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Graduate Student Journal of  Psychology 
2018, Vol. 17

Copyright 2018 by the Department of  Counseling and Clinical Psychology 
Teachers College, Columbia University

Working with Transgender Clients: Considerations for 
Psychological Testing and Assessment

Kat Lewitzke, Psy.D.
Michigan School of  Professional Psychology

Psychological assessment is an important component of  clinical psychology. It allows for a greater under-
standing of  an individual’s in various ways including socio-emotional functioning, cognitive and neurological 
processes, and/or adaptive skill, among others. Psychologists incorporate and execute a combination of  meth-
ods to reach a hypothesis about a person. Tests can be standardized and norm-referenced for particular age 
groups, grades, or gender. Yet, little has been spoken of  regarding protocols to be taken when assessing clients 
who do not identify with their assigned sex. This article provides a theoretical overview regarding sex, gender, 
and transgender identity, and moves into applying professional considerations for utilizing gender-normed 
assessments. In particular, there is a focus on promoting clinical awareness and upholding ethical standards 
when working with transgender populations. As of  present, guidelines and set protocols specifically for psycho-
logical testing with this population have not been established. This article attempts to outline procedures and 
applications which are exclusively intended for working with transgender populations in psychological testing. 
Included are the American Psychological Ethical Standards, the Guidelines for Psychological Practice with Transgender 
and Gender Nonconforming People, along with the Standards of  Care (SOC) for the Health of  Transsexual, Transgender, 
and Gender-Nonconforming People. The importance of  multiculturalism, as well as recognizing issues of  diversity, 
is further discussed. This article also creates a paradigm for future studies to establish norm-referenced testing.

There have been continuous attempts to distinguish 
and understand sex from gender (e.g., Money, 1955; 
Prince, 2005). Traditionally, whereas sex refers to one’s 
assigned gender (i.e., based on genitalia and biological 
characteristics), the perception of  gender is a socially 
constructed concept (Money, 1955). However, gender 
has now been more modernly defined as the collec-
tion of  mental and behavioral traits that differ in one’s 
personal identity and expression of  masculinity and 
femininity (Levay & Baldwin, 2009). This can range in 
everything from the clothes one wears, to the way a 
person talks and walks. There are even gender specific 
names, which can further reinforce the manifestation 
of  one’s identity to his or her sexual category. Yet, while 
gender has traditionally been delineated in binary terms, 
there has been an increase to conceptualize gender 
through a feminist, queer, and/or postmodern approach. 
These theories propose a more fluid approach to gender, 

and further indicate that gender concepts are influenced 
through power differentials, social interactions, and 
group norms (Bilodeau & Renn, 2005; Burdge, 2007; 
Butler, 1990; Halberstam, 1998).

Transgender describes an umbrella term for indi-
viduals who identify with and express a gender that is 
different from their sex assigned at birth (Bornstein, 
1994; Levay & Baldwin, 2009; Prince, 2005). This may 
act as in inclusive category for a wide range of  iden-
tities such as persons classify themselves as gender 
non-conforming, male-to-female persons (i.e., a person 
assigned as male at birth who transitions and identi-
fies as female), female-to-male persons (i.e., a person 
assigned as female at birth who transitions and identifies 
as male), transsexual, bi-gender, or pangender, among 
others (Bornstein, 1994). Gender identity is not easy to 
define, and even Facebook recognizes the complexity 
of  it. Since February of  2014, the social media site now 
offers about 50 custom gender options (Griggs, 2014). 
Despite the recognition for gender variably provided 
by social media, the transgender population has been 
frequently and habitually underrepresented in the field 

Override (Hidden running head text):
Lewitzke
Transgender Testing

Keywords: transgender, clinical, testing, assessment, ethics, 
multiculturalism

Please address correspondence regarding this article to: 
katlew.dr@gmail.com



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TRANSGENDER TESTING

of  psychology. This is especially evident for clinical 
assessment in regards to the creation and interpreta-
tion of  norms for various psychological instruments. 
The purpose of  this article is to promote a working 
model for clinicians in the areas of  psychological testing. 
Throughout this article, a brief  outline of  gender and 
transgender identity and gender non-conforming iden-
tity development will be provided, as well as a review of  
the literature concerning clinical assessment in an effort 
to promote ethical testing protocol and interpretation 
for psychologists working with transgender clients.

Gender and Identity

Children develop an awareness and understand-
ing of  gender and sex differences from an early age. 
Most infants at just 6 months old can already distin-
guish between male and female voices (Miller, 1983); 
and at 1-year of  age can categorize faces by gender, 
along with sex-typical hair length and clothing styles 
(Leinbach & Fagot, 1993). Kohlberg (1966) proposed 
a cognitive developmental model of  gender identity to 
describe how young children learn to understand their 
gender. His theory progresses in three stages: basic gender 
identity, gender stability, and gender consistency. It appears that 
gender identity in children is recognizable in as young as 
2 to 3-years old (Fagot, 1985; Kohlberg, 1966). During 
this stage, children can identify, discriminate, and apply 
gender labels. Around age 3, children move into the 
gender stability stage. It is here that physical appear-
ance or gender stereotyped activities become noticeably 
understood. For instance, if  a man is wearing a dress 
he may be categorized by the child to be a woman; or, 
a girl may believe she will become a boy if  she plays 
football. However, the perception of  gender constancy, 
which is the realization that sex categories are perma-
nent (i.e., the idea that a man dressing up as a woman is 
still a man), begins to occur around ages 3½ to 4-years 
old (Bem, 1989). This is referred to as gender consis-
tency, and is the third stage of  Kohlberg’s (1966) theory. 
Therefore, children apparently go through a one- to two-
year period of  being able to recognize and categorize 
their own sex, prior to developing an awareness of  its 
nature and consistency. When children reach the stage 
of  gender consistency, the idea of  gender permanency is 
developed. Kohlberg claimed that children fully under-
stand that gender will remain the same, or constant, 

