the analyses if they completed at least half of the planned 12-
session treatment. With the exception of one client who terminated at Session 5 due to
schedule conflicts, the remaining 19 clients were considered as having received an active
dosage of their respective interventions and terminated naturalistically at the discretion of
the client. Thus, all 19 were included in the intent-to-treat analyses presented here. All
clients indicated a willingness to be randomized and most (n = 17) clients were assessed at
follow-up. Patterns of recruitment were examined to evaluate acceptability of the
intervention to the population of interest (see Figure 1).

Regarding weekly psychotherapy sessions, 84% (n = 16) indicated that coming in on a

weekly basis was the right timing and pacing for sessions (two of the clients reported that
they would prefer biweekly sessions and one client said sessions more frequently than
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weekly would be preferable). When asked what clients would have wanted to be different
about the study design, most (68.4%, n = 13) clients reported that they would not change the
study design. Examples of offered suggestions for changes in study design included: change
of season (due to winter weather during the study), change of location for pre-post
assessment sessions be more accessible, have less distressing measures, starting the working
alliance inventory at week 3 or 4, and changing weekly sessions to biweekly.

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Regarding session attendance, clients in the BAMS group were more likely to attend all
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available sessions. This difference in mean number of sessions attended corresponds to d =

0.84 [−0.16, 1.86], p = .08. Although it represents a large effect size by Cohen’s (1988)
standards, this difference in treatment lengths was not statistically significant in the present,
small sample. Nonetheless, it suggests that this effect is worth examining in future, larger
clinical trials. It may be that the addition of minority stress psychoeducational components
to trans-affirming interventions results in an increase in client acceptability and engagement.

Qualitative results for this study indicate that the interventions were acceptable. For
example, 100% of clients reported an overall positive experience participating in the study.
All clients (100%, N = 19) reported that they would participate in the study again.
Additionally, 100% (N = 19) indicated that their overall experience of participating in the
study was positive. To illustrate, one client assigned to the TA group noted: “Because [the
psychotherapy] really helped me and I had a really good experience and I started to trust
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therapy again. I’ve been in and out of there therapy all my life, all my adult life I should say,
and so and I had some really bad experiences. This is the exact opposite of that.” From the
BAMS group, this client reported: “It was awesome. I really enjoyed it—it was nice, very
queer-focused and trans-focused therapy. And if it’s not what we always talked about it’s
that the therapist just being educated and being able to empathize. It was really nice.”
Beyond generally indicating a positive experience, some clients noted the importance of
specific factors that assisted with a positive study experience, such as a welcoming waiting
room and trained staff/therapists who used correct pronouns.

One client from the BAMS group said: “It was just nice to go to a place that you know that
you were acknowledged and validated as a person.” When asked how they felt validated/
acknowledged, they elaborated: “Knowing the nature of the study but then also the waiting
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room, or going to therapy, using correct pronouns...” Although this client did not elaborate
on what was welcoming for the waiting room, we ensured that there was LGBTQ
representation around the waiting room (e.g., magazines, pictures, and a sign indicating
affirmation of pronouns). Another client from the BAMS group indicated that specifically
talking about marginalization was beneficial:

It was a really good experience. I’ve had a few experiences in therapy before, but
they never really felt like they went anywhere. I always felt like I wasted a lot of
time defending why I felt a certain way. Like, with oppression and
marginalization…I had to be like, this isn’t just me being depressed or anxious, this
is a real thing and I am having feelings. So I think that aspect was really
validating---not having to defend why I felt that way, and not being treated like it
wouldn’t be normal to feel that way.
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Statistical Analyses
All analyses were conducted in the R programming environment (R Core Team, 2017). We
followed the recommendation of the Publication Manual of the American Psychological
Association, 6th edition (APA, 2010) to report effect sizes (generally standardized mean
differences) and 95% confidence intervals for our main hypothesis tests. Thus, we examined
the standardized mean change scores within groups (dW) as an index of within-group

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change, and statistically compared the effect sizes for the two groups to determine whether
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mean change differed in the two groups. We computed a standard error for the difference
between the two effect sizes following procedures from Borenstein, Hedges, Higgins, and
Rothstein (2009), and computed the p value for t = (dW_BAMS – dW_TA)/SEdiff to determine
whether the difference was statistically significant.

