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Affirmative Cognitive Behavior Therapy with Transgender and Gender Nonconforming Adults
Abstract
KEY POINTS
� Transgender and gender nonconforming (TGNC) individuals continue to be a highly
marginalized population, subject to transphobia that manifests in the form of stigma,
discrimination, and victimization.
� An affirming and trauma-informed perspective recognizes that traumatic events and experiences,
including non–life-threatening forms of transphobic prejudice, may threaten
TGNC clients’ sense of safety, power, and control over their lives.
� Trans-affirmative clinical practice acknowledges and counters the oppressive contexts of
the lives of transgender individuals.
� Transgender-affirmative cognitive behavior therapy (TA-CBT) is a version of cognitive
behavior therapy (CBT) that has been adapted to ensure (1) an affirming stance toward
gender diversity, (2) recognition and awareness of transgender-specific sources of stress,
and (3) the delivery of CBT content within an affirming and trauma-informed framework.
... The results of Polish studies indicate the prevalence of at least mild depressive symptoms in most LGBTA people, while the proportion of people with significantly increased depressive symptoms is more than 5 times higher than in the general population [5]. Studies conducted in the USA provide data on the prevalence of non-self-harming behaviour (42%) [6], suicidal thoughts (54%) [7], or suicide attempts (28-45%) by transgender people [7,8]. Referring to Polish analyses from 2016, as many as 44.2% of LGBTQA respondents had suicidal thoughts [5]. ...
... The effectiveness of cognitive-behavioural therapy (CBT) has been confirmed in the treatment of disorders frequently affecting the transgender group, including anxiety, mood, substance abuse, PTSD, self-harm, and suicidal behaviour [8]. In contrast, trans-affirmative cognitive behavioural therapy (TA-CBT) additionally takes into account the specificity of the developmental experiences and functioning of transgender people, e.g. the impact of minority stress on the formation of negative beliefs and maladaptive coping strategies (Fig. 1). ...
... The specific experiences of transgender people and their possible impact on experiencing chronic stress, symptoms of mood disorders, anxiety, powerlessness, engaging in suicidal behaviour should be taken into account when collecting the interview, creating a conceptualisation (a way of understanding the patient's problem), and planning therapy. As part of the interview, detailed information on the following should be collected: -early memories of recognising and experiencing one's own transsexuality, the reactions of others to its manifestations, and the meaning given to them by the individual; -messages coming from the environment (family, peers, school, media, places of worship) about gender and gender roles; anxieties about coming-out, transition (the process of realigning one's perceived sex with one's assigned sex) socially and medically; -elements of the transition that cause the most stress; -unexpected stressors of post-transition life; -specific stressors of non-binarity; -experiences of discrimination and violence [8]. ...
... Second, throughout this article, we discuss transgender and nonbinary affirmative therapy, which is defined as an approach to therapy that both embraces a positive, celebratory view of diverse transgender and nonbinary identities and relationships and seeks to actively address the negative influences that cissexism and cisnormativity have on the lives of clients (Austin et al., 2017(Austin et al., , 2018Coolhart & Shipman, 2017;Grzanka & Miles, 2016;McGeorge et al., 2020). This involves family therapists taking a non-expert stance of inclusivity, which requires that clinicians first engage in a process of self-exploration in order to deconstruct the ways that cissexism informs their clinical decision-making. ...
... This involves family therapists taking a non-expert stance of inclusivity, which requires that clinicians first engage in a process of self-exploration in order to deconstruct the ways that cissexism informs their clinical decision-making. The existing literature on affirmative therapy with transgender and nonbinary clients suggests an initial step in the process is for therapists to engage in intentional self-of-the-therapist work (Austin et al., 2017;Blumer et al., 2013). Therefore, the model presented in this article adds to the existing literature by providing research and theory-informed suggestions and a detailed, self-of-the-therapist exploration process that family therapists can engage in. ...
... Transnormative assumptions are normative beliefs and expectations based on the notion that transgender people who choose to medically transition and/or subscribe to binary gender categories are more legitimate in their gender identity than those with a nonbinary identity (Johnson, 2016). Transnormativity simultaneously validates some transgender people while marginalizing and rendering invisible transgender and nonbinary people who do not medically transition and/or do not subscribe to binary gender norms (Austin et al., 2017;Johnson, 2016). People of all gender identities can be prone to transnormative assumptions because transnormativity operates as a "regulatory normative ideology," which can be understood as an organizing principle that supports systemic structures of power within Western society (Johnson, 2016, p. 466). ...
This article proposes a model for family therapists to become more competent, inclusive, and affirmative in their clinical work with transgender and nonbinary clients. In particular, this article details: (1) barriers to transgender and nonbinary affirmative therapy, (2) impacts of these barriers on transgender and nonbinary people's mental health, (3) a three‐step model for becoming an affirmative therapist for transgender and nonbinary clients, and (4) strategies for deconstructing cissexism in therapy. This goal of this article is to invite family therapists to join in on a lifelong journey of “becoming” an affirmative therapist for transgender and nonbinary clients, a journey on which none of us will ever “arrive”. We can, however, take continual action to minimize the negative impacts of cissexism on therapists and clients; this article offers ideas for a place to start.
... Further, many approaches to reducing symptoms of depression or anxiety involve helping clients reframe their distress and challenge distorted thoughts about the world. However, without adaptation, these interventions may be less effective for TGNC individuals given that perceptions of isolation or danger may be factual and not the effect of distorted cognition (Austin, Craig, & Alessi, 2017). ...
... As it is possible that therapist factors affected the reduced efficacy of therapy for TGNC clients, we encourage counseling psychologists to develop a better personal understanding of the systemic oppression of TGNC identities and common concerns of TGNC individuals (e.g. Austin et al., 2017). We recommend that therapists familiarize themselves with common therapeutic mistakes made with TGNC individuals, including exaggerating or minimizing the focus on gender, making unwarranted generalizations, and expecting the client to educate the therapist (Mizock & Lundquist, 2016;c.f., Applegarth & Nuttall, 2016;Benson, 2013). ...
... Further, therapists should recognize that gender identity and expression vary significantly based on culture and not seek to impose their own or other views of gender on clients. Finally, counseling psychologists should be aware of the increased violence experienced by TGNC people of color and ensure that they are asking about violence/discrimination in therapy (e.g., Austin et al., 2017). ...
Transgender and gender nonconforming (TGNC) People of Color experience stressors unique to both TGNC and racial and/or ethnic minority communities, resulting in disparities in mental health. Guided by minority stress and intersectionality theories, we examined initial anxiety and depression, as well as changes in symptoms, in 41,691 clients from the Center for Collegiate Mental Health 2012–2016 dataset. We sought to understand disparities that may exist in distress and therapeutic response between TGNC and cisgender clients. We also examined the intersection of gender and racial and/or ethnic identities to examine how these trends differ for TGNC People of Color. Results from hierarchical linear modeling indicated greater symptom severity, but a slower remission of symptoms of depression and anxiety, among TGNC clients. Interaction effects were nonsignificant; however, TGNC Clients of Color experienced more distress than either White TGNC clients or cisgender Clients of Color. On average, TGNC clients, compared to cisgender clients, utilized an additional 2.5 sessions of therapy.
... Transgender affirming cognitive behavioral therapy (TA-CBT) ensures an affirming stance towards gender diversity, recognition, and awareness of transgender-specific sources of stress, and delivery of CBT content within an affirming and trauma-informed framework [44]. TA-CBT stresses the exploration of clients' early experiences of recognizing and understanding their own gender identity, particularly experiences of shame for and subsequent suppression of their transgender identity. ...
... Affirming a transgender identity through connections to others in the transgender community contributes to increased comfort with a person's transgender identity and better behavioral health [46,47]. Fostering resilience by enhancing transgender-specific social support, social connectedness, and self-advocacy represents an important component of affirmative interventions for TGNC individuals [44]. We have certainly observed this to be the case in our work. ...
Purpose of Review
I review the recent literature related to the assessment, treatment, and management of transgender individuals who sexually harm.
Recent Findings
There are no empirical research studies directly focused on the care of this group of individuals that have only recently been identified as an important sub-population among people who sexually harm. Related empirical research and other important professional literature do exist to inform clinicians regarding treatment guidelines for transgender mental healthcare.
Summary
Research is needed to determine how best to assess sexual violence recidivism risk and to distinguish unique treatment needs for transgender individuals who sexually harm. Strength-based approaches to the treatment of sexual violence can help organize treatment approaches to assist transgender individuals in avoiding future incidents of sexually harmful behavior.
... So far, however, there is only one example in the literature of a person with BID being cured by psychotherapy [20]. On the other hand, for transgender people, there are-in addition to the surgical solution-a lot of effective psychotherapeutic treatment options [7,[45][46][47][48][49][50][51]. On the other hand, Chakraborty and coauthors [26] wrote that medical and psychotherapeutic techniques to heal BID were mostly ineffective; in contrast, amputation seems to cure the desire totally [52]. ...
... In contrast, the field has recently seen the emergence of several excellent applications of ESTs specifically focused on tailoring these approaches to the treatment needs of TGD patients, including IPT (Budge, 2013), behavioral activation (BA; Perry et al., 2017), DBT (Sloan et al., 2017), ACT (Bennett & Taylor, 2019), transgenderaffirmative cognitive behavioral therapy (CBT; Austin et al., 2017Austin et al., , 2018Balsam et al., 2019;Coyne et al., 2020;Craig et al., 2019), and CBT-based conceptualizations of transgender-affirming treatment for TGD survivors of trauma and discrimination (Barr et al., 2022;Livingston et al., 2019;Shipherd et al., 2019). However, these applications have yet to be subjected to rigorous clinical trial studies. ...
Transgender and gender diverse (TGD) individuals are disproportionately exposed to traumatic and high-impact minority stressors, which can produce an array of transdiagnostic symptoms. Some clinical presentations align well with established evidence-based treatments, but others may require patient-centered modifications or combined approaches to address treatment needs. In this study, we used a novel, bottom-up approach to derive insights into preferred intervention strategies for a broad range of trauma- and TGD-minority stress-related expressions of clinical distress. Participants (18 TGD individuals and 16 providers) completed a q-sort task by first sorting cards featuring traumatic experiences and/or minority stressors and transdiagnostic psychiatric symptoms into groups based on perceived similarity. Next, participants sorted interventions they believed to be most relevant for addressing these concerns/symptoms. We overlaid networks of stressors and symptoms with intervention networks to evaluate preferred intervention strategies. TGD networks revealed transdiagnostic clustering of intervention strategies and uniquely positioned the expectancy of future harm as a traumatic stressor. Provider networks were more granular in structure; both groups surprisingly emphasized the role of self-defense as an intervention. While both networks had high overlap, their discrepancies highlight patient perspectives that practical, material, and structural changes should occur alongside traditional clinical interventions.
... There are various types of CBT that are tailored to specific problems and groups, such as trauma-centered CBT for children and adolescents and CBT-I for military personnel and pregnant women. [29][30][31][32] CBT has been used to treat a variety of mental and somatic illnesses, including depression, anxiety disorders, chronic pain, eating disorders, schizophrenia, obsessive-compulsive disorders and post-traumatic stress disorder. 12,[33][34][35][36][37][38] A range of CBT interventions and therapy studies have been conducted to address other health issues such as insomnia and stress. ...