throughout the lifespan at around age 6 (Kohlberg, 
1966). Although Kohlberg’s model follows a traditional 
understanding of  gender conformity, it may also be 
applicable to transgender persons as the realization of  
gender identity follows a similar path. Additionally, since 
gender differences have been noted on psychological 
assessments (i.e., De Goede & Postma, 2008; Lippa, 
2010), some tests have been normed; with similarities 
and differences in strengths to be interpreted with fair-
ness (Willingham & Cole, 2013). These concepts will be 
discussed in greater detail throughout the article.

Transgender Identity

Gender identity describes an individual’s internal 
working model and sense of  self  as male or female on 
a spectrum of  characteristics (Wilchins, 2002). Cisgender 
is the word used to refer as any individuals who are not 
transgender, meaning that they identify with a compli-
menting balance between their assigned sex and gender 
expression. This includes the majority of  the popula-
tion, in which a person’s assigned sex and identifying 
gender align (Schilt & Westbrook, 2009). A transman 
refers to a female to male transgender person; wherein 
a person was assigned as female at birth as male, but 
gender identifies as a male. A transwoman is a male to 
female transition, and describes a person who was born 
male, but identifies as female (Levay & Baldwin, 2009). 
In 2013, the DSM-5 (American Psychiatric Association, 
2013) replaced the diagnosis of  gender identity disorder 
to gender dysphoria. This shift highlights that a trans-
gender identity is not a disorder in itself. Furthermore, 
this decision was made as an attempt to ensure clinical 
care and reduce stigma for individuals who see, feel, 
and identify themselves as a different gender than their 
assigned sex (American Psychological Association, 
2013b). Furthermore, Gender dysphoria is demon-
strated in a variety of  ways, such as an intense desire 
to be treated and live one’s life as the opposite of  their 
assigned sex. The incongruence may even create a strong 
desire to alter or get abate primary and/or secondary sex 
characteristics (American Psychiatric Association, 2013).

Transgender men and women have existed through-
out human history, and across all cultures (Levay & 
Baldwin, 2009). While there is not precise number of  
persons identifying as transgender, Gates (2011) esti-
mated that there are approximately 700,000 transgender 



80

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individuals living in the United States; which totals about 
0.3% of  the adult population. A true count remains a 
challenge for various reasons. Many individuals continue 
to struggle with finding self-acceptance, and fear the 
process of  ‘coming out’ due to social acceptance (Grant 
et al., 2010). Additionally, while there are well-regarded 
surveys, such as the U.S. Census Bureau and Center for 
Disease Control, which collect data on one’s biologically 
assigned sex, these fail to capture a person’s identifying 
gender (Chalabi, 2014).

Feminist, postmodern, and queer theories discuss 
gender identity as a function of  a fluid, rather than 
rigid or binary, existence (Bilodeau & Renn, 2005; 
Burdge, 2007; Butler, 1990; Halberstam, 1998). Gender 
schema theory, developed by Bem (1981), emphasizes 
the sociocultural experiences that influence masculine 
and feminine schemas in the development of  gender 
roles. It has also become an increasingly more accepted 
hypothesis that gender identity is programmed at birth 
(Bao & Swaab, 2011), and is influenced by social interac-
tions and power inequalities (Bem, 1981; Butler, 1990; 
Halberstam, 1998).

Feelings of  a lack of  alignment, or mind-body 
discord, between one’s assigned sex and gender gener-
ally begin in early childhood; often as young as ages 2 
or 3 (Kennedy & Hellen, 2010). This is also the time at 
which children begin to conceptualize gender (Fagot, 
1985; Kohlberg, 1966; Pardo, 2008). While Kohlberg 
(1966) discussed the understanding of  one’s gender to 
begin at this young age, it appears that a realization 
of  transgender identity develops for persons at this 
same time (Kennedy & Hellen, 2010). The majority of  
transgender individuals report becoming aware of  their 
identity by age 8 (Kennedy, 2008; Kennedy & Hellen, 
2010). Some may report this recognition as transpir-
ing later, around ages 12 or 13 at the onset of  puberty 
when there are changes in physical body appearance 
(Pardo, 2008). A heart-rending example is the story of  
David Reimer, otherwise known as the John-Joan-John 
case. David was born a boy but tragically lost his penis 
at 8 months during a botched circumcision. He was then 
surgically reassigned as female, forced to take estrogen 
medications, and socially raised as a girl. Despite these 
efforts, as well as not initially knowing his assigned 
sex at birth, David struggled to identify as female and 
eventually transitioned back to male at the age of  15 
(Colapinto, 2000).