Change in General Distress and Impairment

The OQ-45 assesses generic distress and functional impairment in three areas: symptom
distress, interpersonal relationships, and social role functioning. In these analyses, we focus
on the OQ total score, which is a composite of the three areas. Clients in this study reported
significant distress and impairment, with a mean OQ score greater than 75 points at baseline.
This exceeds the OQ clinical cutoff of 63 points (Beckstead et al., 2003). Thus, reduction in
general distress and impairment was an important goal for these interventions.
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Table 2 quantifies change over time as dW for each group, where dW = (Mpost – Mpre)/
sdpooled. For each group, the OQ effect size is large (|d| > 0.8; Cohen, 1988) and the 95%
confidence interval does not include zero, which indicates that clients in each group reported
a substantial and statistically significant decrease in generic distress and impairment over the
course of treatment. In the absence of a wait-list control group, it is not possible to rule out
other causes for this decrease (e.g., history, maturation; Shadish, Cook, & Campbell, 2002),
so caution is warranted in attributing this change solely to treatment effects.

Table 2 also shows effect sizes for change from baseline to follow-up. This change is
numerically smaller for the TA group (dW = −0.46) and larger for the BAMS group (dW =
−0.95; p = .09). However, as shown in the right-most column, pdiff = .46 for this between-
group comparison, which indicates that the difference in dW for the two groups, while
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substantial, was not statistically significant in this sample. We tentatively conclude that OQ
gains were maintained for the BAMS group at the 6-month follow-up assessment, and
further research is desirable to clarify maintenance of gains for the TA-only intervention.

Change in Gender Minority Stress and Resilience

The GMSRM (Testa et al., 2014) is a multidimensional assessment of stressors and supports
related to gender minority identity. Table 2 shows indices of change on two stressors—non-
affirmation NA) and internalized transphobia (IT)—and two resilience factors—pride (P)
and community connections (CC). Effect sizes for pre-post change in stressors for the
BAMS group were large (NA; p = .02) or medium-to-large (IT; p = .07); effect sizes for
these stressors in the TA group were small or small-to-medium and not significantly
different from zero. However, the tests of the group-by-time interaction (pdiff) were not
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significant, indicating that the null hypothesis of equal change for the two groups could not
be rejected in our sample.

The baseline-to-follow-up effect sizes for NA were large and significant or marginally
significant (ps = .04 and .05 for TA and BAMS, respectively), which suggests that both
interventions led to sustained reduction in non-affirmation experiences over the 6-month
follow-up interval. The follow-up effect sizes diverged for the IT scale, with weak effects (d
= −0.11) for the TA group and medium-to-large effects (d = −0.72) for BAMS. It is not

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surprising, given the small sample size, that these two effect sizes did not differ significantly
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(pdiff = .31). We tentatively conclude that the evidence for reduction in gender minority-
related stressors is encouraging, especially for the BAMS condition. Further research is
needed to clarify possible differences between the two treatments, especially related to
reductions in internalized transphobia.

Indices of both proximal and distal change in resilience factors (P, CC) were near zero and
nonsignificant for both TA and BAMS groups. Thus, there is no evidence that either TA or
BAMS conditions strengthened these theorized protective factors in this pilot study.

Working Alliance and Outcome

Prior to sessions 2–12, clients completed a retrospective WAI reporting on their perceptions
of the working alliance in the previous session. Figure 2 shows the trends for mean WAI
scores by session for each group. Group*Time regressions showed a significant linear trend
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(B = 0.72; p = .003) indicating an increase in alliance ratings over time. This trend did not
differ by group (p = .14).

