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Cognitive and Behavioral Practice 26 (2019) 629 – 646

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Trauma Recovery in the Transgender and Gender Diverse Community: Extensions of the Minority Model for Treatment Planning

Jillian C. Shipherd, , Gay, Bisexual, and Transgender Health Program, Veterans Health Administration, Washington, DC; National Center for PTSD, VA Boston Healthcare System; and Boston University School of Medicine Danielle Berke, Hunter College of the City University of New York and The Graduate Center of the City University of New York Nicholas A. Livingston, Boston University School of Medicine and VA Boston Healthcare System

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, , 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.

RANSGENDER and gender diverse (TGD) individuals, their summary, the authors called for precision in T including those whose gender identities are incon- definitions when studying TGD communities as well as gruent with sex assigned at birth, those who do not their risks and resiliencies. They summarized 15 studies identify with gender binary constructs (man or woman), that had documented exposure to violence in adult TGD or those who are expansive and/or fluid in their gender populations and another 16 that looked at posttraumatic identities, are increasingly recognized in health care stress disorder (PTSD) symptoms (American Psychiatric settings. An interdisciplinary approach to the health and Association, 2013), but it was rare to find a study that well-being of TGD people is indicated (e.g., Kauth & assessed both DSM 5 Criterion A traumatic event1 Shipherd, 2017; Shipherd, Kauth, Firek, et al., 2016), but exposure and linked that exposure to PTSD symptoms reliable study of how to best assist TGD people with their (Shipherd, Maguen, Skidmore, & Abramovitz, 2011). mental health needs has only just begun. A recent What was more common (across 26 studies) was to assess empirical review of the literature on the mental health exposure to general discrimination (including but not needs of TGD children and adults highlighted the current limited to traumatic events) among adults and a subset of state of the literature and key areas for further study those also evaluated PTSD symptoms (see Valentine & (Valentine & Shipherd, 2018). The review underscores Shipherd, 2018). Such methods make it impossible to the need for additional attention by researchers and isolate the unique, additive, and/or interactive effects of clinicians focused on best practices for TGD people. In

1 DSM 5 Criterion A definition: The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or Keywords: transgender; trauma; minority stress; treatment; cultural threatened sexual violence, in the following way(s): direct exposure, competence witnessing the trauma, learning that a relative or close friend was exposed to a trauma, Indirect exposure to aversive details of the 1077-7229/13/© 2019 Association for Behavioral and Cognitive trauma, usually in the course of professional duties (e.g., first Therapies. Published by Elsevier Ltd. All rights reserved. responders, medics) 630 Shipherd et al. traumatic and minority stress. This complicates treatment consequences of distal stress experiences, such as fear of planning, as it is unclear if PTSD symptoms are directly rejection, concealment of one’s stigmatized identity, and related to an acute victimization experience or if the the incorporation of societal negative regard of minority symptoms are a result of an interaction between general identity into one’s own values and self-perception (i.e., distress from chronic minority stress and PTSD. internalized ). This model can be applied to understanding symptom development in a variety of minority populations (e.g., Conceptualization of Symptom Development in race, disability status), but Meyer’s work applied the TGD Trauma Survivors Minority Stress Model to sexual orientation minority The Minority Stress Model has been helpful in populations. As applied to TGD individuals, the Gender defining how experiences of stress, stigma, and discrim- Minority Stress Model (Hendricks & Testa, 2012) expands ination combine to increase negative mental health Meyer’s application of the Minority Stress Model to better symptoms (Hendricks & Testa, 2012; Meyer, 1995, represent the range of stressors unique to TGD people 2003). With a foundation in the extant social psychology (see Figure 1). This model has been essential to literature, the model was put forward by (1995, understanding TGD mental health disparities at the 2003) to conceptualize how the health of sexual minority population level and informing interventions and pre- people is adversely impacted by interpersonal, intraper- vention strategies to reduce TGD people’s exposures. sonal, and system-level stressors. Later, Hendricks and However, the Gender Minority Stress Model was not Testa (2012) expanded the model to specifically capture designed to inform conceptualization of post-stressor how gender diverse people’s health is adversely impacted clinical distress, trauma-focused therapy, or trauma by social factors that contribute health disparities recovery among TGD individuals. Indeed, the Gender (see Figure 1). The Minority Stress Model posits that Minority Stress Model is best suited to provide guidance adverse mental health outcomes among stigmatized for prevention efforts. As will be considered below, there populations emerge through a host of unique (i.e., not are some direct interventions that can serve to reduce the experienced by nonstigmatized populations) inter- and burden on TGD people by eliminating or reducing the intrapersonal mechanisms (Meyer, 1995, 2003). These effects of discrimination, minority stress, microaggres- mechanisms include both distal stressors originating from sions, and trauma. What is less clear from the existing the social environment external to the affected individ- literature is how to provide trauma-focused treatment for uals, which includes experiences of trauma, discrimina- those who are already suffering with the sequelae of these tion, and microaggressions, and proximal stress processes that experiences. In particular, the model does not address are activated by marginalizing and oppressive social treatment of posttrauma symptoms, though this paper will pressures, including transphobia (Hendricks & Testa, offer extensions of the Gender Minority Stress Model for 2012; Meyer, 2003). Distal minority stressors include treatment providers. In this paper, we describe several harmful behaviors such as discrimination, harassment, clinically significant experiences that are included as part and violence. Examples of proximal stressors include of Gender Minority Stress Model, but from a trauma endogenous psychological and potentially interpersonal treatment conceptualization and case formulation

Figure 1. Gender Minority Stress Model: Hendricks and Testa, 2012 TGD Trauma Treatment 631 framework to support more refined case conceptualiza- Criterion A Traumatic Exposure Among TGD People tion when working with TGD individuals. In so doing, we Unfortunately, TGD people experience rates of aim to extend the Gender Minority Stress Model to trauma exposure higher than in the general population, ’ synthesize client s specific stress-exposure experiences which could be due to discrimination-based traumatic with theory and research to guide the development of events (e.g., being beaten or sexually assaulted due to individually tailored, multilevel, evidence-based concep- TGD identity). TGD individuals are more than twice as tualizations of distress and treatment. In this paper, we likely to receive threats of violence relative to cisgender refer to the Trauma and Minority Stress Exposure Model sexual minority individuals (who are already at elevated and it is applied to TGD people. risk relative to heterosexual counterparts; Landers & Gilsanz, 2009). This pattern of elevated risk is repeated Clinically Significant Exposures in TGD Trauma across many forms of violence (Reisner, White, Bradford, & Survivors Mimiaga, 2014), including sexual violence (Langenderfer- In order to understand the complex symptom presen- Magruder, Whitfield, Walls, Kattari, & Ramos, 2016)and tation of TGD trauma survivors, several different types of intimate partner violence (Dank, Lachman, Zweig, & interrelated experiences are important to understand, Yahner, 2010; Henry, Perrin, Coston, & Calton, 2018; including trauma. Trauma survivors will sometimes Langenderfer-Magruder et al., 2016; Valentine et al., 2017). present for “trauma treatment” seeking assistance with Overall, lifetime rates of exposure to criterion A traumatic symptoms that follow a variety of clinically significant events are consistently between 90%–100% of TGD partic- experiences including criterion A traumatic events, ipants (Barr, 2018; Beckman, Shipherd, Simpson, & Lehavot, discrimination-based events, minority stressors, and 2018; Shipherd, Green, & Abramovitz, 2010). Indeed, the microaggressions, or some combination (see Figure 2). rate of violence against TGD people has been classified as a Often the client-identified index event can be a “national epidemic” by the Human Rights Campaign (HRC, discrimination-based event such as being fired or denied 2018) and, according to this report, risks of violence are even housing due to their TGD identity. While being fired or higher for TGD people of color. The recovery experience of losing housing are clearly significant and discrimination- TGD people who have experienced discrimination-based based events worthy of clinical attention, they are not traumaticeventsiscomplicated(Beckman et al., 2018). currently considered criterion A events. However, clini- Further, in 74% of initial media or police reports involving cally significant sequelae can result in and can exacerbate anti-TGD violence, the victim was misgendered (HRC, 2018). PTSD symptoms from other traumatic exposures due to This may compound the harms done to the victim and the conceptual relationships or thematic similarity (e.g., TGD community more broadly by invalidating the identities being beaten due to TGD identity). of those involved and those who have similar identities.

Figure 2. Trauma and Minority Stress Exposure Model: Application to Transgender and Gender Diverse People 632 Shipherd et al.