Various models of  transgender identity develop-
ment often begin with an initial awareness, anxiety, and 
distress of  feeling different from a person’s assigned 
sex. This creates confusion, and there may be a period 
denial or attempt to repress the experienced internal 
tension. Yet, a process is followed by educating one’s 
self  and establishing support. When acceptance for 
the desired identity has been formulated, the individ-
ual can then begin to integrate one’s self  into society 
(e.g., Devor, 2004; Lev, 2004). It has been suggested 
that applying traditional human development models, 
such as Erikson (1968) and Marcia (1966), may be not 
be entirely appropriate for transgender populations 
because these constructs are based on traditional gender 
role constructs (Mallon, 1999). There are models that 
exist to specifically address developmental issues, yet 
these rather reflect a social process of  personal experi-
ence in the understanding one’s self  (e.g., Devor, 2004; 
Lev, 2004; Mallon, 1999; Bilodeau & Renn, 2005). One 
example is Lev’s (2004) Transgender Emergence Model; 
which includes six stages that examines how transgender 
individuals come to conceptualize and appreciate their 
identity. This model further integrates the responsibility 
of  the counselor, such as normalizing and exploring the 
process with the individual. However, while research and 
awareness for transgender populations has increased 
(e.g., Denny, 1998; Devor, 1997; Glicksman, 2013; Lev, 
2004), there is still a need to understand and establish 
non-stigmatizing practices of  transgender identity devel-
opment (American Psychological Association, 2015; 
Bockting, 2014; Mallon, 1999; Morgan & Stevens, 2008). 
Additionally, there is even a greater need to understand 
and established standard and ethical psychological test-
ing protocols with transgender clients.

History of  Transgender Testing and Assessment

For several decades, society, along with the 
psychological community, pathologized and stigmatized 
transgender clients (Glicksman, 2013). There has been 
a heavy emphasis on cisgender lifestyles, with a view 
of  binary gender versus gender fluidity. Individuals 
have been expected to conform to an identity that 
aligned with their assigned sex (American Psychological 
Association, 2015). Until the 1970s, psychotherapy as 
a means to reestablish a gender that reflects a person’s 
assigned sex was the primary treatment for gender 



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identity disorder. This treatment has shown to be 
ineffective; and instead, psychologists are now advised 
to maintain a supportive role, create a non-stigmatizing 
environment, and promote acceptance (Glicksman, 
2013). However, despite these strides to establish 
awareness and understanding, it was reported in a 
study as recent as 2013 that transgender populations 
more often face rejection and negatively from society 
than lesbian, gay and bisexual individuals (Norton & 
Herek, 2013). Additionally, practitioners need to be 
educated on proper term usage, and be aware of  the 
harsh social impacts which transgender individuals 
continuously face (American Psychological Association, 
2015; Glicksman, 2013).

Lothstein (1984) completed an extensive review 
of  41 studies spanning over 30 years, from 1953 to 
1983, regarding psychological testing with trans-persons. 
Findings suggested that lower stability and greater 
psychological disturbance appeared more often in male 
to female transgender than female-male transgender. 
There was also evidence which reported that pre-opera-
tive transgender individuals still living in the male gender 
role had higher psychological problems than persons 
living as female. This may be reflective of  social stigma. 
Furthermore, there have been suggestions to propose 
an increase of  psychological stability and adjustment 
in male to female transgender persons following the 
initiation of  sex-reassignment surgery. While this study 
occurred over 30 years ago, the information is still criti-
cal for interpretation of  testing results. Psychologists 
should be mindful of  this when conducting assessments, 
and how existing discomfort may increase symptoms of  
anxiety and/or depression; which may then affect other 
scores, such as processing speed (Tsourtos &Thompson, 
2002) or inattention (Darke, 1988).

It has been consistently emphasized in the research 
that psychopathology is not a requirement of  transgen-
der development. Specifically, maintaining a transgender 
is not rooted in psychopathology, but should be concep-
tualized as a manifestation of  physical, social, and 
psychological conflict with which the client is enduring 
(Fleming & Feinbloom, 1984). Closer examination with 
an adolescent population reported that youth identifying 
as transgender did not significantly differ from cisgender 
individuals in regards to thinking disturbances and nega-
tive self-image. However, adolescents seeking psychiatric 

care conveyed higher levels of  pathology symptoms than 
both transgender persons and non-transgender not in 
treatment (Cohen, Ruiter, Ringelberg, & Cohen-Kettenis, 
1997). Furthermore, while an absence of  pathology in 
transgender populations have been reported in studies 
utilizing various versions of  the MMPI, elevations in 
scale 5 (masculinity-femininity) have been noted (Cole, 
O’Boyle, Emory, & Meyer, 1997; Miach, Berah, Butcher, 
& Rouse, 2000; Tsushima & Wedding, 1979). This eleva-
tion was reported to be most prevalent and significant 
in transwomen populations (Cole et al., 1997). Findings 
from this are suggestive that applying a person’s identify-
ing gender verses assigned sex will reduce the tendency 
to pathologize, and would act as a more congruent and 
clinically appropriate method.

Considerations for Carrying out 
Testing with Transgender Clients

Differences between genders have been noted, but 
research remains narrow in the area of  transgender 
identity. This further leads professionals limited in their 
ability to treat and interpret clinical data from this partic-
ular population. There are currently no set protocols on 
how to ethical administer, score, and infer psychological 
assessment among transgender clients. The question 
remains: Are professionals to interpret data in accor-
dance with one’s assigned sex or identifying gender? 
In this section, concepts have been included from the 
American Psychological Ethics Code, along with the 
Guidelines for Psychological Practice with Transgender and 
Gender Nonconforming People, and attempted to assimilate 
components from Standards of  Care (SOC) for the Health 
of  Transsexual, Transgender, and Gender-Nonconforming People 
to be used for psychological testing use with transgender 
clients.