We examined the relation between working alliance and outcome in these groups by
predicting post-treatment scores on each outcome variable from WAI ratings at session 3,
controlling for baseline scores on the outcome variable. Effect sizes for working alliance on
outcome are summarized in Table 3. Only the effect on OQ scores (β = −.33; p = .053)
approached statistical significance, suggesting that clients reporting a stronger working
alliance at session 3 were apt to experience more symptom reduction, relative to clients
reporting a weaker working alliance. There was no evidence that the association between
working alliance and OQ outcome differed by group (p = .24).
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Discussion
Psychotherapy research with transgender and nonbinary populations is in its infancy and
thus information regarding the feasibility and acceptability of RCTs in this population is
limited. Knowledge regarding the efficacy of psychotherapy for TNG individuals is
unknown, as this is the first RCT to our knowledge to have been conducted with TNG
populations. The first aim of our study was to determine the feasibility and acceptability of
conducting a small randomized controlled trial with TNG clients. Twenty clients were
assigned to receive BAMS or TA using randomization. Feasibility of the study was
supported; 100% of the initial participants screened met criteria and consented to participate
in the study. While it was more difficult to recruit therapists (66.6% of the desired therapist
n), this likely reflected the time of year (recruiting graduate students in November) and that
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trainees already had signed up for their clinical practica. All four of the trainee therapists for
this study saw clients for the RCT in addition to their 20-hour a week practicum experiences.
It is notable that 100% of the clients indicated they had a positive experience participating in
this study and that they would participate in this study again. These findings are encouraging
regarding the need for future RCTs with TNG populations.

Though the primary focus of this study was to determine feasibility and acceptability of this
pilot RCT, we also aimed to longitudinally investigate the impact of BAMS (+ TA) versus

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TA alone. One of our goals was to explore if targeted interventions focusing on minority
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stress would lead to changes in minority stress experiences for transgender clients. Pre-post
analyses indicate that clients randomized to the BAMS group experienced a reduction in
internalized transphobia and non-affirmation experiences and that these effects were
sustained 6-months post intervention. Scholars have addressed the need for psychoeducation
and interventions that focus on oppression (see Pachankis, 2014; Watts, Abdul-Adil, & Pratt,
2002) and previous studies provide evidence that psychoeducation focused on trauma has
been beneficial (e.g., Rice & Moller, 2006). This finding demonstrates that the BAMS
intervention may provide specific targeted treatment that assists with reductions in
experiencing stigma and responding to microaggressions from others. It is also notable that
the resilience measures (pride and community) showed no changes over time. The BAMS
module did not include any elements targeted at enhancing resilience. This is a promising
goal for future development of interventions adapted to TNG populations, given the findings
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from this study and studies indicating the importance of resilience in this group (Edwards,
Bernal, Hanley, & Martin, 2019; Singh, Hayes, & Watson, 2011). Though there were no
statistically significant differences between groups, these results suggest the need for a larger
trial to explore how minority stress interventions uniquely contribute to change in proximal
and distal stressors for transgender clients.

In addition to the targeted measure of minority stress, we were interested in exploring trends
of change in general psychological distress. The mean baseline OQ-45 score for all clients in
this study was 76.32 (SD = 19.65); only four (21%) of clients at baseline indicated a score
below the clinical cutoff of 63. It should be noted that the mean score for clients receiving
outpatient treatment nationally is 80.98 (SD = 24.82) (Lambert, 2015) and that 9 (47%)
clients in the sample scored higher when compared to the general outpatient population.
Thus, the clients in the study demonstrate similar distress to the general outpatient
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population from the original validation study.

Results from the current study indicate that both groups demonstrated a substantial and
statistically significant decrease in psychological distress over the course of receiving
psychotherapy. Although this study did not include a no-treatment comparison, it is
reasonable to infer that psychotherapy likely contributed to some of the improvement
reported. This finding provides initial support for an affirmative answer to a question for
which empirical evidence was previously lacking: Is psychotherapy effective for transgender
clients (see Budge & Moradi, 2018)? That there were no statistically significant differences
between groups on a non-targeted measure may be a function of common factors playing a
primary role in the effectiveness of the psychotherapy in this study (e.g., Wampold & Imel,
2015). The way in which the interventions were designed was to target a specific
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psychoeducational components (e.g., affirmative psychotherapy for the therapists and

minority stress psychoeducation for transgender clients) and there were two separate
theoretical orientations used out of four therapists to provide treatment, which likely
contributes to common factors playing a large role in the outcome for this study. Taken
together, the results from the targeted (minority stress) and non-targeted (distress) measures
demonstrate that both BAMS +TA and TA alone are effective for general symptom relief for
TNG populations and that BAMS +TA shows promise for sustained relief from internalized
transphobia and non-affirmation experiences.

