Cultural competence: An ethical and legal mandate

Cultural competence is recognized as a fundamental obligation in counseling, formally established through ethical codes, accreditation requirements, and licensure regulations. According to the American Counseling Association [1], counselors are ethically obligated to develop awareness, knowledge, skills, and behaviors that enable them to engage effectively with clients from diverse cultural backgrounds. This ethical mandate includes ensuring that the counseling relationship and intervention strategies are culturally responsive, that biases are examined, and notes that value-based referrals are prohibited [1]. In parallel, the Council for Accreditation of Counseling and Related Educational Programs (CACREP) established explicit curriculum and program standards aimed at ensuring graduates are culturally competent. The 2024 CACREP Standards require that counselor education programs include social and cultural diversity as a foundational curricular area; one that is woven throughout the program rather than covered in a single course [7].

Similarly, state licensure boards embed cultural competence within their requirements, both in initial licensure and ongoing continuing education regulation. For example, Florida statutes require that counseling programs include coursework in social and cultural foundations [8], whereas other states like Georgia explicitly require applicants to have a knowledge of societal trends, culture, subgroups, diversity, and competency in counseling diverse populations [9]. Additionally, licensure boards also often require CEUs in multicultural or diversity topics to maintain competence post-licensure. Although specific hours and definitions vary by state, this requirement reinforces the idea that cultural competence is not static but must be maintained and deepened over time. Together, ACA, CACREP, and state licensure boards require: (1) counselor self-awareness and examination of one’s cultural identity; (2) acquisition of knowledge about diverse clients’ worldviews, history, and sociocultural context; (3) development of culturally responsive skills in assessment and intervention; and (4) following legal and ethical mandates in working with diverse clients.

Targeted training and continuing education

CEUs are critical in the counseling profession. They ensure that counselors maintain competence, remain current on best practices, and uphold ethical standards throughout their careers. Research demonstrates that effective continuing education can strengthen practitioner self-efficacy, improve client outcomes, and ensure that interventions remain evidence-based and socially responsive [10]. CEUs also provide structured opportunities for counselors to stay current with evolving ethical codes, diagnostic standards, and culturally responsive practices [2].

Systematic reviews indicate that most training programs explicitly address race and ethnicity, with a substantial portion also focusing on sexual orientation, leading to improved counselor knowledge, attitudes, and skills [3,11]. For example, Chao, Wei [12] reported that targeted training related to color-blindness increases cultural competence among counselors by eliminating racial performance gaps, enhancing racial/ethnic identity development, and reducing color-blind racial attitudes. Similarly, Pachankis, Soulliard [13] provided a strong example for targeted training on sexual orientation; they conducted a randomized controlled trial for an 11-week LGBTQ-affirmative CBT training. The program significantly enhanced providers’ cultural competence by expanding their knowledge of minority stress and increasing both familiarity with and application of affirming clinical skills. With this, the counseling profession has demonstrated advancements in cultural competence through targeted training, exposure, and continuing education. However, in past years, multicultural training has largely remained focused on race, ethnicity, and sexual orientation [3,11]. This limited exposure may result in a lack of understanding of best practices for working with gender diverse clients.

Enhancing competence with gender diverse clients

The Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC), now the Society for Sexual, Affectional, Intersex, and Gender Expansive Identities (SAIGE), created competencies for counselors, educators, and supervisors in 2009 to address this deficit. The competencies were created to guide the exploration of attitudes, awareness, knowledge, and skills; and provide a framework for training curriculum that was historically lacking in counselor preparation programs [14,15]. These competencies serve as a benchmark for best practices when working with LGBTQIA+ clients. However, the language is older (last updated in 2013), and limitations exist. Terms like nonbinary, gender-expansive, and genderfluid are limited; therefore, understanding and application of inclusive practices for working with gender diverse and gender nonconforming clients may be limited. For example, the documents lack guidance in working with nonbinary clients, use of appropriate pronouns, and impact of healthcare and political issues on gender diverse clients [14,15]. Implementation of these competencies are also not uniformly applied or taught in counselor preparation programs [11]. Beyond gender identity, gender expression represents a distinct dimension of diversity that warrants attention in counselor preparation, this includes best practices in working with gender nonconforming clients.