The American Psychological Association estab-
lished the Ethics Code for working psychologists to use 
professional guidance when making decisions as part of  
their clinical, academic, or scientific roles. Instruments 
chosen for evaluations must have established validity 
and reliability. This entails that the psychometrics are 
sound for the instrument, as well as for the population 
of  interest. Some tests, such as the CAARS (Conners, 
Erhardt, & Sparrow, 1999) and MMPI (Butcher, Graham, 
Williams, & Ben-Porath, 1990), are gender-normed, 



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meaning that there are different scores and interopera-
tions for gender. However, as of  present, there are no 
tests, protocols, or studies which specifically normed 
for transgender populations.

Differences in a variety of  cognitive and personal-
ity traits have been found between men and women 
(Levay & Baldwin, 2009); including aspects of  visual-
spatial perception, reasoning, judgments, and memory 
tasks. Specifically, research has found that men generally 
display higher developed visuospatial skills than women, 
as well as greater skills in target accuracy and navigation 
(Goldstein, Haldane, & Mitchell, 1990; Levy & Baldwin 
2009; Peters, Manning, & Reimers, 2007; Moffat, 
Hampson, & Hatzipantelis. 1998; Watson & Kimura, 
1991). However, women reportedly outperform men in 
areas involving fine motor manipulation (Peters, Servos, 
& Day, 1990), recalling object location (De Goede & 
Postma, 2008), and verbal memory and fluency (Weiss 
et al., 2006). Variations in personality traits across 
genders, such as behaviors, feelings, attitudes, interests, 
and values, have also been examined. Men and women 
tend to display different interests; with women being 
more interested in people or socially related activities, 
while men prefer thing-oriented pursuits (Lippa, 2010). 
Gorski (1998) proposed that these differences in male-
female performances on visual-spatial and verbal tasks 
are the result of  early hormonal exposure on specific 
regions of  the brain during neural development. While 
the understanding of  binary cisgender regarding cogni-
tive and personality traits has been established, we could 
further our clinical knowledge by researching transgen-
der performance on such tasks. Studies on brain activity 
have also revealed that one’s brain activity is more 
concurrent with his or her identifying gender (rather 
than assigned sex) (Rametti et al., 2011a; Rametti et al., 
2011b). Therefore, it appears important to assess possi-
ble parallels between the performance of  cisgender men 
with transmen, and cisgender women with transwomen.

Furthermore, differences in cognitive and personal-
ity traits across cisgender populations (Levay & Baldwin, 
2009) need to be taken into consideration when assess-
ing and interpreting data for transgender populations. 
According to results from a meta-analytic review by 
Archer (2004), men also score higher on written tests 
of  aggressiveness. This was noted on both self  and 
peer reporting. Additionally, across most cultures, men 

reportedly show more verbal and physical aggression, 
and have greater incidences of  committing crimes 
(Archer, 2004); whereas women generally tend to 
express aggression through indirect or non-physical 
means, such as malicious gossip (Hess & Hagen, 2006). 
Current available research (although limited) appears 
to suggest the use of  gender identity congruent norms 
use for interpretation (i.e., Lippa, 2010; Micah, 2000; 
Rametti et al., 2011a; Rametti et al., 2011b). There 
appears to be some evidence to support that applying 
gender identity congruent MMPI/-2 norms (in place of  
assigned sex norms) resulted in transgender profiles to 
be reported within normal limits on a majority, if  not 
all, scales (Micah, 2000).

In 2015, the American Psychological Association 
established Guidelines for Psychological Practice with 
Transgender and Gender Nonconforming People (TGNC; 
hereafter Guidelines) as in introductory resource to 

“assist psychologists in the provision of  culturally 
competent, developmentally appropriate, and trans-
affirmative psychological practice with TGNC people” 
(American Psychological Association, 2015, p. 2). Trans-
affirmative practice entails the practice of  marinating 
awareness, consideration, and supportive care for the 
identities and personal experiences of  TGNC individu-
als (Korell & Lorah, 2007). The intent is to recognize 
the importance of  clients of  minority and culturally 
diverse backgrounds, and created guidelines “intended 
to enlighten all areas of  service delivery, not simply clini-
cal or counseling endeavors” (American Psychological 
Association, 2015). Guidelines are aspirational and 
aim to promote respect of  the client’s culture, as well 
as maintaining knowledge on current and relevant 
research. Psychologists should also be aware of  how 
their own attitudes, ethnicity, and cultural background 
may influence interpretation of  data surrounding the 
client’s psychological processes (American Psychological 
Association, 2015). In following with these guidelines, 
psychologists should attempt to understand where 
clients are in their transition process. Yet, even with an 
aspirational outline, it would be more ethically sound 
to engage in research that addresses the interpretation 
and procedures of  transgender identity in psychological 
assessment. I propose that it is important for psycholo-
gists to be fully competent in their education and training 
to deal with the various ethical concerns that deal with 



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transgender clients. Perhaps an awareness and under-
standing of  qualitative analysis should be integrated into 
the interpretation, rather than solely basing practices on 
quantitative reports. Transgender clients experience an 
elevated risk of  becoming victims of  various violent 
and traumatic acts (Mizock & Lewis, 2008). Therefore, 
it is important for working professionals to maintain 
knowledge on feminist and multi-cultural theory and 
techniques to minimize distress of  the client (Richmond, 
Burnes, & Carroll, 2012). Maintaining a fluid verses 
binary approach to gender identity will expand the clini-
cian’s own cultural awareness, and reduce pathology of  
the client (American Psychological Association, 2015). It 
is also advisable that psychologists take reasonable steps 
in explaining the assessment results. This could imply 
that during the feedback session, the examinee is aware 
of  why certain scales were elevated over others; or how 
a particular gender norm was chosen for interpretation.