Microaggression Exposure Among TGD People barrier to these updates was financial and it has real impacts For TGD trauma survivors who have experienced on the lives of TGD individuals; 32% of respondents stated discrimination-based violence, there can be frequent re- that after showing their (outdated) documents they were minders of the index traumatic event in their daily lives in verbally harassed, denied benefits or service, asked to leave, the form of microaggressions and other forms of discrimina- or even assaulted. More than half (59%) of respondents tion including at school, work, in housing, or in public spaces avoided using a public restroom in the past year because they (e.g., public transportation). Microaggressions include “brief were afraid of confrontations, and 32% limited the amount and commonplace daily verbal, behavioral, or environmental they ate or drank to prevent needing to use a public restroom indignities, whether intentional or unintentional, that com- (James et al., 2016). Thus, microaggressions may seem minor municate hostile, derogatory, or negative slights and insults to the independent observer, but they can have real toward members of oppressed groups” (Nadal, 2013, p. 36). consequences with respect to the health and wellbeing of Microaggressions also include “constant, continuing, and TGD individuals. cumulative experience(s)” that disproportionately disadvan- tage minority groups (Sue, 2010; p. 52). Microaggressions can Discrimination Exposure Among TGD People be experienced directly or indirectly (e.g., overheard or In the context of the pervasive and growing threats of learned about from other TGD people), and can be violence, microaggressions, and discrimination (HRC, committed by known or unknown individuals (Swim, 2018; Stotzer, 2008), the distinction between adaptive Pearson, & Johnston, 2007). Sue et al. (2019) has made a vigilance and maladaptive hypervigilance is complicated “ strong case that microaggressions are different from everyday for TGD trauma survivors. For example, the NTDS report ” rudeness in the following ways. They are (a) constant and describes the extent and reach of TGD-related discrim- continual in the lives of stigmatized groups, (b) cumulative in ination in the U.S., with 46% reporting verbal harassment nature and represent a lifelong burden of stress, (c) in the prior year. The TGD community's unemployment ’ continuous reminders of the target group s second-class status rate was three times higher than the U.S. population in society, and (d) symbolic of governmental injustices (15% versus 5%), with 27% of respondents reporting directed toward people belonging to stigmatized groups. being fired or denied a promotion because of their Common examples in the TGD community include mis- gender identity. An alarming 77% of respondents “ gendering in the use of wrong pronouns or use of dead reported taking steps to avoid mistreatment at work, ” name (name from birth). While these incidents may appear such as by hiding or delaying their transition. Nearly 30% minor at the individual incident level, the pervasiveness of of the sample reported being homeless at some point, these experiences for TGD people create a nearly constant with 23% reporting being evicted or denied housing due ’ reminder of larger culture s devaluing of their minority to their identity. For racial minority TGD people, the rates identity. In one revealing study, Livingston, Flentje, Heck, of homelessness and incarceration are even higher than Szalda-Petree, and Cochran (2017) found that daily micro- for white TGD people, likely due to their multiple aggressions based on sexual and gender minority (SGM) minority identities (Brown & Jones, 2014). A discouraging identities were much more harmful to the targets than non- 33% of TGD individuals in the NTDS survey reported that identity-based insults. They concluded that microaggressions they had been refused care or harassed by a health care differed significantly in quality from general non-identity- provider based on their gender identity, and 23% based incivilities, and presumably serve as persistent reminders reported delaying needed health care due to anticipated ’ of SGM individuals overall subjugation and persecution. stigma from providers. Sadly, these findings are consistent Experiences of microaggressions are pervasive in the with other studies that have documented similar chal- TGD community and serve to repeatedly invalidate TGD lenges (Puckett, Cleary, Rossman, Newcomb, & Mus- identities. Microaggression can be perpetrated at the tanski, 2018; Radix, Lelutiu-Weinberger, & Gamarel, individual/interpersonal level in one-on-one interactions, 2014; Reisner et al., 2015; Shipherd, Green, & Abramo- the group level such as transwomen being excluded from a vitz, 2010). In sum, TGD-related discrimination limits women-only social group (including in sexual minority opportunities and access to resources, including health communities), and institutional and policy levels such as care, housing, and employment. with nondiscrimination policies (Nadal et al., 2011). In the largest survey of TGD people in the U.S. (N = 27,715) the Minority Stress and Internalized Transphobia in TGD National Transgender Discrimination Survey (NTDS) re- People ported that only 11% of respondents had updated all their identity documents to reflect current name and gender, Distal Gender Minority Stressors while more than two-thirds (68%) reported that none of Importantly, each of the stressors described above (i.e., their IDs had been updated (James et al., 2016). The primary Criterion A trauma, microaggressions, discrimination) TGD Trauma Treatment 633 may also be categorized as distal minority stressors within the anti-TGD experiences. Moreover, these experiences and Gender Minority Stress Model (Hendricks & Testa, 2012). their consequences accrue across the social ecology, with As we have mentioned, TGD people may experience risk factors operating at the macro- (e.g., policy, distal minority stressors, including documentation prob- legislation), mezzo- (e.g., practices of healthcare settings, lems, difficulty obtaining medical care, and even lack of clinics, and universities), and micro- (e.g., interpersonal access to safe restrooms. In addition, TGD people and intrapersonal functioning) levels. As such, a truly experience chronic and pervasive nonaffirmation or comprehensive case conceptualization and treatment invalidation of TGD identity by society due to cisgender approach to promoting trauma recovery in the TGD binary cultural messages (e.g., sex assigned at birth is the community will require interventions that attend to all cultural default for gender identity) as well as individual- these experiences. Below we provide guidance for mental level invalidation, which occurs when one’s internal sense health providers attempting to address disparities associ- of gender identity is not affirmed by others (e.g., ated with trauma exposure and its sequelae among TGD misgendering or refusal to use correct pronouns). individuals, including prevention strategies. Proximal Gender Minority Stressors Proximal minority stressors include intra- and/or Macro-Level Interventions for Trauma-Exposed TGD interpersonal stressors that may result from exposure to People distal minority stressors. These stressors may also consti- The Gender Minority Stress Model is helpful in tute clinically significant experiences worthy of clinical understanding increased rates of depression, anxiety, attention. For example, because TGD people are chron- substance use, PTSD, and other mental health symptoms ically exposed to invalidating, cisgender binary cultural among TGD people. This model also suggests macro-level messages (Puckett & Levitt, 2015), these stigmatizing interventions for providers to help prevent or mitigate the messages may be internalized, contributing to shame and disparities in exposure. For example, in many cities and guilt (over and above typical trauma reactions), as well as states it is not illegal to discriminate against TGD people social isolation, all of which can complicate and magnify in housing, employment (Gleason et al., 2016), and the impact of trauma (Barr, 2018). Similarly, TGD public accommodations (e.g., public transportation). individuals’ experience of proximal minority stressors More than just the lack of protections against discrimina- are shaped by factors unique to the social expression of tion, the rise of discriminatory policies such as “bathroom gender (Testa, Habarth, Peta, Balsam, & Bockting, 2015). bills” (where people must use restrooms consistent with For example, TGD individuals’ decisions around identity birth sex) and bans on military service in the U.S. send concealment versus disclosure may depend on such clear and consistent messages to TGD people that they are factors as genetics (to the extent that they determine not welcome or valued. In 2018, 21 anti-TGD bills were body shape and size) and access to gender-confirming introduced in 10 states in the U.S. (HRC, 2018). These interventions. Unfortunately, there is growing evidence policies are harmful. As an example, employment that TGD identity concealment is itself stressful and can nondiscrimination protection was associated with 26% be detrimental to health (Rood et al., 2017), though reduced odds of mood disorders and 43% reduced odds concealment makes sense in this societal context. Paired of self-directed violence relative to TGD people without with ongoing threat of future discrimination, traumatic such protections (Blosnich et al., 2016). Discriminatory harm and invalidation, these proximal stressors (i.e., policies devalue TGD people and put them in danger for internalized stigma, identity concealment, fear of rejec- discrimination and outright violence. tion) can degrade a survivor’s ability to cope with TGD people have long been engaged in the frontlines criterion A traumatic events, especially when the trauma and grassroots of fighting macro-level systems of oppres- is perceived to be related to their TGD identity. sion (Stryker, 2004). Such collective activism has the potential to not only advance change in systems but may Implications for Intervention for Trauma-Exposed TGD also help TGD individuals connect with the strength and People resilience of the transgender community. In this way, Theoretical conceptualizations of symptom develop- collective activism may also be an empowering and ment in trauma-exposed TGD individuals presented effective strategy for combatting the effects of internalized above highlight a complex interaction of overlapping stigma and other proximal minority stressors (Ashmore, factors contributing to symptom development, including Deaux, & McLaughlin-Volpe, 2004; Testa, Jimenez, & exposure to violence, discrimination, microaggressions, Rankin, 2014). Indeed, social activism constitutes a and minority stressors (see Figure 2). Thus, it is important rejection of social pressure to conceal stigmatized aspects to consider interventions and treatment for trauma and of identity, replacing isolation and stigma with connection PTSD symptoms, but also for the broader range of clients’ and pride (Hughto, Reisner, & Pachankis, 2015). 634 Shipherd et al.