Gender expression refers to the external manifestation of gender through behavior, clothing, grooming, and presentation; whereas gender nonconforming denotes gender expression that does not align with societal expectations associated with a person’s gender. Gender diverse is broadly used [16] to encompass both gender identity (transgender, nonbinary, genderqueer) and gender expression (presentation that challenges traditional gender norms). This inclusive definition recognizes that clients who express gender in nontraditional ways, regardless of their gender identity, may benefit from counselors who have developed competence and comfort working across the spectrum of gender diversity. The counseling literature has primarily focused on competence with transgender and nonbinary clients, with less attention on how counselors respond to diverse gender expression, including those who are gender nonconforming. Counselors’ comfort with clients who challenge gender norms, regardless of identity, reflects their broader capacity to provide affirming care [17]. Addressing gender expression and gender nonconformance as a component of cultural competence aligns with the MSJCCs’ emphasis on examining one’s own attitudes and biases toward marginalized presentations [18]. Counselors who hold rigid beliefs about gender-appropriate behavior may inadvertently communicate discomfort or judgment to clients who do not conform to traditional gender norms, potentially compromising the therapeutic alliance.

Historically, training programs and professional development have addressed sexual orientation broadly, with limited focus on gender identity. Emerging evidence shows a marked increase in targeted training programs, continuing education, and advocacy efforts specifically designed to improve counselors’ knowledge, skills, and attitudes regarding gender identity [19,20]. One such example includes Pope, St. Germain-Sehr [20], delivering asynchronous LGBTQ+ affirmative training to improve counseling students’ knowledge, clinical preparedness, and advocacy skills when working with transgender, nonbinary, and gender-expansive clients. Findings indicated that students reported increased cultural humility and a deeper understanding of gender diversity, especially regarding language, minority stress, and respectful clinical practice.

These trainings include expanding beyond the gender binary, strategies for affirming practice, self-reflection, cultural humility, and advocacy, which are essential for establishing strong therapeutic alliances with gender diverse clients [19,21]. Professional organizations and advocacy groups have also contributed to this shift by offering workshops, webinars, and competency guidelines that increase visibility and provide structured opportunities for skill development (e.g., Gay, Lesbian, and Straight Education Network (GLSEN); The Trevor Project; World Professional Association for Transgender Health (WPATH)). Despite these advances, questions remain regarding whether increased exposure to targeted training, awareness initiatives, and advocacy participation translates into measurable improvements in counselor competence. Therefore, this study sought to determine whether professional development efforts, such as targeted training and continuing education, are statistically associated with increased counselor self-reported competence in working with gender nonconforming clients, thereby providing empirical insight into whether the field is demonstrating measurable growth in counselor competence when working with gender diverse clients. To add to what is known (e.g., studies that indicate increased competence immediately post-intervention, [20]), we are also seeking to understand if there is a sustained impact of receiving these trainings and later self-reported competence in working with gender nonconforming clients. It is important to acknowledge that the relationship between training and competence may not be straightforward. Counselors who have received gender-specific training have, in most cases, also received training in other diversity-related areas. This raises the question of whether gender-related training confers competencies distinct from general diversity training, or whether observed associations reflect broader training effects. The current study cannot fully disentangle these contributions, and this overlap is addressed as a study limitation. What the study can examine is whether self-reported hours of gender-specific training predict perceived competence over and above general diversity training hours, which a regression analysis can directly address.

Conceptual framework

This study is guided by the Multicultural and Social Justice Counseling Competencies [22]. The MSJCCs were selected over alternative frameworks (e.g., the original Multicultural Counseling Competencies or the ALGBTIC Competencies) because they explicitly integrate social justice and advocacy dimensions while addressing intersectionality, making them particularly suited for examining counselor competence with marginalized gender presentations. The MSJCCs [18] are applied in this study by examining how counselors’ awareness, knowledge, and skills related to gender nonconforming clients are influenced by prior targeted training and continuing education, reflecting the model’s emphasis on culturally responsive and justice-oriented counseling practice. This framework offers a theoretical lens for understanding how targeted professional development may enhance measurable counselor competence with gender nonconforming clients.

The MSJCCs organize competencies across four domains: counselor self-awareness, client worldview, counseling relationship, and counseling and advocacy interventions. Within each domain, competencies address attitudes and beliefs, knowledge, skills, and action. This framework is particularly relevant for understanding counselor competence with gender nonconforming clients because it emphasizes both internal dispositions (awareness of one’s own biases) and external capabilities (knowledge and skills to work effectively across difference).

