Article

An Ecological Approach to Therapy With Gender Minorities

Article

An Ecological Approach to Therapy With Gender Minorities

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Abstract

This special series includes four articles that review important considerations for clinical work with gender minorities, including youth and young adults, individuals who are nonbinary, transgender individuals in inpatient or residential care, and transgender individuals recovering from trauma. These articles provide important insights and concrete suggestions for how to enact affirming practice, spanning across macro, mezzo, and micro levels. Ultimately, a multilevel approach to working with transgender and gender diverse individuals is essential to addressing health disparities in this population, as the work of an affirming provider goes beyond the therapy hour and the therapy office or treatment unit. In this commentary, I review the major themes from these contributions, provide a perspective on how they fit within the existing literature, and provide an overview of pressing future directions in gender minority research.

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... Concurrent with increasing attention to intersectional marginalization, research on health disparities specific to TNB people has expanded to include consideration of structural and systemic factors. Minority-stress theory provided an initial framing in its articulation of stressors as internal and external; subsequent scholarship has further placed anti-trans stigma within a socioecological model to describe how stigma manifests at all levels, from internal to structural and systemic 44,51,52 . Many of the internal stressors outlined by minority-stress theory -such as internalized attitudes, identity non-disclosure or concealment, and stigma avoidance -can be described as individual-level forms of anti-trans stigma 52 . ...
... An aversion or hostility to, disdain for, or other negative attitudes and beliefs about transgender people. Nature reviews | Psychology 0123456789();: practices within psychology, the erasure of non-binary individuals in discourse related to trans health, and the tendency to limit dissemination of new knowledge to academic outlets (for example, peer-reviewed journals and academic conferences) 51 . ...
... These major theories are readily integrated and should be considered additive ( fig. 1). The psychological mediation framework 60 identifies general psychological processes at the individual level, minority-stress theory [27][28][29]75 proposes specific individual (internal or proximal) and interpersonal (external or distal) stressors as driving adverse mental health outcomes, complemented by further structural and systemic factors 51 . Critically, interpersonal and individual-level stigma occurs within the larger context of the structures and systems in which an individual exists; this larger context in turn shapes the specific ways in which stigma Minority stressors for transgender and nonbinary (TNB) people within a socioecological framework, with internal (proximal) stressors occurring at the individual level, and external (distal) stressors occurring at the interpersonal as well as structural and systemic levels. ...
Article
Transgender (or trans) is an umbrella term for individuals who experience their gender differently from what is associated with the sex they were assigned at birth. Individuals who are nonbinary experience their gender outside binary conceptions of gender. Although research has predominantly focused on negative mental health outcomes for transgender and non-binary (TNB) individuals, an emergent literature has begun to explore protective and health-promoting factors and dimensions of psychological well-being. In this Review, we discuss the sociocultural context for TNB people, beginning with a brief history of TNB identity before highlighting frameworks for understanding the higher prevalence of certain mental health concerns among TNB individuals. Next, we summarize the predictive factors associated with higher rates of depression, anxiety, suicidality, trauma-related concerns, disordered eating behaviours and substance use. We also review TNB coping, resilience and resistance to anti-trans stigma, as well as psychological well-being, flourishing and gender euphoria. Tying these topics together, we discuss affirming interventions for reducing mental health disparities and promoting psychological health in TNB individuals and communities. We conclude by discussing future research directions. Individuals who are transgender or nonbinary experience a higher prevalence of certain mental health concerns, including depression, anxiety and disordered eating behaviours. In this Review, Tebbe and Budge discuss these disparities along with factors that protect these individuals from negative outcomes and promote well-being.
... This may reflect a knowledge gap for providers related to the experiences of non-binary people. Prior literature indicates that providers may have outdated understandings of gender that result in microaggressions, particularly for non-binary and genderqueer clients (Matsuno, 2019;Puckett, 2019;Puckett et al., 2018). ...
Article
Objective: Transgender and gender diverse (TGD) people face various challenges when seeking therapy. Given this, we wanted to understand more about TGD people's perceptions of providers and how these compare to researcher ratings of providers on metrics of affirming practice. Method: The sample included 158 TGD adults (Mage = 33.06); 57.6% were in therapy. Participants completed measures about mental health, resilience, and therapy. We systematically coded provider websites and intake forms. Results: Participants in therapy were older, had higher depression, and lower resilience than participants not in therapy. Non-binary/genderqueer participants rated providers as less knowledgeable compared to trans feminine participants. Overall, participants appeared satisfied (71.4% extremely satisfied) and viewed providers as at least moderately knowledgeable (89.1%). Provider coding revealed variation across the markers of affirmation; 66.04% identified a TGD-specialty and only 26.42% shared provider pronouns. Higher frequency of inclusivity (via coding) was related to higher ratings of provider knowledge and more of a focus on gender, however, there was not a significant association with satisfaction. Conclusions: Providers who engaged in more affirming practices were more knowledgeable compared to those who engaged in fewer affirming practices. This may influence the content of therapy and whether clients feel comfortable discussing gender.