However, social activism is not without risk. It is important policies, and work to pass inclusive legislation and to recognize that there could be exacerbations of distress protections in policies. Getting involved in systems change associated with participating in social change activities at the state or national level is easier than most people due to the increased focus on discriminatory policies and think, and might include joining or contributing to invalidation of gender diversity. Moreover, public activism organizations such as the ones listed alphabetically in always carries a risk of exposure to counter protesters Table 1. including those with strong anti-TGD views. Thus, for TGD people who are drawn to social activism, this work Mezzo-Level Interventions for Trauma-Exposed TGD must be approached in a balanced manner, keeping self- People care at the forefront. For non-TGD providers who seek to Even at the mezzo or organizational level, including offer treatments to the TGD community, participation in universities, hospitals, and clinics, it is important that social change is vital, both to demonstrate ally-ship and to policies and protections are in place for TGD people. In assure the provider is aware of the current state of the addition to nondiscrimination policies, a review of systems local culture. (e.g., does the medical record system recognize correct At the macro level of improving the mental health of name and gender), intake processes (e.g., options for TGD people, providers may choose to become involved in specifying pronoun use), physical space (e.g., all gender their communities, to participate in the repeal of harmful bathrooms, inpatient rooms based on gender not birth

Table 1 Organizations Providing Macro-Level Advocacy

Organization Website Description Communities https://communitiesagainsthate.org/ Coalition led by The Leadership Conference Education Fund and Against Hate the Lawyers’ Committee for Civil Rights Under Law to advocate for systems-level change to reduce Hate Crimes. Communities Against Hate receives strategic advisement form The Southern Poverty Law Center. They also provide a safe place for survivors of hate crimes and witnesses to share stories of hate incidents through an online database and telephone hotline and connect survivors and witnesses to legal resources and social services. Human Rights https://www.hrc.org/ Largest national lesbian, gay, bisexual, transgender and queer Campaign civil rights organization. TGNC specific initiatives include efforts to educate the public and provide resources on TGNC issues including workplace discrimination, securing identity documents, accessing culturally competent health care, family and parenting issues, and combating violence. Lambda Legal https://www.lambdalegal.org/ A national organization committed to achieving full recognition of the civil rights of , , bisexuals, transgender people and everyone living with HIV through impact litigation, education and public policy work National Center https://transequality.org National organization that advocates to change policies and for Transgender society to increase understanding and acceptance of Equality transgender people. Current initiatives include legal support services for navigating name and gender change processes as well as efforts to ensure the perspectives and priorities of transgender people of color, and those who live in urban and rural poverty, are part of the national policy and advocacy agenda National Coalition https://avp.org/ncavp/ A national coalition of local member programs and affiliate of Anti-Violence organizations that work to create systemic and social change Programs through data analysis, policy advocacy, education, and technical assistance. Trans Life Line https://www.translifeline.org/ A national trans-led organization focused on intervening to reduce trans- and improve overall life-outcomes of trans people by facilitating justice-oriented, collective community aid. Trans Life Line provides direct service, material support, advocacy, and education. TGD Trauma Treatment 635 sex), and visual cues in the environment (e.g., signs to TGD people (American Psychological Association, indicating TGD people are welcome) can begin to address 2015; Puckett, Barr, Wadsworth, & Thai, 2019). But what these mezzo-level barriers to care. For additional guidance has yet to be addressed is how to conceptualize symptoms on ways to become more inclusive in your clinical settings, resulting from a variety of experiences. Moreover, the see Cochran, Reed, and Gleason’s(2018)suggestions for chronic invalidation of TGD people’s identities is an creating a welcoming environment. Increasingly, clinical ongoing stressor that is likely to continue due to our settings have been adding the rainbow flag to recruitment binary cisgender culture. Best practices in trauma and waiting room signs to demonstrate that SGM clients are treatment for TGD people who present with this variety welcome. This is a good step forward; however, providers of invalidating clinically significant experiences are only should be aware that there is a TGD-specific flag that is blue, now developing. Recently, a book chapter (Valentine, white, and pink and should also be considered for inclusion Woulfe, & Shipherd, 2019)begantooutlinethe in signage. differences between the various clinically significant Organizations may also invest in bystander interven- experiences, including criterion A traumatic events. tion trainings (e.g., teaching people how to speak up and These constructs were further expanded by SGM veteran defend TGD people when they witness discrimination) to focus group participants (Livingston, Berke, Ruben, harness the potential of allies to prosocially intervene to Matza, & Shipherd, 2019) and TGD participants from interrupt and/or prevent social harm to TGD individuals. that focus group, more specifically in a recent presenta- Bystander trainings have primarily focused on addressing tion (Shipherd, Ruben, Berke, & Livingston, 2018). sexual harassment on college campuses (e.g., University Participants in the focus groups described seeking of New Hampshire’s “Bringing in the Bystander”), but treatment for multiple clinically significant experiences, more general discrimination-based trainings (e.g., including the multiple overlapping constructs of criterion American Friends Service Committee) can be applied to A traumatic events, discrimination experiences, minority supporting the TGD community. Such trainings may be stressors (proximal and distal) and microaggressions, as beneficial in that they communicate that protecting the we have described in the Trauma and Minority Stress integrity and safety of TGD individuals is the responsibility Exposure Model (see Fig. 2). In addition to the macro- of the entire community (not just its TGD members). and mezzo-level interventions noted above, below we Moreover, these trainings may teach strategic skills for describe micro-level (in-the-room intervention) trauma making sometimes-invisible harms (e.g., microaggres- treatment conceptualization, assessment, and treatment sions) visible, disarming and educating those who engage strategies for TGD people across these domains. in harmful behavior, and accessing other sources of social and/or institutional support (Sue et al., 2019). Moreover, PTSD Treatment Among Trauma-Exposed TGD People hiring practices should be reviewed. Ideally, universities, hospitals, and clinics should have inclusive hiring policies PTSD assessment. Given the nearly universal exposure to so that the staff are reflective of the community that they traumatic events among TGD people, routine assessment serve. Indeed, hiring, valuing, and retaining TGD mental of trauma exposures is indicated, using measures such as health staff can go a long way to building credibility in the the Life Events Checklist for DSM-5 (LEC-5; Weathers, community. In addition, having support group leaders Blake, Schnurr, Kaloupek, Marx, & Keane, 2013a)or who are members of the TGD community are more other similar measures. For this assessment, it is suggested readily credible. Online support groups can also be to evaluate if interpersonal traumatic events are perceived helpful if there is no reputable support group for TGD to be related to the TGD individual’s identity (e.g., people at the agency or in the surrounding community. discrimination-based trauma) as this can have important However, the oversight and leadership of online support clinical implications (Pantalone, Valentine, & Shipherd, groups can vary and changes happen regularly. Staying 2016; Valentine et al., 2019). Next, evaluation of PTSD up-to-date on the most current options takes some symptoms associated with a specific event would be investment of time but can provide immeasurable support indicated using the gold-standard clinical assessment and validation. In these ways, providers can fulfill their The Clinician-Administered PTSD Scale for DSM-5 ethical responsibilities to assure safe environments for (CAPS-5; Weathers, Blake, Schnurr, Kaloupek, Marx, & treatment. Keane, 2013b), which can provide an excellent overview of the symptoms a client is experiencing.