Heart failure (HF) remains a major cause of morbidity, mortality and healthcare costs, despite available treatments. Psychological issues such as depression, anxiety and poor self-care are prevalent in HF patients. Such issues adversely affect patients' daily lives and increase hospitalization and mortality rates; therefore, effective approaches to address these are needed. Cognitive-behavioral therapy (CBT) has been proposed as potentially useful for psychological comorbidities in HF patients, but its efficacy is not well-established. This narrative review aimed to summarize the evidence on the effectiveness of CBT for HF patients. A search was conducted using PubMed and Google Scholar for randomized controlled trials (RCTs) on CBT for HF patients. Ten studies (nine RCTs and one case study) were included in the review. CBT was found to be an effective intervention for managing depression, anxiety, low quality of life, and impaired social and physical functioning in HF patients. The results suggest that CBT can improve psychological well-being and enhance the benefits of rehabilitation programs. Face-to-face CBT appears to be superior to conventional therapy and can be implemented in cardiac rehabilitation settings. Further research is needed to evaluate the efficacy of internet-based CBT for cardiac patients and identify factors that promote treatment adherence.
... Clinicians' lack of awareness of contextual stressors could lead to diagnostic bias, perpetuating minority stress and exacerbating negative mental health. For example, the clinical interpretation of a patient's reported mistrust of others in public spaces may depend on the individual's racial identity (Whaley & Hall, 2009 1.2 | Gender expansive health disparities and challenges of CHR-p treatment Extensive research has documented ways in which GE patients (including, but not limited to, those identifying as transgender and non-binary) face markedly higher rates of rejection, victimization, and discrimination, compared to CG peers (Austin et al., 2017). In turn, GE individuals are at increased risk for a variety of mental health concerns, including higher rates of mood disorders, suicidal ideation, and trauma histories, compared to CG populations (Connolly et al., 2016;Hanna et al., 2019). ...
Introduction:
Although research has documented the marked disparities in rates of psychosis-spectrum diagnoses in various socially marginalized populations, there is limited research addressing the needs of gender expansive individuals in the context of psychosis-spectrum illnesses using a minority stress lens. As clinical high-risk for psychosis (CHR-p) assessment and treatment becomes accessible to increasingly diverse populations, there is a need for clinicians to demonstrate greater clinical competency working with individuals across diverse social backgrounds and identities.
Methods:
We examined rates of gender expansive (GE) patients seeking evaluation at an urban-based CHR-p clinic and compared the diagnostic profile of GE individuals to cisgender patients. Post-hoc analyses were conducted on clinical variables with significant differences between the cisgender and GE groups.
Results:
The proportion of GE patients seeking evaluation increased from 2017 (9.3%) to 2021 (16.7%). Compared to cisgender youth, GE patients had significantly higher depressive, social anxiety, borderline personality disorder symptoms, higher levels of suicidality and non-suicidal self-injurious behaviour, and lower role functioning. Gender identity was predictive of suicidality controlling for social anxiety, borderline symptoms, and role functioning.
Conclusions:
We review implications for CHR-p treatment and discuss ways to integrate minority stress theory and gender-affirming practices into coordinated specialty care for CHR-p patients.
... Gender-affirming psychological therapies integrate processes related to the biopsychosocial model and the management of sources of stress that historically can affect the quality of life of transgender patients. These perspectives assume that gender expression is problematic when it takes place outside of standardized social patterns, leaving aside the strengthening of the group and individual relational networks that favor care (Austin et al., 2017;Austin et al., 2018;Budge et al., 2021;Craig et al., 2013;Edwards-Leepper et al., 2016;Israel et al., 2021;Knutson et al., 2021;Matsuno, 2019;Oransky et al., 2019;Strauss et al., 2019;Walton & Baker, 2019). ...
This chapter explains how the tensions between the classifications derived from sex and the multidimensional character of gender have an impact on the conceptions and understandings of “sexual identity” and “gender identity” and its impact on social experiences related to the rejection and reaffirmation of identity in the case of women with trans life experiences. It also describes experiences of gender identity awareness and self-determination from the perspective of the trans women participating in the study. Methods: Narrative study conducted with 139 trans women in seven cities in Colombia. In-depth interviews and discussion groups developed between June 2019 and March 2020. Data were analyzed using thematic analysis at Atlas Ti cloud program and Consensual Qualitative Research. Results: The women’s narratives account for some thematic categories regarding: (a) Socio-cultural aspects in the construction and expression of gender identities, (b) Tension between sexual and gender, (c) Awareness and self-determination of identity, and (d) Affirmative pathways and recognition. It reveals socio-cultural aspects in the construction and expression of gender identities corresponding to the hegemonic cis-patriarchal system present in Colombia. Conclusions: Approaches are required to weave in other intersubjective complexities regarding sexual and gender identities in particular contexts, and that urgently allow for the construction of affirmative processes and recognition that expand traditional and hegemonic categories, including language and socio-cultural practices, such as affirmative language, for example, asking and using appropriate pronouns. In the life experiences of the participants, sexual and gender identities are constitutive of human and social processes aimed at possible coexistence. These processes respond to forms of classification consistent with the cis-hetero patriarchal system. As far as this study is concerned, the socio-cultural dimension of the construction of gender identities is the one that alludes to “the disciplining of bodies” based on social practices related to beauty, health, and the binary references of femininity and masculinity.KeywordsRejectionTransgenderGender identityGender equity
... When assessing mental health among TGD youth, screening for any or all of these domains may be useful when assessing the need for or specificity of a mental health referral. If youth have high levels of internalized transphobia, a helpful referral would be to a gender-affirming psychotherapist who may employ established interventions that aim to reduce depressive symptomology by targeting underlying internalized transphobia through cognitive restructuring [43]. In addition, evidence has found that increasing a sense of identity pride in peer support groups may also improve mental health outcomes, particularly for ethnically/racially minoritized TGD youth [19e21]. ...
Purpose:
Prior studies have identified a significant relationship between internalized transphobia and poor mental health among transgender and gender-diverse (TGD) adults; however, this relationship has not been extensively examined among youth. Further, little research has sought to explore protective factors, such as identity pride, and their influence on this relationship. We examined the association between internalized transphobia and depression and anxiety symptoms among TGD youth and explored the moderating role of gender identity pride on these associations.
Methods:
Participants were 315 TGD youth ages 12-20 years (mean = 16; standard deviation = 1.89) seeking gender-affirming hormone treatment at one of four major pediatric hospitals across the United States. At the time of enrollment, participants were naïve to gender-affirming hormone treatment. Participants self-reported mental health, internalized transphobia, and identity pride. Multiple regression models were used with depression and anxiety symptoms as outcomes and age, designated sex at birth, and perceived parental support included as covariates.
Results:
Greater internalized transphobia was associated with greater depressive symptoms, and gender identity pride moderated this relationship, such that greater gender identity pride was associated with fewer depressive symptoms. Greater internalized transphobia was significantly associated with greater anxiety symptoms; no moderation effect was observed for this relationship.
Discussion:
Gender identity pride influenced mental health symptoms for youth experiencing internalized transphobia and represents a potential key protective factor. These results support efforts to further develop, test, and implement clinical inventions to bolster identity pride for TGD youth.
... Australian Journal of Primary Health (Dobson and Dozois 2019). Trans affirmative CBT (Austin et al. 2017), for example, adapts traditional CBT techniques to manage specific minority stressors experienced by TGD individuals. The emphasis on targeting specific causal pathways to change clients' cognitions also enables defining specific strategies and skills for clients to practice independently, which can improve self-efficacy (Dobson and Dozois 2019). ...
Trans and gender-diverse individuals experience poor mental health, and face significant barriers when trying to access appropriate mental health care. Most seek treatment from mainstream primary care services, who have an ethical duty to provide care to all. Primary care practitioners can ameliorate traumatic harms by identifying helpful strategies and avoiding inappropriate or harmful strategies. However, there is limited robust, culturally sensitive evidence informing clinicians about the appropriateness and efficacy of psychological interventions for trans and gender-diverse clients. This forum article argues that the epistemological and ontological frameworks underlying psychotherapies can impact the therapeutic relationship, and are therefore important factors to consider in primary care practice with trans and gender-diverse clients. Our paper synthesises selected psychotherapies into four clusters. Each cluster is accompanied by discussion of the potential or demonstrated benefits and limitations of the underlying framework, in the context of primary care with trans and gender-diverse clients. We also explore power dynamics in therapeutic relationships with trans and gender-diverse clients, and the challenges these factors pose to developing a shared understanding of the client’s needs and preferences. The article concludes with some practical considerations for managing these issues in primary care.
... Additionally, Austin and Craig (2015) were among the first to address TGD behavioral health from a cognitive-behavioral therapy (CBT) perspective. They have developed an affirmative CBT for anxiety and depression for gender diverse adolescents (Austin et al., 2018), with discussion of extending it to adults (Austin et al., 2017). ...
Individuals who identify as transgender and gender diverse (TGD) are presenting at mental health clinicians’ offices with increasing frequency. Many TGD clients are seeking care related to affirming their gender identity but also may present with anxiety, depression, trauma, substance abuse, or other problems forwhich a clinician may commonly provide services. Some clinicians may hesitate to accept TGD clients into their practice if they have little specialized training to work with this population in an affirming manner, especially in more underserved areas where a generalist practice is the norm. Numerous professional associations and experts have developed guidelines for affirmative behavioral health care for TGDpeople.However, what is needed are community-informed recommendations to bridge from the official guidelines to clinicians’ in-session activities. The Trans Collaborations Practice Adaptations for Psychological Interventions for Transgender and Gender Diverse Adults are derived from iterative interviews with TGD community members and affirming mental health clinicians in the Central United States. The 12 practice adaptations are intended to guide clinicians to adapt their usual treatment approach to be TGD affirming, especially in underserved and rural areas. The practice adaptations cover numerous aspects of practice including the office setting and paperwork, understanding gender identity and incorporating it into the case conceptualization, therapist’s self-awareness, and referrals. The Trans Collaborations Practice Adaptations will help clinicians work confidently and competently with adult TGD clients, regardless of the presenting problem, to ensure TGD communities receive the best interventions for their behavioral health concerns.
... For clinicians, this begins with work to educate themselves on gender-affirming, strength-based approaches to care for TGD individuals. Resources available for such education include the American Psychological Association (APA)'s Guidelines for Psychological Practice with Transgender and Gender Nonconforming People (American Psychological Association, 2015), Chang and Singh's (2018) A Clinician's Guide to Gender-Affirming Care: Working with Transgender and Gender Nonconforming Clients, and publications describing transgender affirmative cognitive behavioral therapy (e.g., Austin & Craig, 2015;Austin et al., 2017), all of which inform the following suggestions. ...
While elevated suicide risk in the American military and veteran population has led to the development of targeted interventions, the increased risk of suicidal ideation and behavior among transgender and gender diverse (TGD) servicemembers requires that interventions address suicide risk within the context of minority stressors and gender-affirming care. This case study presents Jordan (an alias), a transgender servicemember who received inpatient psychiatric treatment following a suicide attempt precipitated by distress relating to gender dysphoria, minority status, and associated stressors. Jordan completed Post-Admission Cognitive Therapy (PACT; Ghahramanlou-Holloway, Cox, & Greene, 2012), a cognitive-behavioral intervention targeting suicide risk among military personnel and dependents psychiatrically hospitalized following a suicidal crisis. Within the context of PACT, Jordan’s treatment included identifying and addressing distress related to minority stressors (externalized stigma, internalized transphobia, anticipated rejection, gender concealment) using gender-affirming best practices. Marked changes in Jordan's self-report measures from baseline to follow-up, as well as qualitative changes reported by Jordan, demonstrate that she felt comfortable, safe, and ready to be discharged from the inpatient unit after completing PACT treatment and gaining exposure to the skills necessary to help prevent and/or manage future suicidal crises. Treatment implications and recommendations for addressing suicide risk within the context of gender-affirming care and prevalent minority stressors are discussed.