... Las minorías de género presentan particularidades únicas en la intervención psicológica (APA, 2015;Ellis et al., 2015). Todavía predomina un discurso patologizador en el ámbito sanitario y muy pocos estudios han podido examinar las necesidades terapéuticas específicas de esta población (Puckett, 2019). Por otro lado, muchas personas que viven con el VIH siguen necesitando apoyo para hacer frente a los factores de estrés psicosocial y para lidiar con una enfermedad crónica y estigmatizante (El-Sadr et al., 2019). ...
Article
Desde la eliminación de la homosexualidad como trastorno mental y con la proliferación de la investigación sobre el estigma y sus resultados en la salud mental, se han publicado numerosas investigaciones que tienen como objetivo estudiar la respuesta al tratamiento psicológico de las minorías sexuales y determinar si es necesario llevar a cabo adaptaciones del mismo como se hace con otros grupos minoritarios. Esta revisión reúne la investigación disponible para analizar si las minorías sexuales responden de forma diferencial a los tratamientos habituales y si las intervenciones adaptadas o afirmativas ofrecen mejores resultados que el tratamiento habitual.
... Understandings of marginalization stress need to be adapted to ensure a better fit to the lived experiences of TGD people Puckett, 2019;Puckett et al., 2018;Rood et al., 2017;Testa et al., 2015). For instance, there are unique forms of enacted stigma that TGD people are faced with, such as denial of access to gendered spaces, including restrooms (Testa et al., 2015), or misgendering (DuBois, 2012;McLemore, 2018). ...
Article
Abstract Background Transgender and gender diverse (TGD) people encounter a range of minority stressors (e.g., harassment, victimization, misgendering) that impact many areas of life. Much of the empirical literature on gender minority stress has utilized frameworks that were developed with a focus on sexual orientation and were often limited to cisgender sexual minorities (lesbian, gay, bisexual, and other non-heterosexual individuals), leaving questions about how well existing models fit the experiences of TGD people. Aims To expand understandings of gender minority stress, we conducted a daily diary study where participants detailed the types of stressors they encountered on a daily basis for 56 days. Methods There were 181 TGD participants recruited into the study (M age = 25.6 years; SD = 5.6), with 167 retained in the daily surveys from which these analyses were conducted. Results The written responses revealed a variety of stressors, some of which are novel to the literature. Many participants reported instances of non-affirmation, such as misgendering, as well as vicarious stress when learning of oppressive experiences impacting other TGD people and seeing negative media portrayals of the lives of TGD individuals. Participants also reported bodily vigilance when being on alert for how others were perceiving their gender. Other stressors included rejection, political oppression, physical violence, uneasiness from others, and the enforcement of gender binarism. Discussion These findings highlight gaps in the existing understandings of marginalization for TGD people that must be addressed to ensure that frameworks include and center the experiences of gender minorities.
Article
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Purpose of review: Trauma exposure is widespread but is especially common among lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals. LGBTQ individuals also experience higher rates of discrimination, victimization, and minority stress which can complicate posttraumatic stress disorder (PTSD) treatment but also represent independent intervention targets. In this review, we highlight existing evidence-based practices, current limitations, and provide recommendations for care in the absence of established guidelines for treatment PTSD among LGBTQ patients. Recent findings: Trauma-focused therapies (e.g., CPT, PE) and medications (e.g., SSRIs, SNRIs) have shown benefit for people with PTSD. However, evaluations of these interventions have failed to examine the role of LGBTQ identities in recovery from trauma, and existing PTSD treatments do not account for ongoing threat to safety or the pervasive minority stress experienced by LGBTQ patients. In addition, many LGBTQ patients report negative experiences with healthcare, necessitating increased education and cultural awareness on the part of clinicians to provide patient-centered care and, potentially, corrective mental health treatment experiences. Summary: Providers should routinely assess trauma exposure, PTSD, and minority stress among LGBTQ patients. We provide assessment and screening recommendations, outline current evidence-based treatments, and suggest strategies for integrating existing treatments to treat PTSD among LGBTQ patients.