Micro-Level Interventions: Applying Cultural Additional posttrauma and co-occurring symptom assess- Competence to TGD Trauma Survivor Treatment ments. Clients come to treatment for a variety of In recent years, there has been increased attention on reasons. Sometimes a particular set of symptoms following cultural competence for providing mental health services trauma, with or without PTSD, are particularly 636 Shipherd et al. bothersome and may be worthy of focused clinical sleep quality and patterns of sleep in adults and can attention. Common and notable concerns, which have capture change over the course of treatment with the been shown to increase in frequency and severity in measure assessing 1-month period (Buysse, Reynolds, response to both trauma exposure and distal and Monk, Berman, & Kupfer, 1989). Other quality self-report proximal minority stressors, include (hyper)vigilance, measures are specific sleep concerns such as insomnia intrusive thoughts, sleep problems, substance use prob- (e.g., Insomnia Severity Index; Morin, 1993) and sleep lems, and suicidality. Routine assessment of these apnea (Sleep apnea clinical score; Flemons, Whitelaw, common symptoms among TGD populations can be Brant, & Remmers, 1994) specifically. Daily sleep diaries useful to determine if additional skills training may be that assess client-specific sleep concerns can also provide needed in a particular area following evidence-based useful information. Several standard sleep diaries and self- PTSD treatment. However, none of these standard report measures are reviewed in Ibáñez et al. (2018). measures have been tested or validated specifically for Rates of substance use are higher among trauma use with TGD populations. survivors and among those with PTSD in particular A scale that can be helpful in evaluating vigilance over (McCauley, Killeen, Gros, Brady, & Back, 2012). Individ- the course of treatment is the six-item Heightened uals with trauma histories and PTSD report using Vigilance Scale. This scale was developed for the 1995 substances to manage, avoid, and cope with PTSD Detroit Area Study (Jackson & Williams, 1995); however, it symptoms, such as hyperarousal (McCauley et al., 2012). has been used in subsequent studies assessing the Elevated risk-taking, which is a listed hyperarousal influence of vigilance on health among racial minorities symptom, can also give risk to higher rates of substance (Clark, Benkert, & Flack, 2006; Hicken, Lee, Ailshire, use and related impairment (Tull et al., 2009), whether or Burgard, & Williams, 2013). Another troublesome symp- not the use is also -motivated. Further, higher rates tom can be intrusive thinking, which can span many of substance use have also been observed among TGD disorders (e.g., anxiety, depression, ), but individuals (Day, Fish, Perez-Brumer, Hatzenbuehler, & is salient and prominent among trauma survivors, Russell, 2017), and could be attributable to higher rates of particularly those with PTSD. The five-item Experience trauma exposure, TGD-based discrimination, and coping of Intrusions Scale (EIS; Salters-Pedneault, Vine, Mills, motivations for use (see Hendricks & Testa, 2012). It is Park, & Litz, 2009) measures clinically relevant aspects of therefore critical to monitor substance use and disorder intrusive cognitions, including the frequency and inten- symptoms, which can be accomplished with relative ease sity of the thoughts (e.g., distress, unpredictability, through use of standard assessment measures such as the unwantedness, and interference). clinician-administered Addiction Severity Index (ASI; Sleep problems can be a particularly difficult symptom to McLellan et al., 1992) and self-report screening and cope with and can dramatically impact functioning. Stress symptom monitoring tools such the Alcohol Use Disor- and trauma have been linked to sleep difficulties more ders Identification Test (AUDIT; Saunders, Aasland, generally (Maher, Rego, & Asnis, 2006), and minority Babor, de la Fuente, & Grant, 1993), Quick Drink Screen stress has been shown to contribute to sleep disturbances (QDS; Sobell et al., 2003), Drug Use Disorders Identifi- (Li et al., 2017; Timmins, Rimes, & Rahman, 2017). cation Test (DUDIT; Berman, Bergman, Palmstierna, & Specifically, difficulty initiating and maintaining sleep has Schlyter, 2005), and Drug Abuse Screening Test (DAST; been linked with discrimination and victimization (Li et Skinner, 1982). Supplemental skills-based treatments for al., 2017) and disrupted familial/interpersonal relation- each of these clusters of symptoms are also described ships (Patterson, Tate, Sumontha, & Xu, 2018). Further, below. rumination, psychological distress, and substance use Finally, an additional area of concern among trauma- have been shown to negatively impact sleep (Graham & exposed TGD people is suicidality (Blosnich et al., 2013; Streitel, 2010; Slavish & Graham-Engeland, 2015), and Blosnich, Brown, Wojcio, Jones, & Bossarte, 2014). It is each has been shown to increase following minority stress believed that if distress can be reduced and coping skills exposure (Hatzenbuehler, 2009; Livingston et al., 2017; improved as described below, suicidality will also reduce. Livingston, Christianson, & Cochran, 2016). Although Routine assessment and safety measures (e.g., TransLife- more research is needed, it is important to consider sleep Line) should be a part of any culturally competent quality and possible contributors to sleep problems treatment with TGD clients. among TGD individuals. Assessment of sleep problems can include a variety of techniques including self-report PTSD treatment. Fortunately, when PTSD is present and objective techniques such as polysomnography and there are several empirically supported treatment op- actigraphy, to name a few (Ibáñez, Silva, & Cauli, 2018). tions. These treatments are supported by major psycho- Among the many self-report measures, the nine-item logical organizations such as Association for Behavioral Pittsburgh Sleep Quality Index is designed to measure and Cognitive Therapies (ABCT, n.d.), International TGD Trauma Treatment 637

Society for Traumatic Stress Studies (ISTSS, n.d.) and the that target the clinical needs. PTSD treatment is well American Psychological Association (APA; APA, 2017). suited to address symptoms related to criterion A There are currently three evidence-based treatments for events, but does not address the ongoing context of adults with PTSD: Prolonged Exposure (PE; Foa, chronic invalidation of identities, stress, stigma and Chrestman, & Gilboa-Schechtman, 2008), Cognitive discrimination-based events. Coping skills (e.g., from Processing Therapy (CPT; Resick, Monson, & Chard, DBT, mindfulness-based approaches, general cognitive 2016), and Eye Movement Desensitization and Reproces- behavioral approaches, or even general self-care skills) sing (EMDR; Shapiro, 2005). Although none of these can assist with treatment of chronic invalidation of treatments have been explicitly tested for use with TGD identity in the form of discrimination (see also clients, and TGD identity is often not recorded or Valentine et al., 2019). reported in randomized clinical trials (e.g., Flentje, Routine assessment of symptoms across treatment on a Bacca, & Cochran, 2015; Heck, Mirabito, Lemaire, self-report measure such as the PTSD Checklist for DSM-5 Livingston, & Flentje, 2017), it can be assumed that (PCL-5; Weathers, Litz, et al., 2013) can help track there would be some benefit from these trauma-focused progress in therapy. However, as with any quality treatments as they have documented benefit across a treatment, the context of the trauma exposure and variety of populations. For example, given its emphasis on recovery must be taken into account. For example, most cognitive intervention strategies, CPT may be useful for trauma-focused treatment assumes that the trauma is in TGD individuals, as this treatment targets issues related to the past, and that reminders are due to pathological trust, safety, power, control, and intimacy that can stem hypervigilance or distorted thoughts. This approach from both criterion A trauma and discrimination (invali- presumes safety, which is the exception rather than the dation) experiences. Moreover, a Dialectical Behavior rule for TGD people. Thus, one challenge with PTSD Therapy (DBT) combined with PE has been gaining favor treatment in the TGD community is evaluating adaptive in the global PTSD treatment literature for treatment of vigilance versus hypervigilance. PTSD in clients whose functioning is impacted by the extreme or repetitive invalidation of private experiences, Coping with residual attentional vigilance. Trauma treat- characteristics, or reactions (DBT-PE; Harned, Korslund, ment can benefit from supplementary skills training, & Linehan, 2014; Myers et al., 2017). With its emphasis on particularly around improving the accuracy of threat exposure as the primary treatment strategy for trauma- detection. Unfortunately, it is known that PTSD symptoms related distress, the DBT-PE formulation and treatment can result in quick detection of threat as well as difficulty approach is also likely to be highly applicable to the TGD with redirection of attention from initial perceived threat, community, as it provides a framework for directly termed attentional interference (Pineles, Shipherd, Welch, & confronting and processing both criterion A trauma and Yovel, 2007; Pineles, Shipherd, Mostoufi, Abramovitz, & discrimination (invalidation) experiences. Yovel, 2009; Wisco, Pineles, Shipherd, & Marx, 2013). In Despite clear empirical support for trauma-focused this work, difficulty withdrawing attention from threat was interventions among putatively cisgender populations, it related to increased use of thought suppression and can be difficult to know how to proceed given the lack of worry, which accounted for the relationship between outcome research among TGD clients. This is especially attentional interference and PTSD symptoms (Wisco et true given the focus of these treatments on addressing al., 2013). This suggests that acceptance-based or third- past traumatic events (e.g., addressing trauma-based wave cognitive behavioral interventions might be partic- cognitions about self, others, and the world), which may ularly helpful in addressing thought suppression and be complicated in the context of ongoing and sometimes worry that underlie difficulty in redirecting attention. daily stressors (e.g., discrimination) related to their TGD Though these interventions have not been tested identity. Trauma-focused treatment in the context of specifically with TGD people, attention training tech- ongoing discrimination and even new traumas is a niques (Wells, 1990) could be beneficial and has shown challenge at best. Some have even argued that some promise with trauma survivors (Callinan, Johnson, discrimination-based events should be considered criteri- & Wells, 2015) and following stressful life events (Nassif & on A events, even when they do not meet the DSM Wells, 2014). definition (e.g., Holmes, Facemire, & DaFonseca, 2016). We agree with those authors that chronic invalidation of Coping with residual intrusive thoughts. Many trauma- identity, devaluing by society, and exposure to stress, exposed populations grapple with intrusive thoughts, as stigma, and discrimination are worthy of multilevel they are a common and normative experience following intervention and prevention initiatives. However, we trauma. While the presence of intrusive thoughts is very urge providers to be thoughtful about case conceptuali- common, people often fear that they might be “going zation and treatment planning and consider treatments crazy” (Shipherd, Beck, Hamblen, & Freeman, 2000). 638 Shipherd et al.