... Specifically, the authors found that participants were better able to cope with stressful situations, including those arising from instances of discrimination, as a result of the intervention. Using a similar framework, Austin et al. (2017) proposed and examined a "transgender-affirmative Cognitive Behavior Therapy" approach for transgender and gender-nonconforming youth. ...
Gender and sexually diverse (GSD) students face unique challenges in schools due to the privileging of cisgender and heterosexist norms in these settings. In particular, GSD youth who belong to ethnically and racially minoritized groups face further challenges within school environments that disregard their cultural contexts and intersectional identities. It is important for school psychologists to ensure safe and high‐quality mental health, educational, and behavioral supports for these students. One possible avenue for building these types of supports is through school consultation. When school psychologists collaborate with other professionals in a culturally competent, participatory way, their work has the potential to bolster behavioral, academic, and mental health outcomes at the individual, group, and/or systems levels. Adapting Ingraham's multicultural school consultation model, this article proposes a multicultural, GSD affirming school consultation framework that also approaches the experiences of racially and ethnically minoritized individuals through the lenses of intersectionality and minority stress frameworks. Across its five domains, this adapted framework aims to give practitioners and researchers a conceptual foundation to support GSD students of minoritized ethnic and racial identities by considering interactions among consultants, consultees, and clients within their wider school contexts.
... Rider et al. (2019) published "The Gender Affirmative Lifespan Approach (GALA): A Framework for Competent Clinical Care With Nonbinary Clients," which takes a transtheoretical approach and focuses on positive gender identity development. However, these protocols, as well as previously adapted trans-affirming therapies (e.g., trans-affirming Cognitive Behavioral Therapy; Austin et al., 2017) have not been empirically studied or shown to be effective through RCTs as of yet. ...
... ONLINE PARTNER SEEKING AMONG TRANSGENDER TEENS 9 Finally, there is a need for parents, educators, and health care providers to aid TGD teens in thinking through when, how, to whom, and under what circumstances they should disclose their gender identity online. Training should equip TGD teens with skills to cope with rejection and discrimination online (for example, cognitive restructuring, mindfulness-based skills, and socialfamilial support; Austin & Craig, 2015;Austin et al., 2017;Iacono, 2019). ...
Online relationship seeking is a normative aspect of adolescent development and is common among sexual minority adolescents. Yet, little is known about transgender and gender diverse (TGD) adolescents’ subjective experiences with and needs related to online relationship seeking. This online, mixed-method study examined TGD adolescents’ patterns and experiences of online relationship seeking. A sample of 130 TGD adolescents (68.5% non-Hispanic White, M age 16.8 years, 73.8% transgender men) were recruited online to complete a survey assessing patterns of online relationship seeking and their questions and advice about online partner seeking. Thematic analysis showed that adolescents emphasized maintaining personal safety, setting realistic expectations, and strategies for online relationship seeking as three key areas of advice to share with other sexual and gender minority (SGM) adolescents. Participants also had questions about ways to connect with other SGM teens, gender identity disclosure, and relationship management when seeking partners online. Mixed-methods analysis revealed that participants who had dated before offered more specific advice and asked more nuanced questions about online relationship seeking than those who had not dated. Findings highlighted identity-specific needs and the lack of knowledge about online relationship seeking among TGD adolescents. This study underscored the needs for TGD-inclusive relationship and sex education for this population.
... Thus, special attention to the unique needs of binary transgender youth remains paramount in these settings (Thorne et al., 2019). Clinicians providing intensive services for binary and nonbinary transgender youth at risk for psychiatric hospitalization would benefit from training on the GMSM (Hendricks & Testa, 2012), and awareness of risk for compounded psychiatric and psychosocial maladjustment, to support needs assessment, enhance opportunities to advocate for youth where possible (Dickey & Singh, 2017) as well as reduce the risk of inadvertently perpetuating experiences of gender discrimination, invalidation, and stigma or exacerbate distal risk factors in the service setting (Austin et al., 2017). In addition to enhancing their own awareness and clinical approach, education in the GMSM would also support clinicians' ability to provide psychoeducation and support to families regarding the ways in which the environment, including societal attitudes and beliefs, can have important negative implications for their nonbinary and binary transgender youth, and may exacerbate mental health challenges or create vulnerability for additional problems. ...
Psychological and psychosocial functioning of binary transgender and nonbinary youth has been understudied in settings treating individuals at risk for psychiatric hospitalization. Further, little is currently known about potential differences in baseline levels of psychiatric distress and adaptive functioning across gender-diverse youth and their psychiatrically distressed cisgender counterparts. Key differences may elucidate avenues for adapted treatment and protocols among youth presenting for psychiatric care. Archival data of 426 youth (Mage = 14.94, SD = 1.5 years) referred to a psychiatric Intensive Outpatient Program (IOP) were used to examine differences in self-reported domains of psychological (e.g., depression, anxiety, Posttraumatic Stress Disorder [PTSD], emotion dysregulation) and psychosocial (e.g., parental and interpersonal relations) functioning across gender. The group included N = 272 cisfemale (64.1%), N = 137 cismale (32.2%), N = 10 transgender (2.3%) and N = 7 nonbinary (1.6%) self-identified youth. Cismales reported the lowest levels of distress and highest levels of adaptive functioning as compared to the other groups, whereas binary transgender and cisfemale youth did not significantly differ across any measured domain. Nonbinary youth reported higher levels of anxiety, hyperactivity, psychological inflexibility, and inadequacy than cisfemales, but largely did not differ from binary transgender youth. Beyond statistical comparisons, nonbinary youth demonstrated globally elevated levels of psychiatric distress and compromised adaptive functioning, with most ratings falling in the clinically significant and/or at-risk ranges. Results highlight the need for clinicians to carefully attend to unique needs of nonbinary youth and for future research to expand upon our preliminary findings. Clinical implications are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... Social isolation can be an issue for some trans and non-binary people and therefore there is scope for mental health professionals to work with community organizations and networks to ensure there is effective local services available to provide information and necessary supports [62]. From the perspective of evidence-based therapies, given the scope and extent of the mental health needs of trans and non-binary people, there is a need to ensure that professionals delivering psychological interventions, such as counselling and psychotherapies have the necessary attitudes, values and skills to address their specific concerns [63,64]. ...
People who identify as trans and gender non-binary experience many challenges in their lives and more interest is being paid to their overall health and wellbeing. However, little is known about their experiences and perceptions regarding their distinct psychosocial needs. The aim of this systematic review is to critically evaluate and synthesize the existing research evidence relating to the unique psychological and social experiences of trans people and identify aspects that may help or hinder access to appropriate psychosocial interventions and supports. The PRISMA procedure was utilized. A search of relevant databases from January 2010 to January 2021 was undertaken. Studies were identified that involved trans people, and addressed issues related to their psychosocial needs. The search yielded 954 papers in total. Following the application of rigorous inclusion and exclusion criteria a total of 18 papers were considered suitable for the systematic review. Quality was assessed using the MMAT instrument. Following analysis, four themes were identified: (i) stigma, discrimination and marginalization (ii) trans affirmative experiences (iii) formal and informal supports, and (iv) healthcare access. The policy, education and practice development implications are highlighted and discussed. Future research opportunities have been identified that will add significantly to the body of evidence that may further the development of appropriate health interventions and supports to this population.
... Leading researchers of affirmative practice have generally focused on group and family interventions with youth (e.g., Austin et al., 2016;Romney et al., 2020). In one study of a cognitive behavioral protocol, eight participants between the ages of 16 and 18 participated in an eightmodule pilot study of AFFIRM, a transgender and nonbinary affirmative intervention . ...
The authors discuss their work with a young adult client who identified as gender fluid. The client was a college student in a rural, mid-south town. The authors are two faculty members who worked with the client for a period of 2 years using a cotherapy supervision approach. The counseling approach was affirmative and person-centered. By keeping a focus on the exploration of gender foremost, the clinicians saw an abatement of other symptoms (depression, suicidality, self-harm, disordered eating, low self-confidence, emotion dysregulation, dissociation, and so on) and an improvement in wellness (relationships, emotion regulation, self-concept, assertiveness, appropriate boundary-setting, and so on) over time. The authors offer specific interventions such as collaborative letter writing and the creation of a transition roadmap. They also highlight the advantages and utility of a collaborative, person-centered, consent-based, affirmative approach to therapy with rural transgender and nonbinary clients with complex presenting concerns.
... Beispielsweise schlagen Austin, Craig und Alessi ein fokussiertes kognitiv-verhaltenstherapeutisches Programm vor [3], das sich über 8 Sitzungen erstreckt und Themen wie Psychoedukation im Zusammenhang mit Minderheitenstress, Umgang mit negativen Gedanken und Gefühlen, Hoffnungsinduktion sowie Klärung und Bewältigung im Umgang mit nahen Beziehungen umfasst. ...
Psychotherapie mit transmaskulinen Personen kann ein wichtiges Hilfsmittel sein, um sie bei einer Vielzahl von Anliegen zu unterstützen. Dabei liegen Themen wie Identitätsentwicklung, geschlechtsspezifische traumatisierende Erlebnisse und verinnerlichte Transnegativität (Stigma) im Fokus sowie die Bewältigung belastender Emotionen und Hilfestellungen bei einer Geschlechtsumwandlung.
[Psychotherapy with trans masculine individuals can be an important tool in assisting them with a variety of concerns. The focus of this article is on topics such as identity development, gender-specific traumatic experiences and internalized transnegativity (stigma) as well as coping with stressful emotions and assistance with transition.]
... Levenson and colleagues suggested that such treatment should include aspects of Affirmative Cognitive Behavioural Therapy along with a strong focus on building a compassionate and non-shaming relationship with the individual. Such approaches have proved beneficial for transgender and gender nonconforming adults but have yet to be studied in clinical settings amongst child-attracted persons (Austin, Craig, & Alessi, 2017;. ...
Existing literature suggests that a variety of biopsychosocial factors may be related to sexual attraction to children, but why some individuals successfully refrain from offending remains largely unknown. Emerging research has examined the experiences of child-attracted persons. Child attracted person is a modified version of the self-referential term minor-attracted person, used to describe an individual who is sexually attracted to individuals under the legal age of consent, which varies by legal system. This research program used a multimethod approach to explore heterogeneity among child-attracted persons. First, quantitative data were collected from 116 self-identified child-attracted persons and 208 university students. Participants completed an online survey of 11 self-report measures, assessing a variety of factors that have been found to be related to sexual offending, such as emotional congruence, sexual narcissism, negative affect scales, and personality. Comparative analyses indicated many similarities between the samples, although there were several key differences. A latent profile analysis indicated that a four-profile model best fit the data. The child-attracted profiles were labelled socially energized, psychologically distressed, interpersonally problematic, and childhood focused. Although the profiles differed with respect to key resiliency factors, they did not differ in terms of most demographic characteristics. Second, qualitative data were collected from 23 self-identified child-attracted persons in the form of semi-structured interviews. Thematic analysis of the qualitative data uncovered several key themes across the interviews, including understanding attraction to children as a sexual orientation; how such attractions are viewed and treated societally; engagement in sexuality; mental health concerns and associated therapy services; and the overall impact of the attraction. Finally, several measures related to attraction to children were modified and analyzed for statistical reliability. Taken together, the findings of this research program support the presence of heterogeneity among the child-attracted community. This supports the necessity to develop assessment and treatment options that incorporate such differences. Further, the findings of the research program, and other emerging research exploring sexual attraction to children, suggest serious negative mental health outcomes associated with identifying as attracted to children and with the associated stigma, often beginning in adolescence. These findings underscore the need to continue to pursue research in this area and develop further understandings of sexual attraction to children and related outcomes.