The MSJCCs also highlight that competence is not static but develops through sustained education, training, and self-reflection. This perspective supports our examination of how accumulated professional development, including hours of diversity and gender-specific training, predicts self-reported competence. By framing competence as a developmental process shaped by both formal education and personal characteristics, the MSJCCs provide a theoretical foundation for understanding why some counselors may report greater confidence in working with gender nonconforming clients than others.

The present study

The literature demonstrates that cultural competence is a core ethical and professional obligation in counseling, reinforced through accreditation standards, licensure requirements, and continuing education [1,2,7]. Targeted training, CEUs, and advocacy efforts have advanced counselors’ knowledge, skills, and attitudes, particularly with regard to race, ethnicity, sexual orientation, and, more recently, gender identity [3,10,12]. However, most research on counselor competence with gender diverse populations has focused on transgender and nonbinary clients, with limited attention to how counselors perceive and respond to diverse gender expression among cisgender individuals.

The current study addresses this gap by examining whether counselors’ demographic characteristics and professional training experiences predict their perceived competence in working with clients who challenge traditional gender norms. To explore this question, we used an experimental design that presented participants with images of theoretical clients: cisgender men wearing makeup (treatment group) or cisgender men without makeup (control group). This approach was intentionally selected to isolate the effect of gender expression, apart from gender identity, on counselor perceptions. Cisgender men who wear makeup represent a visible challenge to traditional masculinity norms without requiring participants to make assumptions about transgender or nonbinary identity. By using this stimulus, the study examined whether counselors’ self-reported competence was influenced by exposure to nontraditional gender expression, extending beyond the existing literature’s focus on transgender and nonbinary populations. We examined whether participant characteristics, including hours of diversity and gender-specific training, sexual or gender minority identity, and educational attainment predicted self-reported competence across the full sample. These analyses tested whether the field is demonstrating measurable growth in counselor competence when working with clients who present outside traditional gender norms and whether sustained professional development contributes to this competence.

Ethics statement

This study was reviewed and approved by the University of North Florida Institutional Review Board (IRB Approval #: 1573439–1). All participants were 18 years of age or older. Participants provided written informed consent prior to completing the survey. No participants under the age of 18 were enrolled in this study; parental/guardian consent was therefore not required.

Research design

This study utilized a randomized experimental research survey design. To participate in the study, participants had to be 18 years of age or older, live in the U.S., and be either a counselor-in-training or a professional counselor. In this experiment, participants were randomized into one of two groups: the treatment group or the control group. When completing the survey questionnaire, participants randomized into the treatment group responded to the survey questions after viewing images of cisgender men wearing makeup; the control group received images of cisgender men without makeup and completed the same questionnaire as the treatment group.

The use of static images was selected for two reasons. First, it allowed the study to isolate the effect of gender expression, specifically gender-nonconforming presentation, from gender identity, examining counselor responses to a population underrepresented in the literature. Second, static images provided a standardized, feasible stimulus for an online survey format. Images were selected from a publicly available platform and standardized to present men of similar approximate age and neutral expression, differing only in the presence or absence of makeup. No identity label or backstory was provided with the images. Participants were not told that the pictured individual identified as cisgender; the images were unlabeled so that responses reflected reactions to gender expression rather than identity category. The study’s primary hypothesis was that counselors in the treatment group would report lower perceived competence than those in the control group, reflecting potential discomfort or unfamiliarity with gender-nonconforming expression. Secondary hypotheses posited that more hours of diversity training, LGBTQIA + /gender-specific training, sexual or gender minority identity, and higher educational attainment would predict higher self-reported competence across the full sample.

Procedures

After Institutional Review Board approval, prospective participants were invited to participate in the study in several ways. The researchers contacted several counseling community agencies, organizations, and universities via email and listservs. If prospective participants met the requirements of the study and chose to participate, they were instructed to select the link in the recruitment email that automatically redirected them to a Qualtrics survey. The Qualtrics survey began with an informed consent document. If the prospective participants provided informed consent to participate in the study, they advanced to the questionnaire that was composed of 33 questions used to gather data regarding each participant’s demographic information, diversity training, and perceived competence in working with the theoretical clients who were pictured. Data were collected between March 27, 2020, and June 1, 2020, and participants provided written consent to participate in the study.