Unfortunately, these negative reactions to having intru- Shokoohi, 2016), and the associations between trauma, sive thoughts can be predictive of poorer long-term minority stress, and elevated substance use are well- mental health and functional consequences (e.g., Bliese, documented (Clements-Nolle, Marx, & Katz, 2006; Coulter Wright, Adler, Thomas, & Hoge, 2007; Davidson & Baum, et al., 2015; Gamarel et al., 2015; Gonzalez, Gallego, & 1993). To address this concern, active-duty soldiers were Bockting,2017;Grantetal.,2011;Keuroghlian,Reisner, taught brief mindfulness-based skills to cope with intrusive White, & Weiss, 2015). Substance use is often a central life- thoughts postdeployment and they demonstrated benefits threatening or quality of life-interfering consideration in up to 1 month later, with reductions in distress and therapy and represents a primary target during the earlier interference from the thoughts, PTSD symptoms and states of treatment (Dimeff & Linehan, 2008; Linehan, 1993; general distress (Shipherd, Salters-Pedneault, & Fordiani, Koerner, 2012). Despite the fact that substance use outcome 2016). The benefits were found across a variety of studies rarely if ever report participants’ TGD identity intrusive thoughts following deployment, including (Flentje et al., 2015), it is reasonable to assume that existing thoughts about traditional traumatic events such as injury treatments generalize to TGD individuals until new research and combat, but also among a wider array of concerns becomes available. Empirically supported cognitive behav- such as about family and leadership concerns (Shipherd, ioral interventions, such as Motivational Interviewing Salters-Pedneault, & Matza, 2016). For an interactive (McGovern & Carroll, 2003), Motivational Enhancement demonstration about how to apply mindfulness tech- Therapy (MET; McGovern & Carroll, 2003), and cognitive niques in a therapy session, see Shipherd and Fordiani behavioral interventions for coping and relapse prevention (2015) online. There are several mindfulness-based (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012; McGovern treatments, including ones adapted to address the needs & Carroll, 2003); contingency management and family-based of trauma survivors, such as Acceptance and Commitment interventions (McGovern & Carroll, 2003); and pharmaco- Therapy (ACT; Pohar & Argaez, 2017; Walser & Westrup, therapies (e.g., naltrexone; McGovern & Carroll, 2003)may 2007) and Mindfulness Based Stress Reduction (MBSR; be used as stand-alone or adjunctive interventions in the Kabat-Zinn, 2013; Lehrhaupt & Meibert, 2017; Polusny et contextofongoingtrauma-and/orminoritystress-focused al., 2015) as well as other mindfulness-based treatments therapies. Carefully implemented family-based interventions (for a review see Boyd, Lanius, & McKinnon, 2018). These may be especially useful given the effects of family rejection mindfulness-based approaches to intrusive thoughts can on TGD individuals and the importance of chosen families supplement evidence-based PTSD treatment and are and/or families of origin in supporting substance use entirely consistent with models of care that address the recovery (Agosto,Reitz,Ducheny,&Moaton,2019). sequelae of invalidating environments. It is anticipated that mindfulness of thoughts could assist TGD people Treatment of Discrimination Sequelae With Trauma Exposed who struggle with persistent intrusive thoughts and/or TGD People worry, even after a course of PTSD treatment. Theoret- ically, they could assist with the ability to have more Assessment of discrimination experiences. Everyday Dis- flexible and adaptive attentional capacities. crimination Scale (Williams, Yu, Jackson, & Anderson, 1997) was originally developed for use with racial and Coping with residual sleep problems. When sleep con- ethnic minority clients and has since been applied for use tinues to be problematic, even after PTSD treatment, or in with TGD people (e.g., Reisner et al., 2016). The measure response to past and/or ongoing minority stress, reviewing assesses people treating a TGD person with less courtesy good sleep hygiene practices are often a place to start or respect, threatening or insulting them, receiving poor (National Sleep Foundation, n.d.). In addition, brief sleep- treatment at stores or restaurants, and so on. A nice focused CBT can be beneficial (Germain, Shear, Hall, & feature of the measure is that it allows clients to indicate Buysse, 2006). Some find routine mindfulness meditation the perceived source of the discriminatory experience to helps to calm overall autonomic arousal and improve sleep 10 different individual difference variables (e.g., ances- (e.g., Howell, Digdon, & Buro, 2010; Ong, Ulmer, & try/national origin, gender, race, age, religion, height, Manber, 2012). Finally, for TGD people with inadequate weight, some other aspect of one’s physical appearance, housing (e.g., “couch surfing”) or who are experiencing sexual orientation, education or income level), which can homelessness, sleep may be particularly disrupted and can help identify intersectionality of minority experiences (e, be addressed through housing stability interventions. g., with TGD people of color). A companion, Major Experiences of Discrimination Scale, is also helpful Coping with co-occurring or residual substance use (Williams et al., 2008) to assess experiences such as problems. TGD individuals evidence higher rates of sub- being fired or denied a job, denied housing, and other stance use compared to cisgender individuals (Reisner, such situations related to one’s minority identity. There Greytak, Parsons, & Ybarra, 2014; Scheim, Bauer, & are also shortened versions of both scales, including a five- TGD Trauma Treatment 639 item everyday discrimination and a six-item major identities and expression (Sloan et al., 2017). Because of the discrimination scale (Sternthal, Slopen, & Williams, pervasive and chronic impact of the invalidating environ- 2011). There are also several measures of heteronorma- ment, TGD people may struggle, despite their best efforts, to tive bias, but none specifically adapted to gender identity. regulate resultant emotional distress. Another essential scale to consider is the Gender Minority A DBT approach to the treatment of mental health Stress and Resilience Measure (GMSR; Testa et al., 2015). sequelae of discrimination therefore begins by validating the It includes assessment of nine areas, including gender- challenges of regulating emotion in the context of a dominant related discrimination, gender-related rejection, gender- culture pervaded by transphobia and invalidation of TGD related victimization, nonaffirmation of gender identity, individuals (Sloan et al., 2017; Sloan & Berke, 2018). DBT internalized transphobia, negative expectations for future acceptance skills (e.g., mindfulness, distress tolerance) can be events, nondisclosure, community connectedness, and leveraged to support TGD individuals to acknowledge and self- pride. These constructs can be subsumed under the Trauma validate pain and distress associated with their gender identity, and Minority Stress Exposure Model represented in this including societal responses or interpersonal rejection. Simul- paper under the themes of discrimination, microaggressions, taneously, DBT change skills (e.g., emotion regulation, trauma, and minority stress. interpersonal effectiveness) offer tools for more effectively It is also important to note that while this paper discusses managing distress by working to change the invalidating TGD people generally, there is increasing attention to the environment (e.g., ending destructive relationships, building heterogeneity within this community. As an example, gender supportive community) or to mitigate proximal gender- nonbinary and gender fluid people may face even more minority stressors (e.g., finding safe places to express rather discrimination relative to their binary conforming transgen- than conceal TGD identity; accessing medical transition; Sloan der peers. Indeed, gender nonbinary presentations appear & Berke, 2018). Increasingly, a DBT approach is being taken to to be associated with worse discrimination (Miller & assist TGD people to develop coping and emotion regulation Grollman, 2015) and clinicians struggle with their personal skills to fortify them against stigma and discrimination binary beliefs about gender, which can be a barrier to quality (see Oransky, Burke, & Steever, 2019). However, it bears care (Singh, 2016). Readers are encouraged to review the repeating that prevention of stigma and discrimination paper in this issue (see Matsuno, 2019) explicitly devoted through changes in our culture and policies at the macro to these clients. and mezzo levels are of chief importance, particularly as such prevention efforts would eliminate much of the need for this Treatment of discrimination experiences. Fortunately, tak- type of micro-level intervention to treat TGD people. ing an acceptance-based or third-wave cognitive behavioral Beyond its applicability to coping with the consequences approach, such as that described above with attentional of discrimination, DBT skills building can also be applied in difficulties, could also be useful for coping with the an integrated approach that prepares clients for trauma- experiences of discrimination, microaggressions, and minor- focused treatment (e.g., Harned et al., 2014; Myers et al., ity stressors. In one description of applying these techniques 2017). As one example, DBT-PE is designed to treat PTSD to the TGD population, Sloan and colleagues (Sloan, Berke, among complex clinical populations including suicidal and & Shipherd, 2017) describe the application of a DBT multidiagnostic clients. It is based on PE, one of the three framework to the treatment of TGD clients. The biosocial evidence-based trauma-focused PTSD treatments supported model, the theoretical framework underling DBT, posits that by methodologically rigorous research, and uses a stage- some expressions of clinical distress that disproportionately based approach to integrate DBT and PE procedures to impact TGD individuals (e.g., suicidality, substance use) may, address a full range of problems experienced by clinically in part, reflect underlying emotion regulation difficulties that complex clients with PTSD (Harned et al., 2014). Although arise over time, not as a consequence of biological this treatment approach may lend itself well to the treatment vulnerability to emotion dysregulation, per se,butasa of TGD trauma survivors coping with a complex constellation consequence of trauma exposure and/or chronic and of mental health challenges, it is important to note that DBT- pervasive exposure to an “invalidating environment” over PE has not been specifically evaluated among sexual and/or time (Linehan, 2014). Within biosocial theory, the invalidat- gender minority populations, but it is one of several ing environment is defined as an environment that fails to treatment approaches that hold promise. acknowledge the validity of an individual’s internal experi- ences, including one’semotionsandsenseofself(Linehan, Treatment of Microaggression Sequelae With Trauma-Exposed 1993). This definition encompasses distal minority stressors TGD People at both the interpersonal (e.g., discrimination, microaggres- sions, nonaffirmation of gender identity) and institutional Assessment of microaggressions. Recent work has begun level (e.g., absence of legal protections, lack of access to safe to identify categories of microaggressions against TGD bathrooms) that reject, negate, punish, or ignore TGD people (Chang & Chung, 2015; Nadal, Skolnik, & Wong, 640 Shipherd et al.