... One theoretical model that has been suggested for use with TNB individuals is transgender-affirmative cognitive-behavioral therapy (TA-CBT; Austin & Craig, 2015;Austin, Craig, & Alessi, 2017). TA-CBT includes psychoeducation about how TNB discrimination and systematic oppression affect experiences of depression, anxiety, and suicidality. ...
Transgender and nonbinary (TNB) people report experiencing elevated rates of discrimination and psychological distress (James et al., 2016). Transgender-affirming interventions are recommended to address psychological distress (e.g., anxiety, depression) reported by TNB individuals (Craig & Austin, 2016). TNB people in rural areas report barriers (e.g., lack of financial resources, long commutes) to accessing affirmative and/or quality treatment (Knutson, Koch, Arthur, Mitchell, & Martyr, 2017). Electronically delivered interventions, if found to be effective, could be used to reduce barriers and increase the accessibility of affirmative care to TNB people, especially people in remote areas and during pandemics such as the 2019 novel coronavirus (COVID-19). The current study presents pilot feasibility data examining a 6-month transgender-affirmative intervention based on short message service (SMS). Participants (N = 14) were 18 years old or older and identified as transgender and/or nonbinary. Anxiety, depression, and social support were assessed at pre- and posttreatment and at 3-month follow up. Anxiety, t(13) = 2.95, p = .01, d = 0.40, and depression, t(13) = 2.76, p < .05, d = 0.73, decreased significantly from pre- to postintervention. Anxiety, t(13) = 3.26, p = .01, d = 0.65, further decreased from preintervention to follow-up, and social support, t(13) = −2.45, p < .05, d = 0.29, increased from preintervention to follow-up. The intervention demonstrated good feasibility and acceptability, based on participant feedback. We discuss the implications of our results for technology-based TNB-affirmative care for individuals, as well as future directions for research.
... Similarly, all of the identified research relies on observational studies. Future research using natural and quasi-experimental designs to examine how policy initiatives designed to reduce discrimination [86], or psychological interventions that increase an individual's ability to cope with discrimination [87,88], influence sleep outcomes among sexual and gender minority populations may help address some of these questions. Similarly, understanding how interventions that promote sleep health are associated with an individual's ability to regulate successfully in the context of minority stressors will provide much needed experimental evidence on how sleep health and minority stressors interact over time [89]. ...
While sexual and gender minority populations have been increasingly identified as an at-risk population for negative health outcomes, research has only recently begun to focus on sleep health among sexual and gender minority populations. This chapter defines terms relevant for discussing sexual and gender minority populations, focuses on the theoretical rational for understanding vulnerabilities to poor sleep outcomes among sexual and gender minority populations, reviews the existing literature examining sleep health among sexual and gender minority populations, and suggests directions for future research examining sleep health among sexual and gender minority populations. Indeed, the emerging literature suggests that important sleep disparities may occur across sexual and gender minority identity, and that these sleep disparities may have important consequences for other health outcomes. More work, however, is needed to understand why sexual and gender minority status places individuals at risk for specific sleep outcomes, and why particular sexual and gender minority subgroups may be particularly vulnerable to poor sleep health.
... Regarding individual-level interventions, little research has assessed the impact of TGNC affirmative interventions on mental health. For instance, some authors theoretically discussed an interpersonal therapy model for TGNC individuals (Budge, 2013) or a cognitive-behavioral intervention aimed at reducing anxiety and depression (Austin, Craig, & Alessi, 2017). Both models were framed within an affirmative approach, widely discussing on how to reduce the negative effects of minority stressors on health. ...
Objective
The current study examined the role of internalized transphobia (IT) as a mediator between gender‐related rejection and mental health, and reflective functioning (or mentalization) as a resilience factor moderating the relationship between both rejection and IT with mental health.
Method
This online study included 203 Italian transgender and gender‐nonconforming (TGNC) individuals ranged in age from 18 to 66 years old (M = 30.70; standard deviation = 10.79). Moderated‐mediation analysis was performed using a structural equation modeling approach.
Results
Both rejection and IT were positively associated with mental health, and IT mediated the relationship between rejection and mental health. Mentalization moderated the relationship between rejection and IT with mental health. The indirect effect of rejection on mental health through IT was moderated by mentalization.
Conclusions
Findings highlight psychological paths that may inform individual‐ and group‐level mentalization‐based interventions to reduce minority stress in TGNC individuals.
... SGMY also reported using online tools to find a mental health provider, including social networks, blogs, hospital websites, and internet searches . As effective interventions for SGMY youth continue to develop, such as Gayand Transgender-affirming CBT (Austin & Craig, 2015;Austin, Craig, & Alessi, 2017), technology can provide access to healthcare providers trained in these techniques who are outside of the adolescents' local network. ...
... Furthering their work related to affirmative care, Austin et al. (8) offered specific practice recommendations for therapy with transgender and gender-nonconforming adults. Of note, they clarified that minority stress may lead to high levels of stigma related to mental disorders. ...
Affirmative practice is an approach to health and behavioral health care that validates and supports the identities stated or expressed by those served. Affirmative care requires the practitioner to actively honor and celebrate identity while at the same time validating the oppression felt by individuals seeking services. Validation and empathy fundamentally result from increased understanding of individuals' history, cultural context, and lived experiences. Origins of the approach honored the experience of those in LGBTQ+ communities; however, affirmative care should be valued across cultures, systems, and settings in which health and behavioral health care are offered. Affirmative care principles should be applied across cultures and communities while recognizing the worth of the individual and avoiding stereotyping. Along with delineating historical and demographic contexts, the authors offer recommendations for affirmative care in practice with African American, Asian, Indigenous, and Latinx individuals, as well as those living in rural communities.
... For example, data from the 2014-2015 Transgender Stress and Health Study [51] provide evidence for the use of resilience-focused interventions that focus on strengthening a transgender client's existing skills to increase coping for dealing with genderrelated stress. Such resilience-focused interventions can include promoting transgender-affirmative social support, social connectedness and self-advocacy [52]. ...
Many transgender individuals report violence directed against them. This study examined violence inflicted on transgender Latinas with HIV by primary partners, sexual partners and acquaintances/strangers. Logistic regression was used for analysis. 150 transgender Latinas were recruited. Rates of violence from different perpetrator types were 47–50%. For violence by primary partners, social support from cisgender people was associated with a lower likelihood of violence (AOR 0.56; CI 0.32, 0.98; p < 0.05). For violence by sexual partners, a history of childhood sexual abuse was associated with a higher likelihood of violence (AOR 2.64; CI 1.10, 6.34; p < 0.05). For violence by acquaintances/strangers, discrimination was associated with a higher likelihood of violence (AOR 2.84; CI 1.16, 6.94; p < 0.05) and social support from cisgender people with a lower likelihood (AOR 0.58; CI 0.37, 0.92; p < 0.05). Interventions are needed at individual, institutional and systemic levels to eradicate such violence.
... Psychological intervention components could be integrated and adapted such as Life-Steps cognitive behavioral therapy for PrEP adherence [103]. Gender-affirming psychotherapeutic approaches may be used to address copresenting psychosocial factors, such as trauma or depression [104]. Transportation, shown to be a structural barrier to HIV prevention and treatment for trans women [105], could be circumvented by providing transportation vouchers or delivering services in the community and/or having peer navigators meet trans people where they are. ...
Purpose of review:
Transgender (trans) populations are heavily impacted by HIV, yet face structural, social, and individual barriers to engagement in HIV prevention and care. In this review, we summarize the data on barriers and facilitators and discuss evidence-informed strategies to facilitate access to and engagement in HIV prevention and care by trans communities.
Recent findings:
Intersectional stigma and discrimination at structural, community, individual levels present substantial impediments to HIV prevention and optimal care. Access to gender-affirming health care is a priority for trans communities. Where trans communities are highly networked, these networks may provide a strong infrastructure for disseminating HIV innovations and reaching individuals who are not engaged in HIV services. Efforts to engage trans people in HIV prevention and care must address stigma, provide gender-affirming services, and build on community strengths and priorities to ensure trans populations achieve maximum benefit from advances in HIV prevention and care.
Summary:
Combination approaches that respond to the complex drivers of HIV in trans communities represent promising strategies for engaging trans people and their partners in HIV prevention and care.
... Some theoretical and clinical concepts can be borrowed from affirmative CBT models designed for work with sexual minority clients, which aim to help clinicians avoid judgmental or invalidating responses to sexual orientation or gender identity (Austin et al. 2017). Affirmative CBT helps clients reframe one's view of self from "disordered" and "pathological" toward a more accepting self-narrative, and to cope with a complex range of internal feelings and external messages that are stigmatizing and demoralizing (Austin and Craig 2015, p. 24). ...
Would you feel prepared if a client in your clinical practice shared that he was sexually attracted to children? Mental health professionals come in contact with these individuals primarily through the child welfare or criminal justice systems. But it is now increasingly evident that a population exists of non-offending minor-attracted persons (MAPs) who have never molested a child and have no intention of doing so. By becoming familiar with their unique treatment needs, clinicians can develop competence to provide effective, ethical, and compassionate services for this stigmatized and hard-to-reach population, with a dual focus on sexual abuse prevention and client well-being. This article will first describe what is known about pedophilia and minor-attraction. Next, the legal and ethical questions that therapists may ask in relation to this work will be explored. This paper will review obstacles to help-seeking identified by MAPs and discuss their treatment needs. Finally, recommendations will be offered for engaging MAPs in an emotionally safe and non-shaming therapeutic encounter. In this way, clinical social workers can contribute to advancing child sexual abuse prevention efforts.
... Eine vertiefende und differenzierte Darstellung spezifischer Implikationen würde jedoch den Rahmen des Beitrags übersteigen. Ausführliche Darstellungen geben Austin et al. (2016) für kognitive und verhaltenstherapeutische Ansätze, Lin Fraser (2009) für tiefenpsychologische Ansätze, Knutson und Koch (2018) für humanistische sowie Mallory et al. (2017) für systemische Ansätze. ...
Zusammenfassung
Der Artikel beschäftigt sich mit Fragen zu vielfältigen Geschlechtlichkeiten in psychotherapeutischen Räumen. Wir zeichnen eine Verbindung zwischen Topoi des hegemonialen Diskurses um Inter* und Erfahrungen von Trans* und Gender non Conforming Personen, die Therapie in Anspruch nehmen. Möglichkeiten und Grenzen geschlechtlicher Subjektivierung werden in Diskursen und Praktiken – maßgebend in klinischen – hervorgebracht. Vor diesem Hintergrund diskutieren wir die ambivalente Rolle von Psychotherapeut*innen als Vertreter*innen eines machtstützenden Systems, das gleichzeitig individuelle Selbstbestimmung stärken soll. Aus den Überlegungen leiten wir spezifische Bestärkungs- und Gefahrenpotentiale psychotherapeutischer Räume und Reflexionsebenen für Psychotherapeut*innen ab.
