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A Qualitative Analysis of Adverse Childhood Experiences in Gender Minority Adolescents



Relative to their cisgender peers, gender minority (GM) adolescents—whose gender identity and/or expression differs from their birth-assigned sex (Turban & Ehrensaft, 2018)—are at elevated risk for internalizing psychopathology (Becerra-Culqui et al., 2018). This disparity may be partially attributable to their exposure to adverse childhood experiences (ACEs), that is, potentially traumatic events that confer lifetime risk for negative health outcomes (Hughes et al., 2017). ACEs have conventionally included child abuse, neglect, and familial dysfunction (Felitti et al., 1998; Merrick et al., 2018), and this definition has more recently expanded to encompass peer victimization (e.g., bullying; Karatekin & Hill, 2018), discrimination (Cronholm et al., 2015), community violence (Finkelhor et al., 2015), and other adversities (e.g., life-threatening injury, serious illness; McLaughlin et al., 2012). A growing body of research suggests that GM adolescents are disproportionately exposed to ACEs (e.g., physical/sexual assault, perceived discrimination) compared to cisgender adolescents (Johns et al., 2019; Price-Feeney et al., 2020). However, few studies have comprehensively examined ACE exposure in GM adolescents. Rather, they have focused on specific types of ACEs endorsed via close-ended survey questions and/or structured interviews (Oh et al., 2018), measurement methods that may fail to capture the variety of ACEs to which GM adolescents are exposed (Schrager et al., 2019). To better elucidate ACEs in this population, the present study qualitatively analyzed data from semi-structured clinical interviews with GM adolescents utilizing open-ended questions about ACE exposure. Participants included N = 55 GM adolescents (ages 11–18; M = 15.4, SD = 1.7) seeking gender-affirming care at a pediatric gender clinic. At an initial evaluation, they participated in a clinical interview assessing their readiness for medical transition (Coolhart et al., 2013), which included several questions about ACE exposure (e.g., “Have you experienced or witnessed emotional, physical, or sexual abuse?”), including specific items about negative identity-related experiences they have had at home and in school. Participants identified as White (69.2%), Latinx (21.8%), African American (3.6%), multiracial (1.8%), and with other races/ethnicities (3.6%). They reported gender identities of trans-male (i.e., female-to-male; 69.1%), trans-female (i.e., male-to-female; 20.0%), nonbinary (7.3%), genderqueer (1.8%), and gender fluid (1.8%). Interview transcripts were analyzed using qualitative content analysis (Hsieh & Shannon, 2005), drawing on both inductive and deductive techniques (Elo & Kyngäs, 2008) to answer the following research question: “What types of ACEs are common to GM adolescents?” Prior to coding, both conventional (Felitti et al., 1998) and expanded (Cronholm et al., 2015; Finkelhor et al., 2015; Karatekin & Hill, 2018; McLaughlin et al., 2012) conceptualizations of ACEs were identified from the extant trauma literature. Open coding was also used, which allowed for the potential emergence of previously unrecognized categories of ACEs. Each transcript was coded independently by two coders and subsequently validated by a third. To enhance reliability, coders utilized consensus building (Hill et al., 2005), meeting weekly to discuss biases and resolve discrepancies in coding. Most participants reported exposure to one or more ACEs from the following categories: (a) emotional abuse, (b) physical assault, (c) sexual assault, (d) exposure to community violence, (e) life-threatening injury, (f) serious illness, (g) caregiver divorce, (h) caregiver separation, (i) witnessing intimate partner violence, (j) unexpected loss, and (k) learning of the trauma of a close relative or friend. Of these, emotional abuse and physical assault were frequently described in connection with participants’ gender identity and/or expression. These categories captured instances of transphobic bullying, violence victimization, and perceived discrimination, which occurred in the home, school, mental health treatment, and/or the wider community. Broadly, ACEs were perpetrated by family members (e.g., caregivers, siblings), friends, peers, school personnel (e.g., teachers, administrators), mental health professionals, and strangers. Notably, open coding revealed that past suicide attempts were often described as traumatic by participants and thus categorized as ACEs. The present study utilized qualitative analysis to identify potentially traumatic events in a sample of GM adolescents accessing gender-affirming care. Using an expansive conceptualization (Cronholm et al., 2015; Felitti et al., 1998; Finkelhor et al., 2015; Karatekin & Hill, 2018; McLaughlin et al., 2012), we found a wide range of ACEs across multiple contexts. Among these, acts of emotional abuse and physical assault were often related to participants’ gender identity and/or expression. In combination with more general forms of adversity identified in the present study (e.g. serious illness), identity-related ACEs might partially account for GM adolescents’ elevated risk for psychopathology (Becerra-Culqui et al., 2018). Our findings underscore the importance of comprehensive trauma assessment for GM individuals in research and clinical practice. Consistent with previous recommendations (e.g., Vance & Rosenthal, 2018), the identification of ACEs specific to GM adolescents may improve trauma and risk assessment. For instance, suicide attempts, which were identified as traumatic by multiple participants and/or tied to trauma-related symptomatology, might represent a previously unrecognized ACE (Stanley et al., 2019). Increased awareness of ACEs relevant to this population has the potential to improve mental health assessment and care and to inform emerging research on gender-affirming mental health treatments (Austin et al., 2018) and provider-trainings (Lelutiu-Weinberger et al., 2016).