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The third aim of this study was to study the therapeutic relationship between transgender
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clients and their therapists and its association with treatment outcomes. The only study we
could find to date that has measured the working alliance with transgender populations was
an evidence-based case study that noted ceiling effects within the therapeutic dyad (see
Budge, 2015). Qualitatively, some clients reported that they had trouble filling out the WAI
in the beginning of the study because they were not yet certain about their therapists by
session 2, which demonstrates an understandable level of caution in establishing trust with
therapists. Quantitative results indicated that working alliance scores were on average well
above the midpoint of the scale and increased over time for both groups. Thus, therapists
conducting trans affirmative psychotherapy (which all therapists were trained in) were able
to create trust and strong bonds over the course of the 12 weeks of the trial. Though this is
the first trial to measure the working alliance between transgender clients and their
therapists, this finding supports theories provided by Singh and dickey (2017) and Austin
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and Craig (2015) regarding the impact of transgender affirmative psychotherapy. In addition
to an increase in working alliance throughout the course of treatment, findings also indicate
that greater working alliance scores predicted decreased psychological distress over time for
both groups. This finding is in line with previous research noting the correlation between
working alliance and improvement based on the OQ-45 (e.g., Baldwin, Wampold, & Imel,
2007).

Limitations
Results of this study should be interpreted with limitations in mind. First, the study was
underpowered to detect group differences (though some group differences emerged upon
analysis). The main purpose of the small sample was to determine the feasibility and
acceptability of this pilot trial, with a secondary purpose to note trends in the data. This
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design is in line with recommendations for using phases to conduct RCTs (see Rounsaville,
Carroll, & Onken, 2001). An additional limitation of the study was the lack of a wait list
control group. It was decided to provide interventions for all eligible participants based on
previous data regarding disparities in distress and lack of trust with mental health systems—
we hypothesized that a wait list might cause more harm than not enrolling in the study
(though this has yet to be tested). Thus, we cannot confidently attribute the gains observed
for these clients to the effects of treatment. Although a 6-month follow up is a standard
follow-up period, it may not be the most optimal timeframe to determine if treatment gains
continued for a longer period of time after treatment. In addition, booster sessions were not
offered post-treatment, which may have assisted with better maintenance of treatment gains.

In sum, this is the first pilot psychotherapy trial comparing the effects of two psychological
treatments for transgender populations. This adds to an emerging body of literature
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indicating the importance of transgender affirmative psychotherapy and cultural competence

for therapists working with transgender populations. Namely, both BAMS and TA
interventions appear to be feasible, acceptable, and likely effective treatments for
psychological distress in transgender populations. It is important to replicate and extend the
findings via a larger RCT, however, both interventions demonstrate promise as a means to
improve mental health and cope with minority stress.

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Acknowledgments
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This project was supported by a research grant from the National Institute of Mental Health (NIH UL1TR000427;
Stephanie L. Budge, Principal Investigator).

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Clinical Impact Statement:

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Question:
Can researchers study transgender affirmative therapy using a randomized clinical trial
format? And, what is the effect of psychotherapy for transgender and nonbinary people?

Findings:
This study indicated that it is feasible to conduct an RCT with transgender and nonbinary
clients. It also highlights the importance of providing affirmative psychotherapy to
transgender and nonbinary clients. This study demonstrated that providing information
about minority stress may reduce internalized transphobia and reduce nonaffirmation
experiences for transgender and nonbinary clients.

Meaning:
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This study provides preliminary evidence to support the continued use and justification
for transgender affirmative therapy and to also address minority stress in psychotherapy
with transgender and nonbinary clients.

Next Steps:
A larger RCT should be conducted to determine if trends in data from this study
demonstrate meaningful change in a larger sample.
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Figure 1.
Flowchart of patient enrollment
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Figure 2.
Group WAI means by session.
Note. TA = Trans-affirming intervention; BAMS = Trans-affirming plus Building Awareness
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of Minority Stress
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Table 1.