... Given such concerns, scholars have discussed the importance of practicing affirmatively with LGBT clients (Alessi, 2013). Studies have shown that such treatment enhances the psychotherapy experiences of LGB individuals (Israel, Gorcheva, Burnes, & Walther, 2008;Quiñones, Woodward, & Pantalone, 2017) and transgender clients (Austin, Craig, & Alessi, 2017). Furthermore, affirmative approaches have been shown to reduce mental health symptoms for sexual minority individuals (Craig & Austin, 2016;Pachankis, Hatzenbuehler, Rendina, Safren, & Parsons, 2015). ...
... 9 Outro estudo ressaltou que especialistas em saúde mental podem desempenhar papel fundamental no apoio à saúde e ao bem-estar dos pacientes transgêneros, por meio de abordagens transafirmativas, ou seja, aquelas que reconhecem as experiências de gênero como igualmente saudáveis. 10 Do mesmo modo, outra pesquisa salientou a importância de os cirurgiões que atendem essa população se habituarem com suas características emocionais. 11 De maneira geral, os estudos com profissionais da saúde assinalam as maneiras que podem parecer discriminatórias e fóbicas por parte desses profissionais; tais atitudes podem dever-se à falta de conhecimento, treinamento e educação específica durante a graduação. ...
INTRODUÇÃO À maioria dos bebês, ao nascer, é atribuído o gênero de nascimento, isto é, menino ou menina, que correspon-de ao sexo biológico (genitália), o qual é acompanhado por expectativas sociais, comportamentais e expressões de gênero correspondentes a ele. Com o passar do tempo , no entanto, algumas crianças podem perceber que o gênero que lhes foi atribuído quando nasceram não está em harmonia com o gênero percebido por elas próprias. Nem todas as crianças sentirão desconforto como resulta-do de sua não conformidade com o gênero de nascimento. Contudo, se o ambiente no qual elas se desenvolverem for hostil ou hesitante em aceitar essa condição, algumas se sentirão motivadas a ocultar e/ou reprimir o gênero com o qual se identificam. 1 I Psiquiatra, doutor em ciências da saúde e assistente RESUMO Genericamente, os indivíduos que apresentam incongruência na percepção do próprio gênero, em relação ao gênero que lhes foi atri-buído ao nascimento, são denominados transgêneros. Aqueles que se identificam como transgêneros apresentam maiores índices de depressão, ansiedade, angústia, ideação suicida e tentativas de suicídio, em relação à população em geral. Apesar dessas diferenças, muitos transgêneros relatam preocupações e dificuldades em buscar serviços de saúde, por estes não contarem com preparo para aten-der essas demandas. Diversos estudos procuraram identificar como é realizada a abordagem das particularidades desse grupo de pesso-as pelos profissionais da saúde. Essas pesquisas relatam atitudes que poderiam parecer ou serem consideradas discriminatórias e fóbicas por parte dos especialistas, e salientam que essas atitudes podem dever-se a falta de conhecimento, treinamento e educação durante os cursos de formação profissional. Vários desses estudos apontam a importância de disciplinas específicas constarem na graduação, assim como nos programas de educação continuada. Fornecer cuidados de saúde sensíveis a suas singularidades e otimizar as transições físicas que permitam a essas pessoas sentirem maior conforto com o gênero com o qual se identificam são aspectos que merecem atenção por parte dos profissionais da saúde. PALAVRAS-CHAVE: Transgênero, acesso aos serviços de saúde, pessoal de saúde, programas, educação MEDICINA SEXUAL
The acronym ‘LGBTQ+’ collapses gender and sexuality diversity, at the same time as it treats these as mutually exclusive categories. The collapsing of gender and sexuality often means that trans people are overlooked, while the treatment of gender and sexuality as mutually exclusive often means that trans people’s sexualities are ignored. This chapter explores what it means to work with sexuality diverse trans people in the context of therapeutic practice.
The transgender and gender diverse (TGD) community continues to experience discrimination that is inextricably linked to poorer health outcomes. As state legislators attempt to erase TGD people from existence, systemic therapists can and should be at the forefront of advancing TGD-inclusive therapy practices. In the spirit of such advancement, we present a socioculturally attuned approach to working with TGD individuals and families. Like TGD-inclusive therapy, socioculturally attuned therapy requires systemic therapists to recognize how systemic oppression constrains TGD individuals and families. This approach differs in that it calls for third-order change, or systems changing systems, moving beyond helping families restructure the rules and relational dynamics to becoming agents of change within the systems they operate. We posit that TGD-inclusive therapy practices and socioculturally attuned practice can mutually inform one another to create a more inclusive practice.
A Latinx LGBTIQ+ affirmative psychological interventions overview is presented. An analysis of the chapters and a discussion of their contributions will be oriented to understand a located Latinx perspective in psychological LGBTQ+ affirmative interventions.KeywordsLatinxLGBTQ+Affirmative interventionsLatin AmericaUnited States
Background:
Transgender and nonbinary (TGNB) populations experience high rates of hazardous drinking (HD) and alcohol use disorder (AUD) as well as unique treatment barriers. This is due, in-part, to discrimination and stigma within and outside of the healthcare system. Cultural adaptation of clinical interventions can improve outcomes for marginalized populations, but no such adapted interventions exist for AUD among TGNB individuals. This study sought to understand how TGNB individuals perceive currently available AUD psychotherapies and to generate knowledge about potential areas for cultural adaptation.
Methods:
As part of a qualitative study of HD among TGNB individuals (N=27), participants were asked to imagine that they were clients in psychotherapy vignettes corresponding to cognitive behavioral therapy, motivational enhancement therapy, and twelve step facilitation. Interviews were audio-recorded and professionally transcribed. A coding team used an iterative codebook to guide coding. Categories emerged from this process that reflected participants' perceptions and allowed for the identification of potential cultural-adaptation targets.
Results:
Across all three psychotherapies, participants wanted therapists to explicitly discuss gender identity and culturally salient HD risk factors for TGNB individuals (e.g., discrimination, stigma, gender dysphoria). There were also modality-specific recommendations to incorporate principles of trauma-informed care into cognitive behavioral therapy, avoid motivational enhancement therapy exercises that oversimplify decision-making, and recognize that the twelve-step-facilitation concept of "powerlessness" may conflict with how many TGNB people see themselves.
Conclusions:
These findings highlight areas for cultural adaptation that can be evaluated in future intervention trials in an effort to improve psychotherapy acceptability and efficacy for TGNB individuals.
Background
This research explores trans people’s experiences of healthcare and psychological services in the UK. The project aims to further inform Counselling Psychologists and other professionals of the specific needs of this client group.
Methodology
Semi-structured interviews were conducted with nine participants. The data was analysed using Interpretative Phenomenological Analysis (IPA).
Findings
Three master themes emerged from the analysis. This paper focuses on the master theme ‘Survival’, as it is most pertinent to applied psychologists. This theme explores trans people’s experiences of developing coping strategies to manage the difficulties associated with transition and negotiating healthcare. Strategies included developing resilience and assertiveness, building a social support network, and finding the right therapist.
Discussion
Implications for clinical practice are discussed. Specifically, the need for training and education, a trans affirmative stance, and the potential usefulness of CBT interventions to facilitate the development of relevant coping strategies.
*All names and identifying biographical details have been changed or omitted to ensure confidentiality
Transgender people have higher rates of posttraumatic stress disorder (PTSD) than the general population. This risk can be partially understood by conceptualizing day-to-day bias-related stressors and non-affirmation as potentially traumatic, but there is currently limited empirical evidence to support such a framework. This study aimed to explore this framework by testing the hypothesis that exposure to anti-transgender bias and non-affirmation are related to PTSD symptom severity, even after controlling for exposure to traditionally defined potentially traumatic events. Drawing upon shame-based models of PTSD, this study also tested the hypothesis that internalized transphobia partially mediates the relationships between both bias and non-affirmation and PTSD symptom severity. Cross-sectional data were collected online from 575 individuals who identified as having a gender different from their sex assigned at birth. Data were analyzed utilizing structural equation modeling. As hypothesized, participants with greater exposure to anti-transgender bias and higher levels of non-affirmation experiences had increased PTSD symptom severity, even after controlling for exposure to other trauma. These relationships were partially explained by internalized transphobia. These findings document meaningful relationships between anti-transgender bias, non-affirmation, internalized transphobia, and posttraumatic stress. They provide initial support for conceptualizing anti-transgender bias and non-affirmation experiences as potentially traumatic themselves and/or as trauma response triggers and highlight a potential role of internalized transphobia in PTSD symptoms. Clinical implications for working with trans populations are discussed.
Cognitive Behaviour Therapy is regarded as one of the most effective intervention modalities for a wide range of mental health concerns. This article explores the potential of combining CBT approaches with queer affirmative practices. In section one, the authors present a content review of forty-four articles on affirmative CBT worldwide, to assess how CBT can be effectively used with LGBTQIA+ individuals, how CBT can be beneficial for LGBTQIA+ individuals and how can CBT be modified to make it queer affirmative. In section two, the authors describe experiences in adapting QA-CBT to the Indian context in individual and group therapy, and present suggestions for making this practice intersectional.
Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8.
Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment.
Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings.
Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health.
Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.
Transgender and gender expansive individuals experience high rates of substance use disorders compared to their cisgender peers. However, there is a dearth of research regarding prevalence and correlates of substance use disorders among transgender and gender expansive individuals. Moreover, few evidence-based interventions exist for transgender and gender expansive individuals. We propose that social workers and other practitioners working with members of this community combine affirmative practice models with existing interventions and services to better meet the needs of transgender and gender expansive individuals.
Mental and physical health disparities for transgender and gender diverse (TGD) communities have been well-documented. While advancements have been made in the development of guidelines when providing mental health care to TGD clients, gaps remain, particularly related to concrete applications of cognitive behavior therapy (CBT) approaches to address the unique mental health needs of TGD people. Such gaps leave many mental health professionals inadequately prepared to assess and treat clinical distress in TGD people, which in turn maintains health disparities. Utilizing case vignettes reflecting diverse TGD identities, this paper discusses minority stress and intersectional stigma frameworks and demonstrates their integration with CBT principles in the delivery of culturally tailored assessment, case conceptualization, and treatment of TGD clients.
We conducted a systematic review of research into transgender and gender non-conforming people's experiences of psychological therapy. Ten studies were subjected to a thematic meta-synthesis, resulting in two analytic themes and five subthemes. One theme was concerned with participants' experiences of how gender was approached in therapy, including experiences of it being overemphasized, ignored, or pathologized. The second theme related to participants' views on their therapists' identities, and their approaches to therapeutic work and social action. We argue that therapists should be mindful of issues of power in the co-creation of therapeutic relationships and that therapists should discuss with clients about whether and how gender is discussed within therapy.