2012). In one qualitative study with nine TGD people, 12 dialogue. TGD group members might feel especially categories of microaggressions were identified: (a) use of welcome in cases where at least one of the group transphobic and/or incorrectly gendered terminology, facilitators identifies as TGD and/or when they have (b) assumption of universal transgender experience, (c) clear and demonstrated expertise in concerns facing exoticization, (d) discomfort/disapproval of transgender members of the TGD community. experience, (e) endorsement of gender normative and Whether peer- or provider-led, support groups do have binary culture or behaviors, (f) denial of existence of one drawback in that they can expose participants to stories transphobia, (g) assumption of sexual pathology/abnor- of invalidation of TGD identities, discrimination, and trauma mality, (h) physical threat or harassment, (i) denial of of other participants. Indeed, is not only a individual transphobia, (j) denial of bodily privacy, (k) positive factor but can also increase exposure to stress (e.g., familial microaggressions, and (l) systemic and environ- Carter et al., 2019). Care must be taken to maintain groups mental microaggressions (Nadal et al., 2012). Again, the that remain solution-focused as much as possible. On the “microaggression” categories can overlap with other positive side, support groups offer a space to acknowledge categories described earlier (e.g., physical threat or shared experiences that contextualize and normalize TGD harassment) in the categories of discrimination, minority individuals’ experiences, provide an opportunity for recip- stressors, and criterion A events (see Figure 2). Overlap in rocal support and advice (e.g., to more effectively manage the categories of microaggressions, minority stress, stigma; Bradford, Reisner, Honnold, & Xavier, 2013; discrimination and criterion A traumatic events makes Schrock, Holden, & Reid, 2004), as well as a safe space for interpretation of this literature challenging. For the TGD individuals to openly discuss experiences and concerns clinician, it is a good reminder of the many ways in without reproach. These benefits can be extremely potent which it can be difficult to understand the TGD for TGD individuals who are earlier in their gender identity experience if you are not a member of the community. development (Testa et al., 2014). However, the ability of However, as previously mentioned, this type of pervasive TGD individuals to take advantage of these supports can vary marginalization in combination with the forms of significantly as a function of their ability and willingness to discrimination and trauma described above create an disclose their TGD identity to others and the availability of invalidating environment. personal (e.g., time and finances) and community resources (e.g., local support groups and mental health-care profes- Treatment of microaggressions. Perhaps due to the sionals in rural vs. urban settings). Issues related to complexity of the literature and of understanding the confidentiality are more salient with in-person group options experiences of the TGD community (if this is not your as compared with online groups, as group members may be lived experience), it is important to recognize the value of morally but are not legally bound, as mental health providers TGD support groups. For better or worse, the sequelae of are, to maintain the confidentiality of other group members. microaggressions often are best managed with support Member confidentiality should remain a priority but may be from loved ones and others. Loved ones themselves may of greater importance among TGD individuals given also seek support groups where they can find people in potential safety concerns and desire for identity concealment similar situations supporting one another and offering for some TGD individuals. advice about managing difficult situations. The benefits of In the absence of in-person options, or if safety, in-person support for TGD people from family, chosen confidentiality, and anonymity concerns are the top priority, family, friends, and community members are significant online support options are available and have the capacity to and can promote resilience through activation of healthy connect TGD individuals from across the world (Evans et al., coping (e.g., improved social interaction and belonging, 2017). However, we encourage providers to carefully humor, shared interests and hobbies; Budge, Adelson, & consider their online recommendations to ensure that Howard, 2013; Pflum, Testa, Balsam, Goldblum, & information and practical advice contained therein is Bongar, 2015; Sánchez & Vilain, 2009). The same can correct, safe, and that the support provided is healthy and also be said for peer-based and provider-led support promotes resilience, as well as individual dignity and groups for TGD individuals, which can significantly autonomy (e.g., devoid of hate speech, or promotion of increase a sense of connectedness and bolster psycholog- conversion therapy; Evans et al., 2017). ical well-being among members of the TGD community (Frost & Meyer, 2012; Hendricks & Testa, 2012). Peer-led Treatment of Minority Stress With Trauma Exposed TGD People groups are available to TGD individuals and have the advantage being led and maintained by individuals who Assessment of minority stressors. As mentioned previously, share TGD identities. Provider-led groups provide a the Gender Minority Stress and Resilience Measure complementary alternative, with the added benefit of (GMSR; Testa et al., 2015) includes items assessing both expert leadership to facilitate therapeutic and supportive distal (e.g., gender-related discrimination, gender-related TGD Trauma Treatment 641