Measures

Data analyses

Descriptive statistics were calculated for continuous variables and categorical variables for the total sample and by group. Competency statement responses were also summarized. Independent samples t-tests and chi-square tests compared groups on continuous and categorical variables, respectively. Linear regression models tested interaction effects between treatment group and participant characteristics on competency scores. A multiple regression identified significant predictors of competency while controlling for treatment. Sensitivity analyses stratified the sample to examine diversity training and LGBTQIA + /gender training effects separately by group, with and without covariate adjustment. Stata MP17 was used for all data cleaning and analysis.

Perceived competence and influence of training

A comparison between the treatment and control groups revealed similar levels of perceived competence, indicating that viewing an image of a gender nonconforming client (i.e., a cisgender man wearing makeup) did not significantly influence counselors’ self-reported competence. This null finding shows that the treatment condition itself did not affect perceived competence. Although direct comparisons are limited, prior literature has emphasized the role of multicultural and gender-focused training in promoting counselor awareness, knowledge, and perceived skill when working with gender-diverse clients [26–28]. The lack of significant differences between the treatment and control groups, along with the absence of significant interaction effects across participant characteristics (e.g., education level, professional status, sexual or gender minority identity, and training exposure), further supports the interpretation that counselors’ self-assessed competence reflects long-term professional development rather than situational factors. Few studies have experimentally examined counselor responses to gender-nonconforming expression, making direct comparisons difficult. Most prior research has focused on evaluating the effects of affirmative training interventions and educational experiences on counselor competence [20,26–28] rather than examining whether exposure to a particular client presentation influences self-reported competence. As such, the present study extends the literature by exploring a previously understudied question regarding gender expression and counselor competence.

While these results could suggest that stigma or bias may not overtly influence counselors’ self-perceptions of competence with gender nonconforming clients, alternative explanations are possible. First, the experimental manipulation may have been too subtle to elicit measurable differences in perceived competence. Static images of cisgender men with or without makeup may not have provided sufficient stimulus intensity to activate biases or discomfort that would influence self-reported competence; more immersive stimuli such as video vignettes or interactive role-plays might yield different results. Second, given the self-report nature of the survey and the professional expectations of unconditional positive regard in counseling and cultural competence [1,7], participants may have been motivated to report high competence regardless of their actual comfort or skill. This interpretation aligns with prior research showing discrepancies between self-perception of competence and external evaluation of competence. For example, research has shown that supervisees are more likely to rate themselves as more competent compared to their supervisors’ ratings of them [29]. Thus, the consistently high perceived competence scores in this study may reflect aspirational self-assessments rather than actual preparedness or comfort in working with gender nonconforming clients. To better understand what factors contributed to counselors’ perceived competence, we next examined predictors across the full sample, controlling for the non-significant treatment effect.

Predictors of perceived competence

Because the experimental comparison produced no significant group differences, the following analyses shift from the randomized comparison to an examination of predictors of perceived competence across the full sample. This analytic pivot was planned a priori as the study’s secondary aim: to identify counselor-level characteristics associated with competence regardless of experimental condition. Readers should interpret findings from this section within the constraints of a cross-sectional, self-report design; the associations described do not carry causal inference. The survey-based Likert items are the basis for these analyses, and the discussion focuses on what these self-report responses reveal about the relationship between professional development and perceived competence. In these analyses, age, years since graduation, professional status, and completion of a multicultural counseling class that included gender topics were not significant predictors of competence. By contrast, counselors who reported more hours of diversity and gender-related training showed higher self-reported competence in unadjusted models, but these associations were not statistically significant after covariate adjustment, though point estimates remained positive, indicating that greater training hours continued to correspond with slightly higher perceived competence. This pattern suggests that while counselors with more training tend to perceive themselves as more competent, the relationship is not strong enough to reach statistical significance once other factors are considered. This attenuation of effects following adjustment suggests potential confounding, with variables such as education level and professional status likely sharing variance with training hours. Specifically, counselors with more advanced degrees or professional experience may have had more opportunities for training, making it difficult to isolate the unique contribution of training hours. This could indicate that additional influences (e.g., individual attitudes, professional environment, or prior exposure) may also shape perceptions of competence.