Additionally, an understanding of  the impact 
brought on by minority stress theory, which emphasizes 
the effects of  how social situations cause stress and poor 
health for minority individuals (Meyer, Schwartz, and 
Frost, 2008), is important. This concept describes the 
health risks of  sexual minorities, such as transgender 
individuals, which is increased and a result of  conflict 
with the dominant social environment. The transgender 
population faces higher rates of  psychopathology and 
discrimination compared to their cisgender peers. For 
instance, across the lifespan, it has been reported that 
they are at an increased risk of  substance abuse, suicidal 
attempts, anxiety, and depression (Cochran, Keenan, 
Schober, & Mays, 2000). Despite these conflicts and 
the negative impacts, clinicians are faced with challenges 
due to the lack of  appropriate interventions.

Any professional working with persons from 
transgender populations can follow the core principles 
outlined in the Standards of  Care (SOC) for the Health of  
Transsexual, Transgender, and Gender-Nonconforming People 
(Coleman et al., 2012). The SOC were developed by the 
World Professional Association for Transgender Health; 
an international advocacy association with multidis-
ciplinary goals that aims to promote evidence-based 
treatments, policy, research, healthcare, and educa-
tion for the transgender population. These standards 
were created to assist healthcare professionals when 
working with transgender individuals. Due to the prior 

establishment of  these guidelines, core components 
of  SOC, as outlined by Coleman (et al., 2012), will be 
integrated in attempted to be specifically applied for 
psychological testing and assessment with clients from 
transgender populations:

• Exhibit respect for patients with nonconforming gender 
identities: Psychologists should aim to exhibit 
humanistic principles of  unconditional positive 
regard and empathy to build rapport (Cain, 2002). 
Psychologists need to consider differences in 
cognitive and personality traits between genders 
(Levay & Baldwin, 2009), and how these factors 
may be reflected in individuals’ identifying with 
transgender populations. Psychologists must also 
be knowledgeable in current biological and social 
research regarding this specific population in the 
consideration of  test report interpretation.

• Provide care (or refer to knowledgeable colleagues) that 
affirms patients’ gender identities and reduces the distress 
of  gender dysphoria: Client’s should not be patholo-
gized for their differences in gender identity or 
expression. Thus, using gender-based norms 
that converge with identifying gender may 
promote a more sound interpretation of  results. 
Psychologists should also emphasize and inter-
pret qualitative data (i.e., behavioral observations) 
just as importantly as quantitative results.

• Become knowledgeable about the health care needs of  
transsexual, transgender, and gender nonconforming 
people, including the benefits and risks of  treatment 
options for gender dysphoria: Psychologists need to 
assess all clients in accordance to the referral 
question, and be cautious and sensitive when 
making interpretations, as well as recommen-
dations; especially when working with clients 
from transgender populations. When appropri-
ate, psychologists may recommend goals that 
allow for relief  from negative self-concept and 
psychological distress.

• Be prepared to support and advocate for clients within their 
families and communities (i.e., schools, workplaces, and 
other settings): It is possible that a testing report be 
required and sent to such settings. Psychologists 
need to be prepared to explain testing results 
and interpretations to the involved parties, while 
supporting clients with best intentions.



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Future Directions

There are numerous resources specifically targeted 
for transgender clients. Protocols have been created 
that outline procedures for conducting psychotherapy 
for both individual and group settings (Adler, Hirsch, 
& Mordaunt, 2012; Bockting, Knudson, & Goldberg, 
2006; Mizock, & Lewis, 2008). Transgender clients may 
struggle to connect with professionals who lack compe-
tence and compassion for working with this population 
(Sanchez, Sanchez, & Danoff, 2009). To guarantee that 
a working alliance will be established and maintained, 
psychologists and persons from related professions need 
to become familiar with the gender identity research. 
Transgender terminology and language is continually 
changing. To facilitate better communication, work-
ing professionals should remain aware of  and sensitive 
to the client’s language (American Psychological 
Association, 2015; Bockting, Knudson, & Goldberg, 
2006). Clinicians can turn to the Guidelines for Psychological 
Practice with Transgender and Gender Nonconforming People 
for direction and inspiration. Additionally, this article 
provided an attempt to outline ethical practices when 
applying psychological assessments by integrating parts 
of  the SOC for the Health of  Transsexual, Transgender, and 
Gender-Nonconforming People (Coleman et al., 2012). My 
efforts are mere recommendations and based on ethical 
principles. Yet, this outline barely constitutes a founda-
tion to work from, and it is not nearly enough.

Our practice with this particular population greatly 
lacks empiricism in the area of  psychological testing and 
assessment. Although the notion of  gender has increas-
ingly replaced sex in research settings (Haig, 2004), there 
is extensive investigation needed to further understand 
transgender populations. This is especially true due to 
the lack of  professional guidelines for utilizing transgen-
der norms for psychological assessment. We are missing 
an important piece to the puzzle, and these issues should 
no longer be neglected. If  this problem persists, provid-
ing inadequate (and possibly unethical) care is at risk. It 
is imperative that psychologists address these concerns 
to move away from culturally encapsulated practices and 
improve awareness on the impact of  culture in clinically 
work (Wrenn, 1962). In order to better address the clini-
cal concerns of  individuals identifying as transgender, 
valid measures need to be addressed. There has been 

an ongoing cisgender privilege in the area of  psycho-
logical assessment; which has entailed failing to provide 
adequate standards to address the use of  certain norms 
with transgender populations. If  we are to uphold our 
ethical standards, there is a demand to push for test-
ing instruments to provide interpretations and greater 
knowledge for transgender populations.