Article
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Minority individuals might conceal their identity in social contexts in an effort to avoid stigma and victimization. Unfortunately, identity concealment is thought to impact psychological distress in transgender and gender nonconforming (TGNC) individuals. Thus, through 30 in-depth interviews, we sought to understand if and how identity concealment was experienced by TGNC individuals. Findings indicated that (a) TGNC identity concealment is a source of stress, (b) individuals might conceal their TGNC identity based on social context, (c) concealment of assigned sex and gender history can function to affirm one’s true gender identity, and (d) concealment of gender history is a rejection of one’s assigned sex. In addition, (a) passing/blending is an important interpersonal and intrapersonal process, (b) the importance of passing/blending can change over time, and (c) not passing/blending may result in worrying about personal safety. The authors discuss how concealment can both inhibit and promote psychological health for TGNC individuals, and they offer clinical applications for health providers.
Article
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Gender-affirming care, including hormone therapy, “top” (e.g., chest reconstruction surgery) and “bottom” (e.g., vaginoplasty, phalloplasty, metoidioplasty, etc.) surgeries, and puberty blockers, is an efficacious treatment of gender dysphoria for transgender and gender nonconforming (TGNC) individuals. However, many TGNC people encounter significant barriers in accessing gender-affirming care, which we detail via results from on online study. Participants included 256 TGNC individuals (78.9% White, ages 16–73, Mage = 28.4). Among participants, 61.3% were receiving hormone therapy, 22.7% had undergone top surgery, and 5.5% had undergone bottom surgery. Open-ended responses (n = 201) were thematically analyzed and common barriers included finances and insurance issues, a lack of service availability, and fears or worries. Participants reported various systemic issues and incidents of bias within medical and mental health fields, as well as a lack of medical provider awareness and education. Other themes were interpersonal barriers (e.g., fears of rejection); age and need of parental consent for minors; other medical issues; and a lack of information about how to acquire care. These findings can be utilized to educate professionals in medical and mental health fields about barriers their TGNC patients may encounter in receiving affirming care and suggest a number of ways to improve access to these services.
Article
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Background: Transgender and gender nonconforming (TGNC) individuals encounter a variety of minority stressors that have yet to be fully articulated or explored within the research literature. The purpose of this study is to better understand internalized stigma—the experience of accepting and internalizing negative social messages and experiences about one's identity—an underexplored minority stressor for TGNC people. Method: We conducted in-depth interviews with 30 diverse TGNC participants using consensual qualitative research (CQR) methodology. Results: Following data saturation and analysis, six distinct themes emerged across participants: (1) TGNC identities are regarded negatively by society; (2) social messages are perceived as originating from the media and religious ideology; (3) TGNC individuals report emotional distress; (4) negative self-perceptions in response to social messages; (5) TGNC individuals report resilience processes in response to negative social messages; and (6) social messages are perceived generally to differentially impact TGNC people of color. Conclusion: Findings highlight the common experience of encountering social marginalization for TGNC individuals. Structural interventions that target pervasive sociocultural messages regarding TGNC identities are warranted.
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This research investigates transgender individuals’ experiences with misgendering—the misclassification of gender identity—from a minority stress perspective. Four hundred and ten transgender individuals (M = 30.27 years, 83.9% European American) participated in a survey in which they reported how frequently they are misgendered and how stigmatized they feel when it occurs in addition to protective factors (gender identity importance, social support) and psychological distress (anxiety, depression, stress, transgender felt stigma). On average, participants reported being misgendered sometimes (M = 3.05, SD = 1.18) and feeling somewhat stigmatized by these experiences (M = 3.64, SD = 1.30). Perceived frequency of misgendering and feeling stigmatized by these experiences were positively associated with identity importance, but only perceived frequency was negatively associated with social support. Both perceived frequency and feeling stigmatized were positively associated with psychological distress. In turn, identity importance and social support were positively associated with psychological distress. There was a significant interaction between felt stigma and identity importance in predicting depression and stress. There was a positive association between felt stigma and stress and depression at low and high levels of identity importance, but this association was stronger at low levels of identity importance. In addition, there was a significant interaction between perceived frequency of misgendering and social support such that the association between perceived frequency and felt stigma was positive at low levels of social support but not at high levels of social support. In conclusion, misgendering is likely a novel minority stressor for transgender people.
Article
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Purpose: Transgender and gender-nonconforming (TGNC) individuals often are the target of enacted or external (i.e., distal) experiences of stigma, discrimination, and violence, which are linked to adverse health, particularly psychological distress. There is limited research, however, examining felt or internal (i.e., proximal) stressors faced by TGNC individuals. This study sought to examine one type of internal stressor, expecting rejection, and aimed to (1) identify how and to what extent rejection expectations operate day-to-day for TGNC individuals and (2) explore how TGNC individuals respond to expectations of rejection. Methods: In-depth interviews were conducted with 30 participants from 2014 to 2015 who identified as TGNC (mean age=30.4; 60% people of color); data were analyzed using a consensual qualitative research method. Results: Four thematic categories emerged about expecting rejection: (1) where to expect rejection; (2) thoughts and feelings associated with expectations of rejection; (3) coping strategies used to manage the expectation of rejection; and (4) the intersection of race and ethnicity with rejection expectations. Conclusion: Findings from this study suggest that expecting rejection is a frequent and salient internal stressor for TGNC individuals. We discuss the psychological and cumulative potential health impact of minority stress, and the applicability of Meyer's Minority Stress Model. Therapeutic interventions are needed to address the specific cognitive, emotional, and behavioral responses TGNC individuals experience as a result of the stress associated with expecting rejection, including fear, anxiety, and situational avoidance.