In a cisheteronormative culture, gender and sexual minorities (GSMs) may experience additional challenges that get in the way of a meaningful life. It is crucial that clinicians are mindful of these challenges and cognizant about the specificities of clinical work with GSMs. This article points out how societal structure interferes with mental health, and clarifies what clinicians must take into account when using affirmative cognitive behavioural therapy (CBT) interventions. Knowledge of up-to-date terminology and use of affirmative language are the first steps that contribute to clients’ experience of respect, which is paramount for the development of a good therapeutic relationship. Considering a conceptual framework of minority stress to understand vulnerability in GSM, specificities in formulation and key psychological processes are discussed. Moreover, guidelines and practical tools for intervention are presented within a CBT approach. Some reflections on therapists’ own personal biases are encouraged, in order to increase the efficacy of interventions.
Key learning aims
After reading this article you will be able to: (1) Recognize the uniqueness of gender and sexual minorities (GSM) stressors in broad and specific contexts, and their impact on mental health.
(2) Identify the underlying key processes and specificities in therapeutic work with GSMs, from a CBT perspective.
(3) Recognize the importance of a culturally sensitive approach in affirmative CBT interventions.
Introduction
Transgender populations have high rates of many mental health diagnoses, but often delay or avoid mental health care due to prior poor experiences or fear of discrimination. This indicates a need for supportive and effective transgender mental health care. We aim to identify the features of such care through a systemized narrative review of the literature.
Methods
Comprehensive searches of six databases were run using index terms and keywords. Searches were limited to English language studies published from 2000 to August 2019 and followed SANRA criteria. Identified records underwent title/abstract screen for relevance and then were assessed for inclusion using predetermined criteria. Included articles were tabulated and their results synthesized with attention to areas of thematic overlap.
Results
The search returned 1928 unique articles with 35 meeting inclusion criteria and a further one article identified on bibliography screen. Articles reported a range of experiences and preferences across mental health care settings, with common themes emerging. Several reported on retention in care, satisfaction with care, helpfulness of care, or change in symptom burden after receiving care.
Discussion
We discuss preliminary features of supportive transgender mental health care, recommendations for clinical practice, gaps in the literature, and areas for future research.
Researchers and clinicians are increasingly recognizing the importance of attending to dimensions of diversity in clinical work given the changing demographics of the USA. There exists a growing evidence base demonstrating the effectiveness of cognitive behavioral therapy (CBT) with racial and ethnic minority youth, and there is some work examining CBT with sexual and gender minority youth. In this chapter, we review some of this literature and present a case example with a Latinx transgender girl and her parents. We focus on the importance of developing a strong working alliance within a CBT framework and use the literature on cultural competency to ground our recommendations.
In this chapter, we discuss the role of psychotherapy in the treatment of adolescents holding diverse gender identities. We begin by reviewing the process of exploring gender identity and expression in transgender and gender-diverse (TGD) youth presenting to psychotherapy. We discuss the assessment for psychosocial stressors and sources of support. Readers will develop an understanding of mental health concerns that may stem from psychosocial stressors, including minority stress. We include recommendations for treatment planning and intervention in providing care for TGD youth. This includes a review of modalities, case management, gender-affirming practices, and the process of referring for feminizing/masculinizing medical and surgical procedures.
The transgender and gender non-conforming (TGNC) community continues to represent a notably marginalized population exposed to pervasive discrimination, microaggressions, and victimization. Congruent with Minority Stress Model, TGNC individuals persistently experience barriers to well-being in contemporary society; however, research uncovering resilience-based pathways to health among this population is sparse. This study aimed to explore the impact and interaction between internalized transphobic stigma and a potential buffer against minority stress, social connectedness, on the self-esteem of TGNC identified adults. Data were collected from 65 TGNC identified adults during a national transgender conference. Multiple regression analysis reveal that self-esteem is negatively impacted by internalized transphobia and positively impacted by social connectedness. Social connectedness did not significantly moderate the relationship between internalized transphobia and self-esteem. Micro and macro interventions aimed at increasing social connectedness and decreasing internalized transphobic stigma may be paramount for enhancing resiliency and well-being among the TGNC community.
The primary aim of the present study is to extend discussions of navigating an emerging transgender or gender nonconforming (TGNC) identity during youth and young adulthood in a society in which TGNC identities remain invisible and marginalized. Participants include 13 racially/ethnically diverse TGNC young adults ages 18–29 in the United States. Constructivist grounded theory methods were used to collect, analyze, and interpret data. Navigating a TGNC Identity in the Dark emerged as a journey from initial recognition of an existing, but unidentifiable, difference toward awareness and acceptance of a TGNC identity. Analyses revealed six themes associated with navigating identity: Moving from Uncertainty to Knowing, Recognizing Self in Others, Finding Me, Explaining Work, Struggling for Authenticity, and Evolving Self-Acceptance. Narratives highlighted the complex journeys toward authenticity that included pervasive oppression. Findings from my study can be used to inform clinical work aimed at supporting TGNC individuals as they recognize and make meaning of their TGNC identities. Moreover, findings underscore the importance of increasing the level of visibility and affirmation of a range of TGNC identities and experiences in dominant institutions (e.g., media, schools, health care) in the lives of youth as a way to facilitate self-understanding and acceptance at earlier ages and with fewer obstacles.
Transgender individuals have frequent experiences of trauma, often related to societal prejudice, hatred, or intolerance, because of their gender identity (Mizock & Lewis, 2008; Richmond, Burnes, & Carroll, 2012; Singh & Burnes, 2010). Therefore, there is a critical need for clinicians to focus on specialized, trauma-focused practice and research with transgender individuals. Researchers designed and implemented an exploratory investigation of the trauma experiences of transgender individuals described utilizing constructivist grounded theory (Charmaz, 2000). Fourteen transgender-identified diverse participants completed a semistructured interview about their experiences and perceptions of safety, wellness, and identity. Five intersecting themes and a corresponding theoretical model for participants in this study were identified in the data. Implications for research, practice, training, and advocacy, as well as the study’s limitations, are discussed.
This study examined transgender community belongingness as a mediator between strength of transgender identity and well-being. A total of 571 transgender adults (n = 209 transgender women, n = 217 transgender men, and n = 145 nonbinary-identified individuals) completed an online survey assessing transgender community belongingness, strength of transgender identity (operationalized as the extent to which a person self-categorizes their identity as transgender and the extent to which they believe their gender transition to be important to their self-definition), and well-being (using measures of self-esteem, satisfaction with life, and psychological well-being). Structural equation modeling was used to analyze the data. When controlling for participants' income, age, and stage of gender transition, transgender community belongingness fully mediated the relationship between strength of transgender identity and well-being. Strength of transgender identity was indirectly and positively related to well-being through community belongingness, but was not directly related to well-being. Results suggest that transgender community belongingness is an important construct in the mental health of transgender people. The strength of a person's transgender identity also appears to be a significant construct in transgender people's well-being via its relationship with transgender community belongingness. Implications of the findings are discussed. (PsycINFO Database Record
In this article the author reviews research evidence on the prevalence of mental disorders in lesbians, gay men, and bisexuals (LGBs) and shows, using meta-analyses, that LGBs have a higher prevalence of mental disorders than heterosexuals. The author offers a conceptual framework for understanding this excess in prevalence of disorder in terms of minority stress— explaining that stigma, prejudice, and discrimination create a hostile and stressful social environment that causes mental health problems. The model describes stress processes, including the experience of prejudice events, expectations of rejection, hiding and concealing, internalized homophobia, and ameliorative coping processes. This conceptual framework is the basis for the review of research evidence, suggestions for future research directions, and exploration of public policy implications.
Taken together, these papers offer evidence supporting continued research into SE. The papers on disaster response in particular, although not definitive, are strongly suggestive of the efficacy of SE as an early, low-dose, culturally flexible intervention for victims and providers in the context of natural disasters.
Conflict of interest statement
Peter Payne is an SE practitioner (SEP) who derives income from his practice. Peter A. Levine declares that teaching, royalties and consulting related to SE are a source of income. Mardi A. Crane-Godreau is an SEP and non-paid member of the Board of Directors of the Somatic Experiencing Trauma Institute™.
Research in various populations has shown that, starting early in childhood, individuals often demonstrate resilience in the face of stress and adversity. Against the experience of minority stress, LGBT people mount coping responses and most survive and even thrive despite stress. But research on resilience in LGBT populations has lagged. In this commentary, I address 2 broad issues that I have found wanting of special exploration in LGBT research on resilience: First, I note that resilience, like coping, is inherently related to minority stress in that it is an element of the stress model. Understanding resilience as a partner in the stress to illness causal chain is essential for LGBT health research. Second, I explore individual- versus community-based resilience in the context of minority stress. Although individual and community resilience should be seen as part of a continuum of resilience, it is important to recognize the significance of community resilience in the context of minority stress.
For those identifying as transgender or gender nonconforming (TGNC), the support of others can be instrumental in mitigating the challenges associated with cross-gender transition and identification. Social support and connectedness to the TGNC community can positively impact psychological well-being, facilitate resilience, and buffer against external stigmatization, prejudice, and discrimination (Frost & Meyer, 2012; Hendricks & Testa, 2012). The present study seeks to improve understanding of relationships among general social support (GSS), trans community connectedness (TCC), depressive symptoms, and anxiety symptoms. The inclusion of 2 forms of social support allows for greater examination of the differential impact of perceived general support (i.e., from both cisgender and TGNC friends and family members) and TGNC-specific social support (i.e., feeling connected to other TGNC people). To honor the diversity within the TGNC community, the impact of social support was examined among TGNC participants differentiated by gender identity, ethnicity, and living environment. As part of the Internet-based Trans Health Survey, standardized measures of depression, generalized anxiety, and social support were administered to 865 TGNC adults. For both trans male spectrum (TMS) and trans female spectrum (TFS) participants, general social support was significantly negatively associated with symptoms of anxiety and depression. However, the negative correlation between trans community connectedness and mental health symptoms was significant only for TFS participants. Variations in perceived TCC among ethnicity and living environment groups--distinguished by gender identity--are also explored. Finally, targets for future minority stress and social support research with the TGNC population are discussed. Language: en
When empirically supported treatments (ESTs) are effectively adapted for use with minority populations, they may be more efficacious. As such, there is a need to adapt existing ESTs for use with diverse sexual and gender minority youth (SGMY). The unique bias-based challenges faced by SGMY require the integration of affirmative practices into ESTs to effectively address the specific needs of this underserved group of youth. The primary purpose of the authors in this article is to present a clearly articulated stakeholder driven model for developing an affirmative adapted version of cognitive behavioral therapy (CBT) for use with diverse SGMY. The authors' approach to adaptation follows the "adapt and evaluate" framework for enhancing cultural congruence of interventions for minority groups. A community based participatory research approach, consistent with a stakeholder driven process, is utilized to develop the intervention from the ground up through the voices of the target community. Researchers conducted 3 focus groups with culturally diverse SGMY to explore salient aspects of youths' cultural and SGM identities in order to inform the intervention and ensure its applicability to a wide range of SGMY. Focus group data is analyzed and integrated into an existing group-based CBT intervention. The following themes emerge as critical to affirmative work with diverse SGMY: (1) the interplay between cultural norms, gender norms, sexual orientation, and gender identity; (2) the complex role of religious community within the lives of SGMY; and (3) consideration of extended family and cultural community as youth navigate their SGM identities.