References

Adler, R. K., Hirsch, S., & Mordaunt, M. (2012). Voice 
and communication therapy for the transgender/transsexual 
client: A comprehensive clinical guide. San Diego, CA: 
Plural Publishing.

American Psychiatric Association. (1980). Diagnostic 
and statistical manual of  mental disorders (3rd ed.). 
Washington, DC: Author.

American Psychiatric Association. (2013a). Diagnostic 
and statistical manual of  mental disorders (5th ed.). 
Washington, DC: Author.

American Psychiatric Association. (2013b). Gender 
Dysphoria. APA DSM-5, Retrieved on May 18, 2015 
from http://www.dsm5.org/documents/gender 
dysphoria fact sheet.pdf

American Psychological Association. (2015). Guidelines 
for psychological practice with transgender and 
gender nonconforming people. American Psychological 
Association, Retrieved on May 21, 2015 from http://
www.apa.org/practice/guidelines/transgender.pdf

Archer, J. (2004). Sex differences in aggression in 
real-world settings: A meta-analytic review. Review 
of  General Psychology, 8(4), 291. Retrieved from 
http://domestic-violence.martinsewell.com/
Archer2004.pdf

Bao, A. M., & Swaab, D. F. (2011). Sexual differentiation 
of  the human brain: relation to gender identity, 
sexual orientation and neuropsychiatric disorders. 
Frontiers in Neuroendocrinology, 32, 214–226. 
doi:10.1016/j.yfrne.2011.02.007

Bem, S. L. (1981). Gender schema theory: A cognitive 
account of  sex typing. Psychological Review, 88, 
354–364.

Bem, S. L. (1989). Genital knowledge and gender 
constancy in preschool children. Child Development, 
60, 649–662. doi:10.2307/1130730



85

TRANSGENDER TESTING

Bilodeau, B. L., & Renn, K. A. (2005). Analysis of  LGBT 
identity development models and implications 
for practice. New Directions for Student Services, 
2005, 25–39.

Bockting, W. O., Knudson, G., & Goldberg, J. M. 
(2006). Counseling and mental health care for 
transgender adults and loved ones. International 
Journal of  Transgenderism, 9, 35–82. doi:10.1300/
J485v09n03_03

Bornstein, K. (1994). Gender outlaw: On men, women, and 
the rest of  us. New York: Vintage Books.

Burdge, B. J. (2007). Bending gender, ending gender: 
Theoretical foundations for social work practice 
with the transgender community. Social Work, 52, 
243–250.

Butcher, J. N., Graham, J. R., Williams, C. L., & 
Ben-Porath, Y. S. (1990). Development and use of  the 
MMPI-2 Content Scales. Minneapolis, MN: University 
of  Minnesota Press.

Butler, J. (1990). Feminism and the subversion of  identity. 
New York: Routledge.

Cain, D. J. (2002). Humanistic psychotherapies: Handbook 
of  research and practice. Washington, DC: American 
Psychological Association.

Chalabi, M. (2014, July 29). Why we don’t Know the Size 
of  the Transgender Population. Retrieved May 2, 
2015. http://fivethirtyeight.com/features/why-we-
dont-know-the-size-of-the-transgender-population/

Cochran, S. D., Keenan, C., Schober, C., & Mays, 
V. M. (2000). Estimates of  alcohol use and clinical 
treatment needs among homosexually active 
men and women in the US population. Journal of  
Consulting and Clinical Psychology, 68, 1062–1071.

Cohen, L., de Ruiter, C., Ringelberg, H., & Cohen-
Kettenis, P. T. (1997). Psychological functioning 
of  adolescent transsexuals: Personality and 
psychopathology. Journal of  Clinical Psychology, 
53 ,  187–196.  doi :10.1002/(SICI)1097-
4679(199702)53:2<187::AID-JCLP12>3.0.CO;2-G

Colapinto, J. (2000). As nature made him: The boy who 
was raised as a girl. New York, NY: Harper Collins 
Publishers.

Cole, C. M., O’Boyle, M., Emory, L. E., & Meyer III, W. J. 
(1997). Comorbidity of  gender dysphoria and other 
major psychiatric diagnoses. Archives of  Sexual Behavior, 
26(1), 13–26. doi:10.1023/A:1024517302481

Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, 
P., DeCuypere, G., Feldman, J., & Zucker, K. (2012). 
Standards of  care for the health of  transsexual, 
transgender, and gender-nonconforming people, 
version 7. International Journal of  Transgenderism, 13, 
165–232. doi:10.1080/15532739.2011.700873

Conners, C. K., Erhardt, D., & Sparrow, E. (1999). 
Conner’s Adult ADHD Rating Scales: CAARS. 
Toronto: MHS.

Darke, S. (1988). Anxiety and working memory capacity. 
Cognition and emotion, 2, 145–154.

De Goede, M., & Postma, A. (2008). Gender differences 
in memory for objects and their locations: A study 
on automatic versus controlled encoding and 
retrieval contexts. Brain and Cognition, 66, 232–242. 
doi:10.1016/j.bandc.2007.08.004

DeLacoste-Utamsing, C., & Holloway, R. L. (1982). 
Sexual dimorphism in the human corpus callosum. 
Science, 216, 1431–1432.