Research Questions
§What ACEs do trans and nonbinary
(TNB) adolescents experience?
§Are these ACEs related to gender
identity and/or expression?
§ACEs traditionally include child abuse,
neglect, & family dysfunction1-3
§ACEs have expanded to encompass
discrimination & victimization4-7
§Relative to cisgender youth, TNB
adolescents are at elevated risk for
mental health concerns8
§This risk is partially attributable to
disproportionate exposure to ACEs9-10
§Few studies with TNB adolescents
have comprehensively examined
ACEs11-12, particularly those relevant
to gender identity and/or expression
§We analyzed qualitative data from
clinical interviews to better elucidate
ACEs specific to TNB adolescents
§Directed content analysis13 of clinical
interviews assessing readiness for
gender transition14
§Codebook developed from expanded
definition of ACEs4, including gender
minority stressors15
§Interview transcripts coded by five-
member research team &validated by
coding team leader
§Consensus building process used to
ensure reliability16
Findings & Conclusions
A Qualitative Analysis of
Adverse Childhood Experiences
in Gender Minority Adolescents
Nathan Hollinsaid1, Gabrielle Kaufman2,3, Emma Bokhour3, Christy Olezeski 4, & Maggi Price1,3
Harvard University
; 2
University of Denver
; 3
Boston College
; 4
Yale School of Medicine
§Most TNB adolescents reported >1
ACEs, often related to gender identity
and/or expression
§ACEs occurred in multiple contexts
(e.g., home, school, & community)
§ACEs were perpetrated by caregivers,
peers, mental health professionals,
school personnel, &strangers
§Increased awareness of ACES specific
to TNB adolescents might improve
mental health assessment & care17
Trans & nonbinary adolescents
reported a range of adverse
childhood experiences, many of
which were specific to their
gender identity or expression.
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§Gender identity: 69.1% trans-male,
20.0% trans-female, 7.3% nonbinary,
1.8% gender-fluid, & 1.8% genderqueer
§Race/ethnicity: 69.2% White, 21.8%
Latinx, 3.6% Black, 1.8% multiracial,
& 3.6% other
= 55 TNB adolescents seeking
gender-affirming care
*Both gender-and nongender-related
Witnessed dad
beat mom. One time,
I fell out of her arms
when he pushed her
so hard.
Mom made fun
of binding and boobs.
She said, “You’ll never
be a man...I’m going
to talk to my real
son now.”
Family Dysfunction
Witnessed IPV
Substance Use
Mental Health
Child Maltreatment
Physical Abuse*
Verbal Abuse*
Peer Victimization
Verbal Bullying*
Physical Assault*
Sexual Assault*
Social Isolation*
Gender Adversity
Dad thinks it’s
a phase. It’s invalidating.
He said, “That’s the
one thing I’ll never
approve of.”
People call me
names at school:
“tranny,” “fag,” and
“it.” They say,
“Look! It’s coming!”
§Age: range: 11-18;
age = 15.4,
= 1.7
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