rejection, gender-related victimization, nonaffirmation of Summary gender identity) and proximal gender minority stressors TGD people are exposed to a variety of interrelated (internalized transphobia, negative expectations for clinically significant experiences, including criterion A future events, nondisclosure). The GMSR comprises a traumatic events, microaggressions, discrimination, and number of important strengths. In a recent systematic minority stress. These experiences can be experientially review of the psychometric literature on measures and cognitively related to one another, can complicate designed for use with TGD populations, GMSR subscales trauma recovery, and are described in the Trauma and received optimal ratings indicating suitability as gold- Minority Stress Exposure Model. The application of that standard indicators of transnegativity (Morrison, Bishop, model to TGD trauma survivors for the purpose of & Morrison, 2018). Moreover, the GMSR was designed to improving case conceptualization for appropriate treat- tap experiences of minority stress mapping directly onto ment plannng was described. Macro-level interventions to the Gender Minority Stress Model (Hendricks & Testa, improve environments where TGD people live, work, and 2012). As such, it contains questions that assess stressors recreate are essential, and a part of a clinician’s ethical unique to TGD individuals, including internalized trans- responsibility (Sloan and Shipherd, 2019). Similarly, phobia. Understanding the extent to which clients have mezzo-level change in the environment where treatments internalized stigmatizing messages about TGD identity are being delivered are essential to assure that the setting and expression is particularly valuable for treatment does not reinforce pathologizing messages. At the micro planning of micro-level interventions; the cognitive (e.g., level, we provide numerous assessment and intervention negative beliefs about oneself), behavioral (substance use, suggestions for helping TGD people overcome and fortify suicidality), and emotional (shame, guilt, emotion regu- themselves against the consequences of trauma, discrim- lation difficulties) correlates of internalized stigma may ination, microaggressions, and minority stress in their each warrant direct clinical intervention. A final strength daily lives. Empirically supported treatments that simul- of the GMSR is its inclusion of items to assess potential taneously address the resulting array of symptoms, sources of gender minority strength and resilience, including but not limited to PTSD, are generally including community connectedness and pride. Clini- indicated. In the Trauma and Minority Stress Exposure cians are encouraged to utilize information derived from Model described here, we posit a comprehensive case this measure to better understand these sources of conceptualization approach to treatment planning that is resilience, as these strengths can be leveraged to facilitate inclusive of the variety of experiences TGD people seek trauma recovery. treatment to address, including traumatic events, micro- aggressions, discrimination, and minority stressors. For Treatment of minority stressors. Reducing the shame some clients, evidence-based treatments for PTSD (PE, around one’s TGD identity conferred by the internalization CPT, and EMDR) may be delivered as a clear and linear of social stigma is a primary focus of micro-level interven- path toward symptom reduction. However, in many cases tions to help individuals to cope with the effects of minority trauma-recovery among TGD clients may require ap- stress (Coleman et al., 2012; Johnson & Yarhouse, 2013). proaches that also bolster skills for coping with the ESTEEM, a transdiagnositic CBT adapted for gay and residual or co-occurring consequences of traumatic bisexual men, focuses specifically on reducing minority events, microaggressions, discrimination, and minority stress processes that underlie sexual-orientation-related stress. These residual or co-occurring consequences can mental health disparities (Pachankis, Hatzenbuehler, include, but are not limited to, attentional vigilance, Rendina, Safren, & Parsons, 2015). For example, intrusive thinking, sleep and substance use problems, and ESTEEM session content focuses on raising client aware- suicidality. Skill-based interventions may be integrated ness of the impact of minority stress on health, emotion, into the delivery of trauma-focused PTSD treatment (e.g., behavior, and cognition as a means of motivating engage- DBT-PE), delivered sequentially as an adjunct to PTSD ment in cognitive restructuring and behavioral exposure treatment (e.g., Motivation Enhancement Therapy, brief activities designed to challenge internalized stigma, shame, sleep-focused CBT), or offered as a stand-alone interven- avoidance, and self-defeating behaviors (Pachankis et al., tion (e.g., ESTEEM). This can also include support group- 2015). Despite the tremendous promise of the ESTEEM based interventions and advocacy work. However, further model for redressing the effects of minority stress in gay and work is needed to empirically evaluate the use of these bisexual men, to date, the efficacy of this model has yet to be interventions among TGD trauma survivors, as well as to evaluated among TGD clients. Moreover, existing minority guide decision-making regarding the sequence and stress treatment models do not directly address the role of timing of treatment delivery for these interrelated trauma exposure on efforts to cope with ongoing minority clinically significant experiences (e.g., when to treat stressors (Livingston et al., 2019). PTSD and discrimination-related distress, separately 642 Shipherd et al. versus simultaneously). To improve recommendations, treatment literature and neurobiological evidence. Journal of Psychiatry and Neuroscience, 43(1), 7–25. https://doi.org/10.1503/ more research is needed with investigators who are jpn.170021 focused on better understanding trauma recovery Bradford, J., Reisner, S. L., Honnold, J. A., & Xavier, J. (2013). among TGD people. Similarly, an increase in the Experiences of transgender-related discrimination and implica- tions for health: Results from the Virginia Transgender Health availability of TGD clinicians would be of benefit in Initiative study. American Journal of Public Health, 103(10), reducing the burden experienced by the TGD commu- 1820–1829. https://doi.org/10.2015/AJPH.2012.300796 nity. Brown, G. R., & Jones, K. T. (2014). Racial health disparities in a cohort of 5,135 transgender veterans. Journal of Racial and Ethnic Health Disparities, 1(4), 257–266. References Budge, S. L., Adelson, J. L., & Howard, K. A. S. (2013). Anxiety and depression in transgender individuals: The roles of transition status, loss, social support, and coping. Journal of Consulting and Agosto, S., Reitz, K., Ducheny, K., & Moaton, T. (2019). Substance Clinical Psychology, 81, 545–557. use and recovery in the transgender and gender nonconform- Buysse,D.J.,Reynolds,C.F.,Monk,T.H.,Berman,S.R.,&Kupfer,D.J. ing(TGNC)olderadultcommunity.InC.Hardacker,K. (1989). The Pittsburgh sleep quality index: a new instrument for Ducheny, & M. Houlberg (Eds.), Transgender and gender psychiatric practice and research. Psychiatry Research, 28(2), 193–213. nonconforming health and aging (pp. 97–112). Cham, Switzer- Callinan, S., Johnson, D., & Wells, A. (2015). A randomised controlled land: Springer. https://doi.org/10.1007/978-3-319-95031-0_6 study of the effects of the attention training technique on American Friends Service Committee (d). Bystander Intervention. (n. traumatic stress symptoms, emotional attention set shifting and d.). Retrieved from. https://www.afsc.org/bystanderintervention. flexibility. Cognitive Therapy and Research, 39(1), 4–13. American Psychiatric Association [APA] (2013). Diagnostic and statistical Carter, S. P., Allred, K. M., Tucker, R. P., Simpson, T. L., Shipherd, J. C., manual of mental disorders,(5th ed.). Washington, DC: Author. & Lehavot, K. (2019). Discrimination and suicidal ideation among American Psychological Association (2015). Guidelines for psychological transgender veterans: The role of social support and connection. practice with transgender and gender nonconforming people. American LGBT Health.. https://doi.org/10.1089/lgbt.2018.0239 Psychologist, 70(9), 832–864. https://doi.org/10.1037/a0039906 Chang, T. K., & Chung, Y. B. (2015). Transgender microaggressions: American Psychological Association (2017). PTSD treatments. Complexity of the heterogeneity of transgender identities. Journal Retrieved January 28, 2019, from. https://www.apa.org/ptsd- of LGBT Issues in Counseling, 9(3), 217–234. guideline/treatments/index.aspx Clark, R., Benkert, R., & Flack, J. (2006). Large arterial elasticity varies Ashmore, R. D., Deaux, K., & McLaughlin-Volpe, T. (2004). An as a function of gender and -related vigilance in Black organizing framework for collective identity: Articulation and youth. Journal of Adolescent Health, 39, 562–569. significance of multidimensionality. Psychological Bulletin, 130, Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted suicide 80–114. https://doi.org/10.1037/0033-2909.130.1.80 among transgender persons: The influence of gender-based Association for Behavioral and Cognitive Therapies (d). Trauma.[Fact discrimination and victimization. Journal of , 51, sheet.]. (n.d.). Retrieved January 28, 2019, from. http://www.abct.org/ 53–69. https://doi.org/10.1300/J082v51n03_04 Information/?fa=fs_TRAUMA Cochran, B. N., Reed, O. M., & Gleason, H. A. (2018). Providing a Barr, S.M. (2018, November). Anti-transgender bias and non- welcoming environment. In M. R. Kauth, & J. C. Shipherd (Eds.), affirmation predict PTSD symptom severity in transgender adults: Adult transgender care: An interdisciplinary approach for training mental Evaluation of a model with partial mediation by internalized health professionals (pp. 44–60). New York, NY: Routledge. transphobia. In J. Shipherd (Discussant), Understanding the Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, experience of trauma and minority stress in lesbian, gay, bisexual, and G., Feldman, J., & Zucker, K. (2012). Standards of care for the transgender populations: Implications for conceptualization, practice, and health of transsexual, transgender, and gender-nonconforming policy. Symposium presented at the International Society of people, version 7. International Journal of Transgenderism, 13(4), Traumatic Stress Studies Annual Meeting, Washington, DC. 165–232. https://doi.org/10.1080/15532739.2011.700873 Beckman, K., Shipherd, J. C., Simpson, T. L., & Lehavot, K. (2018). Coulter, R. W. S., Blosnich, J. R., Bukowski, L. A., Herrick, A. L., Siconolfi, D. Military sexual assault and mental health in transgender veterans: E., & Stall, R. D. (2015). Differences in alcohol use and Results from a nationwide survey. Journal of Traumatic Stress, 31, alcohol-related problems between transgender- and nontransgender- 181–190. https://doi.org/10.1002/jts.22280 identified young adults. Drug and Alcohol Dependence, 154,251–259. Berman, A. H., Bergman, H., Palmstierna, T., & Schlyter, F. (2005). https://doi.org/10.1016/j.drugalcdep.2015.07.006 Evaluation of the Drug Use Disorders Identification Test Dank, M., Lachman, P., Zweig, J. M., & Yahner, J. (2010). Dating (DUDIT) in criminal justice and detoxification settings in a violence experiences of lesbian, gay, bisexual, and transgender Swedish population sample. European Addiction Research, 11(10), youth. Journal of Youth and Adolescence, 43, 846–857. 22–31. https://doi.org/10.1159/000081413 Davidson, L. M., & Baum, A. (1993). Predictors of among Bliese, P. D., Wright, K. M., Adler, A. B., Thomas, J. L., & Hoge, C. W. Vietnam veterans: Stressor exposure and intrusive recall. Journal of (2007). Timing of postcombat mental health assessments. Traumatic Stress, 6, 195–212. Psychological Services, 4(3), 141–148. Day, J. K., Fish, J. N., Perez-Brumer, A., Hatzenbuehler, M. L., & Russell, S. T. Blosnich, J. R., Brown, G. R., Shipherd, J. C., Kauth, M., Piegari, R. I., & (2017). Transgender youth substance use disparities: Results from a Bossarte, R. M. (2013). Prevalence of gender identity disorder and population-based sample. Journal of Adolescent Health, 61(6), 729–735. suicide risk among transgender veterans utilizing Veterans Health https://doi.org/10.1016/j.jadohealth.2017.06.024 Administration care. American Journal of Public Health, 103,e27–e32. Dimeff, L. A., & Linehan, M. M. (2008). Dialectical behavior therapy Blosnich, J. R., Brown, G. R., Wojcio, S., Jones, K. T., & Bossarte, R. M. for substance abusers. Addiction Science & Clinical Practice, 4(2), (2014). Mortality among veterans with transgender-related 39–47. diagnoses in the Veterans Health Administration, FY2000–2009. Evans,Y.N.,Gridley,S.J.,Crouch,J.,Wang,A.,Moreno,M.A., LGBT Health, 1, 269–276. Ahrens, K., & Breland, D. J. (2017). Understanding online Blosnich, J. R., Marsiglio, M. C., Gao, S., Gordon, A. J., Shipherd, J. C., resource use by transgender youth and caregivers: A qualitative Kauth, M., . . . Fine, M. J. (2016). Mental health of transgender study. Transgender Health, 2(1), 129–139. https://doi. veterans in US states with and without discrimination and hate org/10.1089/trgh.2017.0011 crime legal protection. American Journal of Public Health, 106(3), Flemons, W. W., Whitelaw, W. A., Brant, R., & Remmers, J. E. (1994). 534–540. Likelihood ratios for a sleep apnea clinical prediction rule. Boyd, J. E., Lanius, R. A., & McKinnon, M. C. (2018). Mindfulness- American Journal of Respiratory and Critical Care Medicine, 150(5), based treatments for posttraumatic stress disorder: A review of the 1279–1285. TGD Trauma Treatment 643