Devor, A. H. (2004). Witnessing and mirroring: A 
fourteen stage model of  transsexual identity 
formation. Journal of  Gay & Lesbian Psychotherapy, 
8(1–2), 41–67.

Dubb, A., Gur, R., Avants, B., & Gee, J. (2003). 
Characterization of  sexual dimorphism in the 
human corpus callosum. Neuroimage, 20, 512–519.

Erikson, E. H. (1968). Identity: Youth and crisis. New York, 
NY: Norton.

Fagot, B. I. (1985). Changes in thinking about early sex 
role development. Developmental Review, 5, 83–98. 
doi:10.1016/0273-2297(85)90031-0

Fernández-Guasti, A., Kruijver, F. P., Fodor, M., & Swaab, 
D. F. (2000). Sex differences in the distribution of  
androgen receptors in the human hypothalamus. 
Journal of  comparative neurology, 425, 422–435.

Fleming, M., & Feinbloom, D. (1983). Similarities in 
becoming: transsexuals and adolescents. Adolescence, 
19, 729–748.

Gates, G. (2011). How many people are lesbian, gay, 
bisexual, and transgender? Williams Institute, UCLA 
School of  Law. Retrieved May 21, 2015 from http://
williamsinstitute.law.ucla.edu/wp-content/uploads/
Gates-How-Many-People-LGBT-Apr-2011.pdf

Glicksman, E. (2013). Transgender today. Monitor 
on Psychology, 44. Retrieved on October 21, 
2015 from http://static1.1.sqspcdn.com/stat
ic/f/1468080/25884892/1421967436930/



86

LEWITZKE

Glicksman-transgender.pdf?token=m1nfd4Tu%2
FMTISLUmJUBOlKcmBtM%3D

Goldstein, D., Haldane, D., & Mitchell, C. (1990). 
Sex differences in visual-spatial ability: The role 
of  performance factors. Memory & Cognition, 18, 
546–550. doi:10.3758/BF03198487

Gorski, R.A. (1998). Development of  the cerebral 
cortex: XV. Sexual differentiation of  the central 
nervous system. Journal of  American Academy of  Child 
and Adolescent Psychiatry, 37, 1337–1339.

Grant, J. M., Mottet, L. A., Tanis, J., Herman, J. L., 
Harrison, J., & Keisling, M. (2010). National 
transgender discrimination survey report on health 
and health care. National Center for Transgender 
Equality and National Gay and Lesbian Task Force. 
Retrieved on May 23, 2015 from http://www.
thetaskforce.org/static_html/downloads/reports/
reports/ntds_full.pdf

Griggs, B. (2014, February 13). Facebook goes beyond 
‘male’ and ‘female’ with new gender options—CNN.
com. Retrieved on May 17, 2015 from http://
www.cnn.com/2014/02/13/tech/social-media/
facebook-gender-custom/

Haig, D. (2004). The inexorable rise of  gender and the 
decline of  sex: Social change in academic titles, 
1945–2001. Archives of  Sexual Behavior, 33(2), 87–96. 
doi:10.1023/B:ASEB.0000014323.56281.0d

Halberstam, J. (1998). Female masculinity. Durham, NC: 
Duke University Press.

Hess, N. H., & Hagen, E. H. (2006). Sex differences 
in indirect aggression: Psychological evidence 
from young adults. Evolution and Human Behavior, 
27, 231–245. http://dx.doi.org/10.1016/j.
evolhumbehav.2005.11.001

Kennedy, N. (2008). Transgendered Children in Schools: 
a critical review of  homophobic bullying: Safe to 
learn—embedding anti-bullying work in schools, 
FORUM, 50, 383–396. http://dx.doi.org/10.2304/
forum.2008.50.3.383

Kennedy, N., & Hellen, M. (2010). Transgender children: 
more than a theoretical challenge. Graduate Journal of  
Social Science, 7(2), 25–43. Retrieved from http://www.
iiav.nl/ezines/IAV_607530/IAV_607530_2010_2.
pdf#page=26

Kohlberg, L. A. (1966). A cognitive-developmental 
analysis of  children’s sex role concepts and attitudes. 
In E. E. Maccoby (Ed.), The development of  sex 

differences (pp. 82–173). Stanford, CA: Stanford 
University Press.

Korell, S. C., & Lorah, P. (2007). An overview of  
affirmative psychotherapy and counseling with 
transgender clients. In K. J. Bieschke, R. M. Perez, 
& K. A. DeBord (Eds.), Handbook of  counseling and 
psychotherapy with lesbian, gay, bisexual, and transgender 
clients (2nd ed.) (pp. 271–288). Washington, DC: 
American Psychological Association.

Leinbach, M. D., & Fagot, B. I. (1993). Categorical 
habituation to male and female faces: 
Gender schematic processing in infancy. 
Infant Behavior and Development, 16, 317–332. 
doi:10.1016/0163-6383(93)80038-A

Levay, S. & Baldwin, J. (2009). Human Sexuality. 
Sunderland, MA: Sinauer Associates.

Lippa, R. A. (2010). Gender differences in personality 
and interests: when, where, and why?. Social 
and Personality Psychology Compass, 4, 1098–1110. 
doi:10.1111/j.1751-9004.2010.00320.x

Lothstein, L. M. (1984). Psychological testing 
with transsexuals: A 30-year study. Journal of  
Personality Assessment, 48, 500–507. doi:10.1207/
s15327752jpa4805_9

Mallon, G. P. (1999). Social work practice with gay, lesbian, 
and transgender people. New York: NY: Harworth Press.