Comparison of TA and BAMS Groups on Demographic Variables and Baseline Distress and Resilience
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TA BAMS

M (SD) n (%) M (SD) n (%) p

Age 27.50 (4.93) 31.11 (13.4) .46
Annual Ind. Income 21,200 (12,594) 32,650 (22,825) .21
Race .58
Multiracial 2 (20) 1 (11.11)
White 8 (80) 8 (88.89)
Gender Identity .82
Nonbinary 7 (70) 5 (55.56)
Transfeminine 2 (20) 2 (22.22)
Transmasculine 1 (10) 2 (22.22)
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Sex Assigned at Birth 1

Female 7 (70) 7 (77.78.)
Male 3 (30) 2 (22.22)
Sexual Orientation 1
Bisexual 1 (10) 1 (11.11)
Lesbian 1 (10) 0 (0)
Pansexual 2 (20) 1 (11.11)
Queer 5 (50) 5 (5.56)
Straight 1 (10) 2 (22.22)
Highest Education .35
Associates / Technical 3 (30) 0 (0)
Bachelors 3 (30) 3 (33.33)
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Masters 1 (10) 3 (33.33)

Some College 3 (30) 3 (33.33)
OQ 76.80 (20.81) 75.78 (19.51) .91
GMSRM-NA 20.30 (3.06) 18.22 (4.27) .24
GMSRM-IT 10.40 (9.28) 15.22 (8.11) .25
GMSRM-P 21.10 (7.19) 18.00 (6.04) .33
GMSRM-CC 5.60 (3.98) 8.22 (4.60) .20

Note. Ind. Annual Income = Individual Annual Income in USD; TA = Trans-affirming intervention; BAMS = Trans-affirming plus Building
Awareness of Minority Stress; OQ = Outcome Questionnaire-45 () total score; GMSRM = Gender Minority Stress and Resilience Measure (Testa et
al., 2014); NA = Non-Affirmation; IT = Internalized Transphobia; P = Pride; CC = Community Connectedness; p value tests H0 (group means are
equal for quantitative variables; category proportions are equal for nominal variables
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Table 2.

Within-group change: Standardized Mean Differences (dW)

TA BAMS
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dW 95% CI p dW 95% CI p pdiff

Baseline to Post-treatment
OQ −0.87 −1.51, −0.23 .01 −0.90 −1.60, −0.21 .02 .93
GMSRM-NA −0.35 −1.01, 0.31 .27 −1.07 −1.93, −0.22 .02 .15
GMSRM-IT −0.15 −0.70, 0.41 .57 −0.59 −1.23, 0.05 .07 .26
GMSRM-P 0.15 −0.49, 0.79 .62 0.18 −0.51, 0.87 .56 .94
GMSRM-CC −0.09 −0.73, 0.55 .76 −0.28 −0.98, 0.42 .39 .66
Baseline to Follow-up
OQ −0.46 −1.36, 0.43 .27 −0.95 −2.05, 0.15 .09 .46
GMSRM-NA −0.97 −1.88, −0.07 .04 −1.00 −1.99, −0.01 .05 .97
GMSRM-IT −0.11 −0.96, 0.74 .78 −0.72 −1.74, 0.31 .15 .31
GMSRM-P −0.01 −0.76, 0.73 .97 0.17 −0.64, 0.98 .65 .71
GMSRM-CC 0.45 −0.34, 1.23 .23 −0.38 −1.21, 0.46 .33 .12

Note. TA = Trans-affirming intervention; BAMS = Trans-affirming plus Building Awareness of Minority Stress; OQ = Outcome Questionnaire-45 (Beckstead et al., 2003); GMSRM = Gender Minority
Stress and Resilience Measure (Testa et al., 2014); NA = Non-affirmation; IT = Internalized transphobia; P = Pride; CC = Community connections; dW = within-group standardized mean difference
(Cohen’s d); pdiff = test of H0: dW_TA = dW_BAMS.

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Table 3.

Standardized regression weights predicting post-treatment outcomes from Session 3 WAI ratings, controlling
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for baseline scores on outcome variables

Outcome β 95% CI p
OQ −.33 [−.66, .00] .05
GMSRM-NA −.19 [−.66, .28] .43
GMSRM-IT .28 [−.06, .62] .11
GMSRM-P −.16 [−.41, .10] .24
GMSRM-CC .27 [−.15, .68] .22

Note. OQ = Outcome Questionnaire-45 (Beckstead et al., 2003); GMSRM = Gender Minority Stress and Resilience Measure (Testa et al., 2014);
NA = Non-affirmation; IT = Internalized transphobia; P = Pride; CC = Community connections
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