Article
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Rationale Transgender people in the United States experience widespread prejudice, discrimination, violence, and other forms of stigma. Objective This critical review aims to integrate the literature on stigma towards transgender people in the US. Results This review demonstrates that transgender stigma limits opportunities and access to resources in a number of critical domains (e.g., employment, healthcare), persistently affecting the physical and mental health of transgender people. The applied social ecological model employed here elucidates that transgender stigma operates at multiple levels (i.e., individual, interpersonal, structural) to impact health. Stigma prevention and coping interventions hold promise for reducing stigma and its adverse health-related effects in transgender populations. Conclusion Additional research is needed to document the causal relationship between stigma and adverse health as well as the mediators and moderators of stigma in US transgender populations. Multi-level interventions to prevent stigma towards transgender people are warranted. DOI: http://dx.doi.org/10.1016/j.socscimed.2015.11.010
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Transgender people are increasingly depicted in both offline and online media. These representations inform the general public about transgender communities and have a significant impact on transgender young peoples’ identity development and lived experiences. However, despite increasing awareness of this representation, a lack of research persists on the perspectives of LGBTQ (lesbian, gay, bisexual, transgender, and queer) youth regarding depictions of transgender people in contemporary media. This is despite the fact that this population may be particularly well positioned to consider the impact of these representations on themselves and their peers in the LGBTQ community. In this article the trends in contemporary media representations of transgender individuals are described, the perspectives of LGBTQ youth (N = 19) regarding these messages are examined, and the particular perspectives of transgender youth participants (n = 4) are explored. Clinical implications for social work practice are considered, including the potential usefulness of an ecological framework in considering the media engagement of LGBTQ young people.
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Ironically, while scholars and policy-makers have long referred to hate crime as a ‘message crime’, the assumption that those beyond the immediate victim are likewise intimidated by the violence has gone untested. Grounded in a recent study of the community impacts of hate crime, we offer some insights into these in terrorem effects of hate crime. We present here some of our qualitative findings. Interestingly, our findings suggest that, in many ways, awareness of violence directed toward another within an identifiable target group yields strikingly similar patterns of emotional and behavioural responses among vicarious victims. They, too, note a complex syndrome of reactions, including shock, anger, fear/vulnerability, inferiority, and a sense of the normativity of violence. And, like the proximal victim, the distal victims often engage in subsequent behavioural shifts, such as changing patterns of social interaction. On a positive note, there is also some evidence that these reactions can culminate not in withdrawal, but in the potential for community mobilization.
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Purpose: This study is one of the first to examine the physical and mental health of transgender older adults and to identify modifiable factors that account for health risks in this underserved population. Design and methods: Utilizing data from a cross-sectional survey of lesbian, gay, bisexual, and transgender older adults aged 50 and older (N = 2,560), we assessed direct and indirect effects of gender identity on 4 health outcomes (physical health, disability, depressive symptomatology, and perceived stress) based on a resilience conceptual framework. Results: Transgender older adults were at significantly higher risk of poor physical health, disability, depressive symptomatology, and perceived stress compared with nontransgender participants. We found significant indirect effects of gender identity on the health outcomes via fear of accessing health services, lack of physical activity, internalized stigma, victimization, and lack of social support; other mediators included obesity for physical health and disability, identity concealment for perceived stress, and community belonging for depressive symptomatology and perceived stress. Further analyses revealed that risk factors (victimization and stigma) explained the highest proportion of the total effect of gender identity on health outcomes. Implications: The study identifies important modifiable factors (stigma, victimization, health-related behaviors, and social support) associated with health among transgender older adults. Reducing stigma and victimization and including gender identity in nondiscrimination and hate crime statutes are important steps to reduce health risks. Attention to bolstering individual and community-level social support must be considered when developing tailored interventions to address transgender older adults' distinct health and aging needs.
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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.