These findings are consistent with several previous studies examining counselor competence with LGBTQIA+ populations. LGBTQIA+ ally training has been associated with greater counselor competency [27], and school counselors with greater preparation related to LGBTQIA+ populations have demonstrated higher competence when working with students [28]. Similarly, training and professional development have been identified as important factors associated with competence in working with transgender students [26], and LGBTQ + -affirmative training has been shown to increase counseling students’ preparedness to work with transgender, nonbinary, and gender-expansive clients [20]. Collectively, this suggests that targeted educational experiences may contribute to counselors’ perceptions of preparedness when working with gender-diverse populations.

We also found that, when controlling for the treatment effect, counselors with a master’s degree reported significantly higher perceived competence compared to those currently enrolled in master’s programs. Counselors who identified as a sexual or gender minority also reported higher perceived competence. Although relatively little research has directly examined this relationship among counseling professionals, higher competence among counselors who identified as a sexual or gender minority is broadly consistent with scholarship emphasizing the importance of familiarity with LGBTQIA+ experiences and identities when providing affirming care [26,30]. It is possible that personal experiences related to identity development, minority stress, or engagement with LGBTQIA+ communities contribute to greater confidence when working with gender-diverse clients. However, the present study cannot determine the mechanisms underlying this association. Higher competence among counselors with a master’s degree suggests that perceived competence in working with gender diverse clients may increase as counselors progress through their formal education and acquire more exposure to multicultural and gender-related training. Notably, this finding may also reflect general confidence gained through educational completion rather than specific competence development with gender diverse populations. Although there is limited evidence that professional experience alone, beyond completion of a degree, leads to higher perceived competence, post-graduate professional development and continuing education have been shown to enhance competence [26].

The primary contribution of this study is its extension of the counselor competence literature beyond the transgender and nonbinary focus that has dominated recent scholarship. By using cisgender men wearing makeup as the experimental stimulus, the study explicitly examined counselor responses to gender nonconforming expression among cisgender individuals, which is a population largely absent from the competence literature. To our knowledge, this is among the first studies in the counseling literature to experimentally examine counselor responses to gender nonconforming expression independent of transgender or nonbinary identity. By focusing on gender expression rather than gender identity, the study broadens understanding of how counselor competence may apply across diverse presentations of gender. This design tests whether counselor competence frameworks apply to gender expression diversity, not only gender identity diversity, addressing a gap noted in the literature on ALGBTIC and SAIGE competencies [14,15]. The null experimental finding itself carries theoretical significance: it suggests counselors’ self-perceptions of competence are not destabilized by a single gender-nonconforming image, which may reflect genuine professional confidence, consistent training exposure across the sample, or social desirability. The regression findings add to a small but growing body of evidence that sustained training hours, not isolated exposure, predict perceived preparedness, with direct implications for how counselor education program’s structure continuing education requirements around gender diversity.

Limitations and recommendations for future research

Several limitations exist in the present study. First, the study relied on volunteer participants, which may have introduced self-selection bias if individuals with greater interest or experience in diversity topics were more likely to participate. Second, because the study used self-report measures, participants may have underreported their biases or overestimated their competence, particularly given the counseling profession’s emphasis on unconditional positive regard, nondiscrimination, and cultural humility [1,7]. Clinicians who internalize these values may report high competence regardless of their actual clinical preparedness. This tendency can create ceiling effects in data. These effects hide the true differences in actual skill levels. This issue is likely due to the sample composition. Most participants were licensed or pre-licensed professionals who completed multicultural training. Therefore, they could easily identify the socially desirable answers on a competence scale. The high scores in both groups support this idea. Prior studies show that self-reported competence often differs from external evaluations (e.g., counselors regularly rate themselves higher than their supervisors do) [29]. Future research should continue examining how educational and professional experiences contribute to both perceived and demonstrated competence. Longitudinal and observational designs could clarify whether increased training and education translate into observable counseling behaviors and client outcomes. Expanding samples to include a broader range of counselors and related professionals (e.g., social workers, psychologists, psychiatrists) would enhance generalizability. Researchers might also refine measurement tools to more accurately assess both self-perceived and observed competence. Collectively, these directions can deepen understanding of how counselors’ training, education, and lived experiences shape their perceived competence to provide affirming care to gender nonconforming individuals.