Marcia, J. E. (1966). Development and validation of  
ego-identity status. Journal of  Personality and Social 
Psychology, 3, 551–558. doi:10.1037/h0023281

Meyer, I.H., Schwartz, S., & Frost, D.M. (2008). Social 
patterning of  stress and coping: Does disadvantaged 
social statuses confer more stress and fewer coping 
resources? Social Science & Medicine, 67, 368–379.

Miach, P. P., Berah, E. F., Butcher, J. N., & Rouse, S. 
(2000). Utility of  the MMPI-2 in assessing gender 
dysphoric patients. Journal of  Personality Assessment, 
75, 268–279. doi:10.1207/S15327752JPA7502_7

Miller, C. L. (1983). Developmental changes in male/
female voice classification by infants. Infant 
Behavior and Development, 6, 313–330. doi:10.1016/
S0163-6383(83)80040-X

Mizock, L., & Lewis, T. K. (2008). Trauma in 
transgender populations: Risk, resilience, and 
clinical care. Journal of  Emotional Abuse, 8, 335–354. 
doi:10.1080/10926790802262523

Moffat, S. D., Hampson, E., & Hatzipantelis, M. (1998). 
Navigation in a virtual maze: Sex differences 



87

TRANSGENDER TESTING

and correlation with psychometric measures of  
spatial ability in humans. Evolution and Human 
Behavior, 19(2), 73–87. http://dx.doi.org/10.1016/
S1090-5138(97)00104-9

Money, J. (1955). Hermaphroditism, gender and 
precocity in hyperadrenocorticism: Psychologic 
findings. Bulletin of  the Johns Hopkins Hospital, 96, 
253–264.

Peters, M., Manning, J. T., & Reimers, S. (2007). The 
effects of  sex, sexual orientation, and digit ratio 
(2D: 4D) on mental rotation performance. Archives 
of  Sexual Behavior, 36, 251–260. doi:10.1007/
s10508-006-9166-8

Peters, M., Servos, P., & Day, R. (1990). Marked sex 
differences on a fine motor skill task disappear 
when finger size is used as covariate. Journal of  
Applied Psychology, 75(1), 87–90. http://dx.doi.
org/10.1037/0021-9010.75.1.87

Prince, V. (2005). Sex vs. gender. International Journal 
of  Transgenderism, 8(4), 29–32. doi:10.1300/
J485v08n04_05

Rametti, G., Carrillo, B., Gómez-Gil, E., Junque, C., 
Segovia, S., Gomez, Á., & Guillamon, A. (2011a). 
White matter microstructure in female to male 
transsexuals before cross-sex hormonal treatment. 
A diffusion tensor imaging study. Journal of  Psychiatric 
Research, 45, 199–204. http://dx.doi.org/10.1016/j.
jpsychires.2010.05.006

Rametti, G., Carrillo, B., Gómez-Gil, E., Junque, C., 
Zubiarre-Elorza, L., Segovia, S., & Guillamon, A. 
(2011b). The microstructure of  white matter in male 
to female transsexuals before cross-sex hormonal 
treatment. A DTI study. Journal of  Psychiatric 
Research, 45, 949–954. http://dx.doi.org/10.1016/j.
jpsychires.2010.11.007

Richmond, K. A., Burnes, T., & Carroll, K. (2012). Lost 
in trans-lation: Interpreting systems of  trauma for 
transgendered clients. Traumatology, 18(1), 45–57. 
doi:10.1177/1534765610396726

Sanchez, N. F., Sanchez, J. P., & Danoff, A. (2009). Health 
care utilization, barriers to care, and hormone usage 
among male-to-female transgender persons in 
New York City. American Journal of  Public Health, 99, 
713–719. doi:10.2105/AJPH.2007.132035

Schilt, K., & Westbrook, L. (2009). Doing gender, 
doing heteronormativity: “Gender normals,” 
transgender people, and the social maintenance 
of  heterosexuality. Gender and Society, 23, 440–464. 
doi:10.1177/0891243209340034

Tsourtos, G., Thompson, J. C., & Stough, C. (2002). 
Evidence of  an early information processing speed 
deficit in unipolar major depression. Psychological 
Medicine, 32, 259–265.

Tsushima, W. T., & Wedding, D. (1979). MMPI results 
of  male candidates for transsexual surgery. Journal 
of  Personality Assessment, 43, 385–387. doi:10.1207/
s15327752jpa4304_8

Watson, N. V., & Kimura, D. (1991). Nontrivial sex 
differences in throwing and intercepting: relation 
to psychometrically-defined spatial functions. 
Personality and Individual Differences, 12, 375–385. 
doi:10.1016/0191-8869(91)90053-E

Weiss, E. M., Ragland, J. D., Brensinger, C. M., Bilker, 
W. B., Deisenhammer, E. A., & Delazer, M. (2006). 
Sex differences in clustering and switching in 
verbal fluency tasks. Journal of  the International 
Neuropsychological Society, 12, 502–509. doi:10.1017/
S1355617706060656

Wilchins, R. A. (2002). Queerer Bodies. In J. Nestle, C. 
Howell, & R. A. Wilchins (Eds.), Genderqueer: Voices 
from Beyond the Sexual Binary. Los Angeles: Alyson.

Willingham, W. W., & Cole, N. S. (2013). Gender and fair 
assessment. New York, NY: Routledge.

Wrenn, C. G. (1962). The culturally encapsulated 
counselor. Harvard Educational Review, 32, 444–449.