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Objectives: We examined relationships between social determinants of health and experiences of transgender-related discrimination reported by transgender people in Virginia. Methods: In 2005 through 2006, 387 self-identified transgender people completed a statewide health needs assessment; 350 who completed eligibility questions were included in this examination of factors associated with experiences of discrimination in health care, employment, or housing. We fit multivariate logistic regression models using generalized estimating equations to adjust for survey modality (online vs paper). Results: Of participants, 41% (n = 143) reported experiences of transgender-related discrimination. Factors associated with transgender-related discrimination were geographic context, gender (female-to male spectrum vs male-to-female spectrum), low socioeconomic status, being a racial/ethnic minority, not having health insurance, gender transition indicators (younger age at first transgender awareness), health care needed but unable to be obtained (hormone therapy and mental health services), history of violence (sexual and physical), substance use health behaviors (tobacco and alcohol), and interpersonal factors (family support and community connectedness). Conclusions: Findings suggest that transgender Virginians experience widespread discrimination in health care, employment, and housing. Multilevel interventions are needed for transgender populations, including legal protections and training for health care providers.
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Culturally sensitive information is crucial for providing appropriate care to any minority population. This article provides an overview of important issues to consider when working with transgender patients, including clarification of transgender terminology, diagnosis issues, identity development, and appropriate pronoun use. We also review common clinical issues for transgender individuals seeking mental health care, how these can be addressed within a CBT framework, and the process of setting up a CBT support group within a VA hospital system. CBT group outcome data and demonstrative examples from male to female transsexuals are also presented.
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To characterize challenges experienced during stages of female-to-male sex transition and investigate associations between transition-specific measures of psychosocial stress, nocturnal decline in ambulatory blood pressure (amBP), and changes in C-reactive protein (CRP) levels. For this biocultural study, 65 healthy transmen who were using testosterone (T) therapy participated in interviews to assess transition-specific stress experience. They provided perceived stress scores, self-esteem scores, 24-h amBP measures, salivary samples for T levels, and a blood spot for CRP levels. Psychosocial stress was examined in relation to amBP and CRP using linear regression while adjusting for age, body mass index, and smoking. There were no differences in mean levels of amBP in association with stage of transition. Men reporting stress associated with being "out" as transgender had significantly diminished nocturnal decline in systolic and diastolic amBP compared to men who did not report such stress. The associations remained significant when examined among men in stages 1 and 2 (≤ 3 years on T), but not among men in stage 3 (>3 years on T) of transition. Men reporting stress related to "passing" as someone born male had higher CRP levels than those who did not report such stress. The association remained significant when examined among men in stages 2 and 3 (>0.5-3 years on T). Measures of stress that captured individuals' experiences of gender liminality were associated with diminished nocturnal decline in amBP and increased levels of CRP. There are significant differences between men grouped into different stages of the transition process.
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For people who are transgender, transsexual, or transitioned (trans), access to primary, emergency, and transition-related health care is often problematic. Results from Phase I of the Trans PULSE Project, a community-based research project in Ontario, Canada, are presented. Based on qualitative data from focus groups with 85 trans community members, a theoretical framework describing how erasure functions to impact experiences interacting with the health care system was developed. Two key sites of erasure were identified: informational erasure and institutional erasure. How these processes work in a mutually reinforcing manner to erase trans individuals and communities and produce a system in which a trans patient or client is seen as an anomaly is shown. Thus, the impetus often falls on trans individuals to attempt to remedy systematic deficiencies. The concept of cisnormativity is introduced to aid in explaining the pervasiveness of trans erasure. Strategies for change are identified.
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This study describes stress as derived from minority status and explores its effect on psychological distress in gay men. The concept of minority stress is based on the premise that gay people in a heterosexist society are subjected to chronic stress related to their stigmatization. Minority stressors were conceptualized as: internalized homophobia, which relates to gay men's direction of societal negative attitudes toward the self; stigma, which relates to expectations of rejection and discrimination; and actual experiences of discrimination and violence. The mental health effects of the three minority stressors were tested in a community sample of 741 New York City gay men. The results supported minority stress hypotheses: each of the stressors had a significant independent association with a variety of mental health measures. Odds ratios suggested that men who had high levels of minority stress were twice to three times as likely to suffer also from high levels of distress.
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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.
Article
Transgender and gender diverse (TGD) populations, including those that do not identify with gender binary constructs (man or woman) are increasingly presenting for treatment of posttrauma sequelae. Providers who offer services for trauma survivors including posttraumatic stress disorder (PTSD) treatment should be knowledgeable about evidence-based care and have some cultural familiarity with TGD experiences. Indeed, the Minority Stress Model suggests that the combination of distal and proximal minority stressors can combine to produce increased mental health symptoms as compared with cisgender peers, though this model has yet to be fully tested. Clients often present with a complicated picture of experiences, which include a variety of minority stressors, microaggressions, discrimination, and traumatic events that can all be related to their identity. However, conceptualizations of trauma treatment in the context of extensive minority stress are lacking. This paper summarizes the existing literature and offers guidance to mental health providers who are well positioned to address stigma, discrimination, violence, and related symptoms that arise from micro-, mezzo- and macro-level spheres of TGD individuals’ experience.