Non-suicidal self-injury (NSSI) has been increasing in clinical as well as nonclinical populations in recent years. There are few published reports examining lifetime occurrence of this behavior in transgender and gender nonconforming (TGNC) people. An online survey was conducted with self-identified TGNC adults (n = 773) in the United States over the course of 6 months in 2009. The mean age for the sample was 40.4 years (SD = 13.9). Most participants identified on the trans masculine spectrum (female-to-male or FTM; 52.0%), 33.9% identified on the trans feminine spectrum (male-to-female or MTF), and 8.0% identified as genderqueer. Participants completed the Body Investment Scale, the Depression, Anxiety, and Stress Scales, and the Inventory of Statements about Self-Injury. Results indicated that 41.9% of participants had a lifetime history of NSSI. Scores on the subscales of Protection and Feeling from the Body Investment Scale were found to be statistically predictive of NSSI. These findings shed new light on the lifetime prevalence of NSSI in this online TGNC respondent sample. Practice implications are discussed for mental health professionals who work with TGNC clients in addition to research recommendations.
Homophobic bullying is pervasive and deleterious, and a source of extensive health and mental health disparities affecting sexual and gender minority youth (SGMY). Investigations conducted over the past two decades across the social ecology of SGMY indicate individual (e.g., gender), microsystem (e.g., schools), and exosystem level (e.g., community norms) factors associated with homophobic bullying. Emerging evidence at the macrosystem level demonstrates the powerful influence of laws, policies, and ideologies on the population health of sexual minority adults. Based on social ecological theory and emerging evidence at the macrosystem level, we advance a conceptualization of the religious social ecology of homophobic bullying and articulate the construct of conversion bullying, a form of bias-based bullying that may be unique to SGMY. Conversion bullying is manifested in the invocation of religious rhetoric and rationalizations in repeated acts of peer aggression against SGMY that cause harm, based on the premise that same-sex attractions and behaviors are immoral or unnatural and with implicit or explicit communication that one should change one's sexuality to conform to heteronormative ideals. We describe implications of conversion bullying for social work practice, education, social policy, and research.
Transgender individuals report pervasive discrimination, microaggressions, and victimization across the life span, contributing to disparate rates of suicide, anxiety, and depression. Clinical interventions must be empirically supported and affirming, competently and sensitively attending to the effect of transphobic discrimination on the lives and experiences of transgender people. Transgender affirmative clinical practice acknowledges and counters the oppressive contexts in which transgender clients often experience health and mental health care. The primary aim of this article is to introduce a transgender-affirming adaptation of a cognitive behavior therapy intervention (TA-CBT) for use with transgender individuals suffering from depression, anxiety, and/or suicidality. Clinical considerations such as the historical context of transgender issues in mental health care, the minority stress framework, current mental health disparities, and resilience will be explored. Transgender-affirming practice applications focused on psychoeducation, modifying problematic thinking styles, enhancing social support, and preventing suicidality will be provided.
Background. Cognitive behavioural therapy (CBT) is increasingly being delivered in primary care, in a variety of delivery formats such as guided self-help CBT, telephone-based CBT, computerized CBT and standard, one-to-one CBT. However, the vast majority of research has focused on CBT in specialized services, and no previous meta-analysis has examined CBT’s effectiveness across delivery formats in primary care.
Objective. To determine the effectiveness of multi-modal CBT (i.e. CBT across delivery formats) for symptoms of anxiety and depression, in primary care.
Methods. A meta-analysis of CBT-focused RCTs, for symptoms of anxiety or depression, in primary care. The authors searched four databases. To be included, RCTs had to be set in primary care or have primary care participants.
Results. Twenty-nine RCTs were included in three separate meta-analyses. Results showed multi-modal CBT was more effective than no primary care treatment (d =0.59), and primary care treatment-as-usual (TAU) (d = 0.48) for anxiety and depression symptoms. Moreover, multi-modal CBT in addition to primary care TAU was shown to be more effective than primary care TAU for depression symptoms (no comparisons of this kind were available for anxiety) (d = 0.37).
Conclusions. The results from conducted meta-analyses indicate that multi-modal CBT is effective for anxiety and depression symptoms in primary care. Furthermore, based on CBT’s economic viability, increasing the provision of CBT in primary care seems justified. Future research should examine if varying levels of qualification among primary care CBT practitioners impacts on the effectiveness of CBT in this setting
This article presents empirical research findings from a subsample of 290 transgender participants in the Virginia Transgender Health Initiative Survey (THIS) who reported whether or not they had experienced hostility or insensitivity related to their gender identity or expression during high school, termed in-school gender-based victimization (GBV). The purpose of this study was to assess the impact of in-school GBV on rates of suicide attempts among transgender people. Of the 290 respondents, 44.8% reported they had experienced in-school GBV, and 28.5% reported a history of suicide attempt. Among those who had attempted, 32.5% reported having made one attempt, 28.6% reported a history of two attempts, and 39.0% reported having made three or more attempts. Participants who reported experiencing GBV were approximately four times more likely to have attempted suicide than those who did not. Among the subgroups of 147 trans women and 81 trans men, GBV was associated both with history of suicide attempt, and with a higher number of suicide attempts over the life span. Implications for policy and clinical interventions are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
In the last few years, transgender and gender nonconforming people have become more visible in our society, which has sparked a marked increase in awareness, interest, and attention among psychologists. Questions have emerged about the extent to which psychologists are able to work competently with this population. This article presents a framework for understanding key clinical issues that psychologists who work with transgender and gender nonconforming individuals will likely encounter in their clinical work. This article does not address the knowledge and skills required to provide services related to gender transition, but rather to provide other psychological services that these clients may need, in light of the high levels of gender-related victimization and discrimination to which they are exposed. An adaptation of the Minority Stress Model (Meyer, 2003) is presented and translated to incorporate the unique experiences encountered by transgender and gender nonconforming individuals. In particular, we examine adverse experiences that are closely related to gender identity and expression, resulting expectations for future victimization or rejection, and internalized transphobia. The impact of Minority Stress Model factors on suicide attempts is presented as a detailed example. Mechanisms by which transgender and gender nonconforming persons develop resilience to the negative psychological effects of these adverse experiences are also discussed. Recommendations for clinicians are then made to assist psychologists in developing competence in working with this population. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Transgender individuals encounter stigma related to nonconforming gender identity, contributing to
elevated symptoms of depression, anxiety, and suicidality. Stigma toward transgender individuals (i.e.,
transphobia) poses significant barriers to employment and other areas of functioning. Transgender
individuals with a history of mental health concerns may encounter double stigma. The present 2-part
study was conducted to investigate experiences of double stigma, internalized stigma, and coping
strategies for dealing with transphobia. In Study 1, quantitative findings with 55 transgender participants
indicated that employed participants reported higher levels of stigma (both internalized and external).
Higher levels of coping with stigma were associated with lower levels of stigma (both internalized and
external). Higher levels of coping were reported by participants utilizing psychiatric medication, with
lower levels of coping with mental health stigma in particular found among those receiving outpatient
mental health services. In Study 2, a grounded theory analysis was conducted with 45 of these
participants to identify coping strategies that transgender individuals use to deal with transphobia. Coping
strategies were categorized into individual factors (gender normative coping, self-affirmative coping,
emotional regulation coping, cognitive reframe coping); interpersonal factors (social-relational coping,
preventative-preparative coping, disengagement coping); and systemic factors (resource access coping,
spiritual and religious coping, and political empowerment coping). Findings of Study 2 also revealed the
presence of disclosure strategies—decisions to reveal or conceal one’s transgender identity, and
anticipatory stigma—expecting and preparing for prejudice and discrimination. Results suggest the need
for interventions for transgender individuals to enhance coping with stigma and reduce internalized
stigma.
Objective:
People with substance use disorders who present with suicidal behavior are at high risk of subsequent suicide. There are few effective treatments specifically tailored for this population that diminish this risk. We aimed to assess the impact of an opportunistic cognitive behavioral intervention package (OCB) among adult outpatients with a substance use and comorbid suicide risk.
Method:
A randomized controlled trial was conducted across 2 sites in which 185 patients presenting with suicide risk and concurrent substance use received either OCB (8 sessions plus group therapy) or treatment as usual (TAU) over a 6-month period. Primary outcomes were suicidal behavior (suicide attempts, suicidal intent and presence of suicide ideation) and level of drug and alcohol consumption. Secondary outcomes were changes in psychological measures of suicide ideation, depression, anxiety, and self-efficacy.
Results:
There were no completed suicides, and only 2 participants reported suicide attempts at follow-up. Suicide ideation, alcohol consumption, and cannabis use fell over time but no significant Treatment × Time differences were found. There were also no differences between OCB and TAU over time on psychological measures of depression, anxiety, or self-efficacy. Suicide ideation at 6-month follow-up was predicted by cannabis use and higher scores on the Brief Psychiatric Rating Scale at baseline.
Conclusions:
The opportunistic cognitive behavioral intervention package did not appear to be beneficial in reducing suicide ideation, drug and alcohol consumption, or depression relative to treatment as usual.
Internet-based new media is increasingly utilized by lesbian, gay, bisexual, transgender and queer [LGBTQ] youth, yet little is known about the ways in which it influences their identity development. Employing grounded theory, this study explores the influence of online media on the identity development and coming out processes (n = 19) of LGBTQ youth. Results indicate that new media enabled participants to access resources, explore identity, find likeness, and digitally engage in coming out. Participants also discussed the expansion of these newly developed identities into their offline lives. Practice implications are addressed.
Transgender clients frequently experience multiple types of violence (Mizock & Lewis, 2008), including interpersonal (violence that occurs between, at least, two people), self-directed (violence that is self-inflicted), and collective (violence that is inflicted by larger groups of people/institutions; Krug et al., 2002). Transgender clients who experience any of these types of violence are at a higher risk for developing psychiatric symptoms that may require the attention of a mental health care provider (Mizock & Lewis, 2008). Thus, it is crucial that clinicians understand how transgender clients respond to such violence and how these reactions relate to the clinical needs of transgender clients (Lev, 2004). In this article, we will summarize and cluster the types of violence that have been documented in the transgender literature. We will then highlight PTSD and complex PTSD as conceptual frameworks for working with transgender clients. Furthermore, we will examine how the binary notion of gender ignores ways in which race, class, and other identities interact with gender and make recommendations for how clinicians can affirm multiple identities as a way to minimize psychological distress following a traumatic event (Roen, 2006). We will also highlight clinical guidelines and provide feminist and multicultural recommendations for working with transgender clients.
The frequency of potentially traumatic events (PTEs) and associated symptoms were examined in a cross-sectional study of 97 transgender participants who had been classified as male at birth. A total of 98% reported at least one PTE and 91% endorsed multiple events. Of those with PTE exposures, 42% reported that at least one event was transgender bias-related. Among those with PTEs, 17.8% endorsed clinically significant symptoms of PTSD and 64% reported clinically significant depressive symptoms. The percentage of transgender individuals in this sample reporting clinically significant symptoms was higher than in trauma-exposed samples of men in the general population, but roughly similar to rates of female trauma survivors. Amount of time spent dressed consistent with gender identity was associated with increased risk for PTE exposure and was positively associated with mental health symptoms. No differences in symptoms were observed when comparing those with and without transgender bias-related PTEs. Overall, transgender individuals endorsed high prevalence of PTE exposure along with elevated PTSD and depressive symptoms, when compared to other traumatized populations.