Article
Nonbinary individuals experience unique stressors and stigma compared to binary transgender individuals. Given the many social systems that operate on a binary gender system, nonbinary individuals frequently experience microaggressions, discrimination, and harassment and suffer from high rates of negative mental health outcomes as a result. The unique stressors that nonbinary individuals face warrant specific clinical considerations for working with this population. Yet, limited published clinical guidance exists on working with nonbinary clients. This article uses minority stress theory to understand the unique stressors and mental health risks that nonbinary individuals face, a cultural competency framework to describe affirming practices, and ecological theory to contextualize how mental health providers can intervene and support nonbinary individuals. Concrete micro-, mezzo-, and macro-level interventions are provided for clinicians to enact to support the well-being of nonbinary clients including affirming the client's experience of gender, taking a stance of openness and flexibility, and advocating for inclusive policies and practices.
Article
Transgender and gender nonconforming (TGNC) adolescents and young adults face significant mental health disparities, including increased rates of suicidality, depression, and self-harm. These disparities are multidetermined and stem, in part, from the emotional consequences of family rejection, peer and community victimization, social isolation, and discrimination and transphobia in both daily settings (e.g., school) and society as a whole. In order to meet the mental health needs of TGNC youth, we must intervene in multiple levels of youths' lives and provide gender-affirming evidence-based therapies. In this paper, we describe an integrated model of meeting the mental health needs of TGNC youth, with the ultimate goal of reducing mental health disparities. We provide guidance for macro-level interventions, including efforts to implement social change; mezzo-level interventions, including structuring a health care setting to be gender-affirming; and micro-level interventions, including gender-affirming dialectical behavior therapy, cognitive behavioral therapy, family therapy and support group interventions. Throughout, we highlight our descriptions of interventions with case examples in order to provide additional practical guidance.
Article
Background: When accessing mental healthcare services, transgender and gender nonconforming (TGNC) individuals face systemic barriers to gender-affirmative care. Initial points of contact, like intake forms, may show limited consideration for the heterogeneity of TGNC identities and can lead to negative consequences prior to face-to-face interaction with providers. Aims: The first aim was to mimic a likely pathway a TGNC individual may follow to seek mental healthcare services in the USA and to describe the extent to which they may encounter enacted stigma or affirmative messages that may impede or facilitate access to care. The second aim was to determine if a positive State legal climate for TGNC people was associated with more affirmative provider materials. Methods: Content analysis was used to examine a national sample of websites and intake forms of mental healthcare providers who advertise online as working with TGNC clients. Intake forms were coded for usage of affirmative language in gender/sex questions and including questions for a client's pronouns and preferred name. Websites were coded for mentioning a variety of services or resources for TGNC clients. Results: While provider websites were found through Google searches for a "gender therapist," only 56.6% of websites stated a provider specialty to work with TGNC clients and 32.1% of websites had no mention of services or resources for TGNC people. Additionally, a significantly larger proportion of intake forms from States with legal protections for TGNC people used affirmative language in gender/sex questions and asked for a client's pronouns than intake forms from States without legal protections. Discussion: Barriers to affirmative healthcare for TGNC people within patient and provider interactions have been identified in previous research and these data show TGNC individuals may face enacted stigma even in their search for a provider, particularly those TGNC people living in States without legal protections.
Article
Background: Depression is a serious disorder which significantly impacts wellbeing and quality of life. Studies exploring mental wellbeing in the transgender population are mostly limited by small, non-homogenous samples and lack of matched controls. This study aimed to address these limitations and explore depression rates in a large sample of transgender people, compared with matched controls from the general population, as well as factors predicting depression in those taking cross-sex hormone treatment (CHT) compared to those not. Methods: Transgender individuals (n = 913) completed a measure of depression, measures which predict psychopathology (self-esteem, victimization, social support, interpersonal problems), and information regarding CHT use. Participants were matched by age and experienced gender with adults from the general population who had completed the measure of depression. Results: Individuals were categorized as having no, possible or probable depressive disorder. Transgender individuals not on CHT had a nearly four-fold increased risk of probable depressive disorder, compared to controls. Older age, lower self-esteem, poorer interpersonal function and less social support predicted depressive disorder. Use of CHT was associated with less depression. Limitations: Participants were attending a national gender identity service and therefore represent only a sub-group of transgender people. Due to the cross-sectional design, longitudinal research is required to fully confirm the finding that CHT use reduces depression. Conclusion: This study confirms that non-treated transgender individuals have an increased risk of a depressive disorder. Interventions offered alongside gender affirming treatment to develop interpersonal skills, increase self-esteem and improve social support may reduce depression and prepare individuals for a more successful transition.
Article
Authentically expressing and navigating a transgender or gender nonconforming identity during adolescence can be a difficult and painful process. Using a transgender affirmative approach to clinical practice, psychologists and other mental health professionals can play a key role in supporting youth through this process. To date, there is a paucity of research exploring the impact of transgender affirmative interventions on well-being. The primary objective of this article is to present the results of a pilot study exploring the preliminary effectiveness and acceptability of AFFIRM, an affirmative cognitive–behavioral coping skills group intervention with transgender youth. This article will also describe transgender-specific considerations for delivering transgender affirmative interventions. The transgender subsample (N = 8) of participants in the study were between the ages of 16 and 18 and represented a diversity of intersecting racial/ethnic, sexual, and gender identities. Results indicate that AFFIRM was effective in significantly decreasing depression scores, and changes persisted through the 3-month follow-up. While changes in coping were not statistically significant, scores trended in a positive direction. Data indicate favorable responses to AFFIRM among transgender participants across a variety of dimensions of satisfaction. While findings are preliminary, they are promising, addressing a critical gap in intervention research aimed at decreasing depression and improving coping among transgender youth. Future controlled studies are needed to explore the efficacy of AFFIRM with larger samples of transgender youth.
Article
This article describes the need for specific guidelines regarding how to manage inpatient and residential mental health programming with respect to transgender individuals. The article discusses what is known about transgender mental health and how it is related to sociopolitical factors, how inpatient and residential programs can address the impact of sociopolitical factors on transgender individuals and send a welcoming message to prospective consumers, how programs can attend to policies and procedures in ways that create the best milieu for an inpatient or residential unit that provides care for one or more transgender individuals, and how providers and interdisciplinary teams can meet the unique clinical needs of transgender individuals. These guidelines are designed to assist providers in creating a safe environment that affords quality inpatient and residential mental health care to transgender individuals.
Article
Current psychotherapy research with sexual and gender minorities (SGMs) is inadequate to address the health disparities in this population. Psychotherapy can benefit from research demonstrating the unique experiences of SGMs with respect to behavioral health, internalized stigma, coping, and resilience. This article describes research approaches, questions, and measurement that can be employed to study psychotherapy. Given the impact of minority stress and microaggressions on SGM individuals, many of the recommendations provided in this article focus on how these components should be infused throughout a diverse range of psychotherapy interventions. Namely, we provide recommendations for researchers focusing on SGM populations in randomized controlled trials and psychotherapy process research. We also provide 7 specific recommendations that focus on psychotherapy research measurement with SGM populations and how researchers can focus their efforts to reduce disparities for SGM individuals. Finally, we identify additional constructs to consider for future intervention research with SGM individuals.
Article
While affirmative approaches with transgender and gender nonconforming (TGNC) clients are gaining momentum within psychological practice (American Counseling Association, 2010; American Psychological Association, 2015), there is a simultaneous and pressing need to move beyond TGNC-affirmative to TGNC-liberatory approaches to more fully address how societal gender binaries influence both psychologist and client. Psychologists may use the lens of liberation psychology (Martín-Baró, 1996) to transform the ways they work with TGNC clients. Using this perspective, psychologists can reflect on their own gender journey and experiences, identify how cisgender privilege influences counseling and psychological practice, and advocate for TGNC people to be better served in the settings in which they work. Psychologists are then able to engage in social change on behalf of, and in collaboration with, TGNC people in ways that simultaneously liberate psychologists from their own gender oppression experiences.
Article
In 2015, the American Psychological Association adopted Guidelines for Psychological Practice with Transgender and Gender Nonconforming Clients in order to describe affirmative psychological practice with transgender and gender nonconforming (TGNC) clients. There are 16 guidelines in this document that guide TGNC-affirmative psychological practice across the lifespan, from TGNC children to older adults. The Guidelines are organized into five clusters: (a) foundational knowledge and awareness; (b) stigma, discrimination, and barriers to care; (c) lifespan development; (d) assessment, therapy, and intervention; and (e) research, education, and training. In addition, the guidelines provide attention to TGNC people across a range of gender and racial/ethnic identities. The psychological practice guidelines also attend to issues of research and how psychologists may address the many social inequities TGNC people experience.
Article
The presence of individuals who identify as transgender has emerged into public awareness in the United States in recent years. Celebrities who publicly transition have expanded the national conversation about gender variation beyond gender and women’s studies classrooms and certain specialty health and mental health services. This increased public visibility has been accompanied by increased visibility in the mental health literature, including the publishing of competencies or guidelines for working with clients who identify as transgender by various professional organizations. However, rapid societal changes and increased understanding of the experience of being transgender in our society means literature can rapidly become dated. This commentary identifies key points that will move forward professional competency, both of the field and of individual practitioners, in the provision of psychological services. Topics discussed include (1) how mental health has contributed to trans stigma, (2) why more than good intentions are needed, (3) a research agenda for the development of high-quality evidence-based behavioral health care for the trans community, and (4) clinician recommendations.