This qualitative study explored the resilience of 13 transgender youth of color in the southeastern region of the U.S. The definition of resilience framing this study was a participant’s ability to “bounce back” from challenging experiences as transgender youth of color. Using a phenomenological research tradition and a feminist, intersectionality (intercategorical) theoretical framework, the research question guiding the study was: “What are the daily lived experiences of resilience transgender youth of color describe as they negotiate intersections of transprejudice and racism?” The researchers’ individuated findings included five major domains of the essence of participants’ daily lived experiences of resilience despite experiencing racism and transprejudice: (1) evolving, simultaneous self-definition of racial/ethnic and gender identities, (2) being aware of adultism experiences, (3) self-advocacy in educational systems, (4) finding one’s place in the LGBTQQ (lesbian, gay, bisexual, transgender, queer, questioning) youth community, and (5) use of social media to affirm one’s identities as a transgender youth of color. Implications for practice, research, and advocacy, in addition to the study’s limitations are discussed.
Although transgender clients seek services in a number of settings in which social workers practice, there is a dearth of scholarly literature available to guide effective clinical practice with this population. When transgender issues are included in the practice literature, the trend has been to consolidate the needs of transgender clients with those of the larger lesbian, gay, and bisexual community or to simply focus on increasing the comfort level of clinicians working with this population. This is concerning because transgender individuals represent a vulnerable subgroup of clients with unique and specific treatment needs related to the transition experience. Social workers play a critical role; they may serve transgender clients and their families in many ways: as advocate, educator, diagnostician, and individual, couples or family therapist. The purpose of this article is to identify several key components of trans-specific clinical practice and the role of social workers in supporting and facilitating client transition. Specifically, the authors will discuss: (a) relevant definitions and terminology, (b) emerging issues related to depathologizing the needs and experiences of transgender individuals, (c) the critical elements of trans-specific clinical assessment, and (d) clinical advocacy associated with the medical legal and social aspects of the transition process. Specific recommendations for trans-affirmative social work practice will be offered.
Sexual minority youth (SMY) are at high risk for negative mental health outcomes such as depression, anxiety, substance abuse, and suicidality. However, there has been a disconnect between clinical social work practice and research with SMY, resulting in a lack of rigorous research that demonstrates the use of effective interventions. While cognitive behavioral therapy (CBT) has long been established as a best practice option for the general adolescent population suffering from mental health problems, knowledge about the use of CBT with SMY lags far behind. Thus, the purpose of this article is to present a clearly defined adaptation of CBT for SMY that integrates gay affirmative practices for youth (e.g., coming out, stigma and discrimination, the role of social support and community). Specifically, the authors: (a) discuss the impact of minority stress on SMY; (b) highlight the specific components of CBT that represent a good fit for SMY and also address the criticisms of using such an approach; (c) consider the importance of using gay affirmative practices with SMY; and (d) offer recommendations for incorporating gay affirmative practices into traditional CBT models to better meet the needs of SMY.
Family support is protective against health risks in sexual minority individuals. However, few studies have focused specifically on transgender youth, who often experience rejection, marginalization, and victimization that place them at risk for poor mental health. This study investigated the relationships among parental support, quality of life, and depression in transgender adolescents.
A total of 66 transgender youth presenting for care at Children's Hospital Los Angeles completed a survey assessing parental support (defined as help, advice, and confidante support), quality of life, and depression. Regression analyses assessed the associations between parental support and mental health outcomes.
Parental support was significantly associated with higher life satisfaction, lower perceived burden of being transgender, and fewer depressive symptoms.
Parental support is associated with higher quality of life and is protective against depression in transgender adolescents. Interventions that promote parental support may significantly affect the mental health of transgender youth.
Transgender people seek social services for a variety of reasons. This literature review highlights needs assessments and social science research articles (N = 30) from the last 16 years that demonstrate the many ways in which social services are further revictimizing transgender people. Studies indicate that transgender people often encounter ignorance, hostility, and transphobic environments while attempting to access social services, and these environments can dissuade transgender people from gaining needed care. Suggestions are made to address these inequalities and include simple measures that social service agencies can begin with to make their services more transinclusive. Future research should address the bias in social services more directly and also develop a clear plan of action and best practices to help agencies remove discrimination from social service settings.
This cross-sectional study utilized data gathered from 350 lesbian, gay, and bisexual (LGB) youth, and examined the relationship between significant life experiences and posttraumatic stress symptoms (PSS), with an ultimate goal of analyzing contribution of sexual orientation victimization (SOV) to PSS among LGB youth. Results of bivariate analyses indicate that verbal and physical sexual orientation victimization, childhood gender atypicality, internalized homophobia, and stressful life events unrelated to sexual orientation were all individually related to PSS. Multivariate analysis showed that verbal and physical sexual orientation victimization explained a significant portion of variance, over and above the study's other variables. Internalized homophobia, stressful life events, and verbal sexual orientation victimization were found to be the most significant predictors of PSS among LGB youth.
Objectives:
We assessed the association between minority stress, mental health, and potential ameliorating factors in a large, community-based, geographically diverse sample of the US transgender population.
Methods:
In 2003, we recruited through the Internet a sample of 1093 male-to-female and female-to-male transgender persons, stratified by gender. Participants completed an online survey that included standardized measures of mental health. Guided by the minority stress model, we evaluated associations between stigma and mental health and tested whether indicators of resilience (family support, peer support, identity pride) moderated these associations.
Results:
Respondents had a high prevalence of clinical depression (44.1%), anxiety (33.2%), and somatization (27.5%). Social stigma was positively associated with psychological distress. Peer support (from other transgender people) moderated this relationship. We found few differences by gender identity.
Conclusions:
Our findings support the minority stress model. Prevention needs to confront social structures, norms, and attitudes that produce minority stress for gender-variant people; enhance peer support; and improve access to mental health and social services that affirm transgender identity and promote resilience.
Objective:
The purpose of the current study was to examine facilitative and avoidant coping as mediators between distress and transition status, social support, and loss.
Method:
A total of 351 transgender individuals (n = 226 transgender women and n = 125 transgender men) participated in this study. Participants completed measures on transgender identity, family history of mental health concerns, perceptions of loss, coping, depression, and anxiety.
Results:
The rates of depressive symptoms (51.4% for transgender women; 48.3% for transgender men) and anxiety (40.4% for transgender women; 47.5% for transgender men) within the current study far surpass the rates of those for the general population. Structural equation modeling (SEM) was used to analyze the data-2 separate models were hypothesized, based on reports of anxiety or depression. The SEM results suggest that the processes for transgender women and transgender men are primarily similar for depression and anxiety; avoidant coping served as a mediator between transition status and both distress variables. Social support was directly related to distress variables, as well as indirectly related through avoidant coping.
Conclusion:
Results suggest the need for practitioners to focus on interventions that reduce avoidant coping strategies, while simultaneously increasing social support, in order to improve mental health for transgender individuals. Individuals who are in the beginning stages of their transition will use different coping strategies than those who are in later stages; interventions should be adjusted on the basis of the transition status of transgender clients.
This large-scale cross-sectional study compared posttraumatic stress disorder (PTSD) prevalence among White, Black, and Latino lesbian, gay and bisexual individuals (LGBs; n = 382) and compared them with heterosexual individuals (n = 126). Building on previous research, we relaxed the criteria of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM–IV; American Psychiatric Association, 1994), allowing non-Criterion A1 events such as ending a relationship, unemployment, homelessness, and separation from parents to qualify, and we assessed differences in PTSD prevalence between standard DSM–IV criteria and the relaxed criteria. Findings revealed that participants reporting a non-Criterion A1 event were more likely than those reporting a Criterion A1 event to have symptoms diagnosable as PTSD. There was no significant difference in either DSM–IV or relaxed Criterion A1 PTSD prevalence between lesbian and gay, and heterosexual individuals or between bisexual and heterosexual individuals. Compared with White LGBs, Black and Latino LGBs had higher prevalence of PTSD with the relaxed Criterion A1 definition, but this was statistically significant only for Latinos. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
We examined whether lifetime risk of posttraumatic stress disorder (PTSD) was elevated in sexual minority versus heterosexual youths, whether childhood abuse accounted for disparities in PTSD, and whether childhood gender nonconformity explained sexual-orientation disparities in abuse and subsequent PTSD.
We used data from a population-based study (n=9369, mean age=22.7 years) to estimate risk ratios for PTSD. We calculated the percentage of PTSD disparities by sexual orientation accounted for by childhood abuse and gender nonconformity, and the percentage of abuse disparities by sexual orientation accounted for by gender nonconformity.
Sexual minorities had between 1.6 and 3.9 times greater risk of probable PTSD than heterosexuals. Child abuse victimization disparities accounted for one third to one half of PTSD disparities by sexual orientation. Higher prevalence of gender nonconformity before age 11 years partly accounted for higher prevalence of abuse exposure before age 11 years and PTSD by early adulthood in sexual minorities (range=5.2%-33.2%).
Clinicians, teachers, and others who work with youths should consider abuse prevention and treatment measures for gender-nonconforming children and sexual minority youths.
We determined racial/ethnic differences in social support and exposure to violence and transphobia, and explored correlates of depression among male-to-female transgender women with a history of sex work (THSW).
A total of 573 THSW who worked or resided in San Francisco or Oakland, California, were recruited through street outreach and referrals and completed individual interviews using a structured questionnaire.
More than half of Latina and White participants were depressed on the basis of Center For Epidemiologic Studies Depression Scale scores. About three quarters of White participants reported ever having suicidal ideation, of whom 64% reported suicide attempts. Half of the participants reported being physically assaulted, and 38% reported being raped or sexually assaulted before age 18 years. White and African American participants reported transphobia experiences more frequently than did others. Social support, transphobia, suicidal ideation, and levels of income and education were significantly and independently correlated with depression.
For THSW, psychological vulnerability must be addressed in counseling, support groups, and health promotion programs specifically tailored to race/ethnicity.
This pilot study sought to evaluate the feasibility and effectiveness of a brief, eight module affirmative cognitive behavioral coping skills group intervention (AFFIRM) with sexual and gender minority youth (SGMY) developed through community partnerships. A diverse sample of SGMY (n = 30) participated in the AFFIRM pilot and completed reliable measures of depression, reflective coping, and stress appraisal at three time points. Over the study duration, significant reductions were found in depression and appraising stress as a threat. Significant increases were found in reflective coping and perceiving stress as a challenge. Participants found the intervention to be valuable and reported high levels of acceptability and skills acquisition. These promising findings suggest that AFFIRM has potential effectiveness as a community-based intervention for SGMY. Implications for practice and research are provided.
Research examining risk and resilience among transgender individuals suggests that connection to a transgender community may be protective. Utilizing archival survey data of 3,087 adult transgender participants collected in 2005–06, this study further evaluated how awareness and engagement with other transgender people influences risk and resilience during early gender identity development. As hypothesized, among male-to-female and female-to-male respondents, both prior awareness and prior engagement with other transgender people were independently related to less fearfulness, less suicidality, and more comfort. These relationships were not significant among male-to-different-gender or female-to-different-gender participants. Implications of these findings are discussed.
This chapter reviews the psychological literature on attitudes about homosexuality. First, it provides a brief overview of the ways that attitudes about sexual orientation have been studied historically. Then, it reviews current trends in research on attitudes about sexual orientation. Finally, it provides a framework for understanding the complexities of contemporary attitudes about sexual orientation and how this framework might help continue to shape research in this area.