Article
Psychological research with transgender and gender nonconforming (TGNC) people is a relatively new field with great promise to advance our understanding of this population’s needs and develop, implement, and evaluate corresponding interventions to reduce their health disparities and promote psychosocial adjustment, mental health, and well-being. After a brief review of the history of research with TGNC people, this article discusses several issues to ensure that research with this population is culturally competent and meaningful. This includes issues to consider for participant recruitment, data collection, working with institutional review boards, and distribution of research findings. We conclude with a discussion of gaps in the literature and corresponding opportunities for future psychological research with TGNC people.
Article
Objective: Transgender children who have socially transitioned, that is, who identify as the gender "opposite" their natal sex and are supported to live openly as that gender, are increasingly visible in society, yet we know nothing about their mental health. Previous work with children with gender identity disorder (GID; now termed gender dysphoria) has found remarkably high rates of anxiety and depression in these children. Here we examine, for the first time, mental health in a sample of socially transitioned transgender children. Methods: A community-based national sample of transgender, prepubescent children (n = 73, aged 3-12 years), along with control groups of nontransgender children in the same age range (n = 73 age- and gender-matched community controls; n = 49 sibling of transgender participants), were recruited as part of the TransYouth Project. Parents completed anxiety and depression measures. Results: Transgender children showed no elevations in depression and slightly elevated anxiety relative to population averages. They did not differ from the control groups on depression symptoms and had only marginally higher anxiety symptoms. Conclusions: Socially transitioned transgender children who are supported in their gender identity have developmentally normative levels of depression and only minimal elevations in anxiety, suggesting that psychopathology is not inevitable within this group. Especially striking is the comparison with reports of children with GID; socially transitioned transgender children have notably lower rates of internalizing psychopathology than previously reported among children with GID living as their natal sex.
Article
Mental health research and practice has traditionally maintained a view of transgender people through the narrow lens of gender identity disorder. Recently, broader understandings of gender have influenced affirmative therapy with transgender clients. The purpose of the present research is to critically review historical views of transgender clients and to highlight experiences of transgender clients in therapy. Feminist phenomenology informed in-depth interviews with seven people who self-identify as transgender. Four themes emerged: the purposes transgender clients sought therapy, problems in practice, therapist reputation, and transgender affirmative therapy. Transgender affirmative practice and training implications are discussed.
Article
Researchers currently lack a reliable and valid means of assessing minority stress and resilience factors in transgender and gender-nonconforming (TGNC) people. This study was conducted to develop and evaluate the validity of a tool to better assess these constructs in TGNC populations. The Gender Minority Stress and Resilience (GMSR) measure was developed grounded on Meyer’s minority stress model, and adjusted to reflect the experiences of TGNC populations based on TGNC literature and archival data from TGNC focus groups. The final GMSR includes scales assessing 9 constructs: gender-related discrimination, gender-related rejection, gender-related victimization, nonaffirmation of gender identity, internalized transphobia, negative expectations for future events, nondisclosure, community connectedness, and pride. In the current study, 844 participants completed the GMSR measure as well as measures related to mental health, general life stress, and social support. Results indicated good model fit, criterion validity, convergent validity, and discriminant validity for the 9 hypothesized scales. Discriminant validity for the scales were also partially supported. Overall, the current study offers preliminary evidence of the reliability and validity of the GMSR Measure for use with TGNC populations. The GMSR Measure has several uses for both research and clinical purposes, including increasing understanding of the experiences and correlates of gender minority stress and resilience factors and assessing whether specific therapies or interventions are helpful in reducing risk and supporting resilience in TGNC populations.
Article
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.
Article
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)
Article
The author documents her experiences as she researched homosexual men. She discusses the adverse conditions that potentially threatened her achieving her research goals, including the demand of university officials that the research be conducted at the university. As confidentiality was imperative, the author insisted on conducting interviews at her home office. Starting in 1953 she received grants from the National Institute of Mental Health (NIMH) to research male homosexuality and in 1969 proposed an agenda outlining research and policy issues at NIMH. Hooker recently received a trust fund for almost a half million dollars from a gay man she had interviewed in the late 1950s to conduct research for the understanding of gay men and lesbians. The funds are now in the American Psychological Foundation under control of selected officers of Division 44. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
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.
Lawmaker to trans community: ‘Sorry you’re so twisted.’ The Argus Leader
  • D Ferguson