Flentje, A., Bacca, C., & Cochran, B. N. (2015). Missing data in substance Holmes,S.C.,Facemire,V.C.,&DaFonseca,A.M.(2016). abuse research? Researchers’ reporting practices of sexual orienta- Expanding criterion A for Posttraumatic Stress Disorder: tion and gender identity. Drug and Alcohol Dependence, 147,280–284. Considering the deleterious impact of oppression. Traumatology, https://doi.org/10.1016/j.drugalcdep.2014.11.012 22(4), 314–321. Foa, E. B., Chrestman, K. R., & Gilboa-Schechtman, E. (2008). Prolonged Howell, A. J., Digdon, N. L., & Buro, K. (2010). Mindfulness predicts Exposure Therapy for adolescents with PTSD: Emotional processing of sleep-related self regulation and well-being. Personality and traumatic experiences, therapist guide. New York, NY: Oxford Individual Differences, 48(4), 419–424. University Press. Hughto, J. M. W., Reisner, S. L., & Pachankis, J. E. (2015). Transgender Frost, D. M., & Meyer, I. H. (2012). Measuring community connectedness stigma and health: A critical review of stigma determinants, among diverse sexual minority populations. Journal of Sex Research, 49, mechanisms, and interventions. Social Science & Medicine, 147, 36–49. https://doi.org/10.1080/00224499.2011.565427 222–231. https://doi.org/10.1016/j.socscimed.2015.11.010 Gamarel, K. E., Mareish, E. H., Manning, D., Iwamoto, M., Operario, Human Rights Campaign (2018). A national epidemic: Fatal anti- D., & Nemoto, T. (2015). Minority stress, patterns, and transgender violence in America In 2018. Retrieved December 24, cessation attempts: Findings from a community sample of 2018, from. https://assets2.hrc.org/files/assets/resources/ transgender women in the San Francisco Bay Area. Nicotine & AntiTransViolence-2018Report-Final.pdf?_ga=2.242598210. Tobacco Research, 18(3), 306–313. 1782862444.1545663952-1283472057.1545663952. Germain, A. M., Shear, K., Hall, M., & Buysse, D. J. (2006). Effects of Ibáñez, V., Silva, J., & Cauli, O. (2018). A survey on sleep assessment a brief behavioral treatment for PTSD-related sleep distur- methods. PeerJ, 6e4849. bances: A pilot study. Behaviour Research and Therapy, 45(3), International Society for Traumatic Stress Studies (d). ISTSS guide- 627–632. lines position paper on complex PTSD in adults. (n.d.). Retrieved Gleason,H.,Livingston,N.A.,Peters,M.,Oost,K.,Reely,E.,&Cochran,B. January 28, 2019, from. http://www.istss.org/getattachment/ (2016). Effects of state nondiscrimination laws on transgender and Treating-Trauma/New-ISTSS-Prevention-and-Treatment- gender nonconforming individuals’ perceived community stigma and Guidelines/ISTSS_CPTSD-Position-Paper-(Adults)_FNL.pdf.aspx mental health. Journal of Gay and Lesbian Mental Health, 20(4), 350–362. Jackson, J. S., & Williams, D. (1995). Detroit Area Study, 1995: Social https://doi.org/10.1080/19359705.2016.1207582 influence on health: Stress, racism, and health protective resources. Ann Gonzalez, C. A., Gallego, J. D., & Bockting, W. O. (2017). An Arbor, MI: Inter-university Consortium for Political and Social Research, examination of demographic characteristics, components of 2002-08-16. . https://doi.org/10.3886/ICPSR03272.v1 sexuality and gender, and minority stress as predictors of excessive James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, alcohol, cannabis, and illicit (noncannabis) drug use among a M. A. (2016). The report of the 2015 US Transgender Survey. large sample of transgender people in the United States. Journal of Washington, DC: National Center for Transgender Equality Primary Prevention, 38(4), 419–445. https://doi.org/10.1007/ Retrieved from. https://transequality.org/sites/default/files/ s10935-017 0469-4 docs/resources/NTDS_Report.pdf Graham, S. E., & Streitel, K. L. (2010). Sleep quality and acute pain Johnson, V. R. F., & Yarhouse, M. A. (2013). Shame in sexual minorities: Stigma, severity among young adults with and without chronic pain: The internal cognitions, and counseling considerations. Counseling and Values, role of biobehavioral factors. Journal of Behavioral Medicine, 33(5), 58(1), 85–103. https://doi.org/10.1002/j.2161-007X.2013.00027.x 335–345. https://doi.org/10.1007/s10865-010-9263-y Kabat-Zinn, J. (2013). Full catastrophe living: Using the wisdom of your body Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & and mind to face stress, pain, and illness, Rev. ed. New York, NY: Keisling, M. (2011). Injustice at every turn: A report of the National Bantam Books. Transgender Discrimination Survey. Washington, DC: National Kauth, M.,. R., & Shipherd, J. C. (2017). How to begin: An introduction Center for Transgender Equality and National Gay and Lesbian to the book. In M. R. Kauth, & J. C. Shipherd (Eds.), Adult Task Force. transgender care: An interdisciplinary approach for training mental health Harned, M. S., Korslund, K. E., & Linehan, M. M. (2014). A pilot professionals (pp. 1–10). New York, NY: Routledge. randomized controlled trial of Dialectical Behavior Therapy with Keuroghlian, A. S., Reisner, S. L., White, J. M., & Weiss, R. D. (2015). and without the Dialectical Behavior Therapy Prolonged Expo- Substance use and treatment of substance use disorders in a sure protocol for suicidal and self-injuring women with borderline community sample of transgender adults. Drug and Alcohol Dependence, personality disorder and PTSD. Behaviour Research and Therapy, 55, 152,139–146. https://doi.org/10.1016/j.drugalcdep.2015.04.008 7–17. Koerner, K. (2012). Guides to individualized evidence-based treatment. Doing Hatzenbuehler, M. L. (2009). How does sexual minority stigma “get dialectical behavior therapy: A practical guide. New York, NY: Guilford under the skin”? A psychological mediation framework. Psycholog- Press. ical Bulletin, 135(5), 707–730. https://doi.org/10.1037/a0016441 Landers, S. J., & Gilsanz, P. (2009). The health of lesbian, gay, bisexual and Heck, N. C., Mirabito, L. A., LeMaire, K., Livingston, N. A., & Flentje, transgender (LGBT) persons in Massachusetts: A survey of health issues A. (2017). Omitted data in randomized controlled trials for comparing LGBT persons with their heterosexual and non-transgender anxiety and depression: A systematic review of the inclusion of counterparts. Commonwealth of Massachusetts: Dept. of Public sexual orientation and gender identity. Journal of Consulting and Health. Clinical Psychology, 85(1), 72–76. https://doi.org/10.1037/ Langenderfer-Magruder, L., Whitfield, D. L., Walls, N. E., Kattari, S. K., ccp0000123 & Ramos, D. (2016). Experiences of intimate partner violence and Hendricks, M. L., & Testa, R. J. (2012). A conceptual framework for subsequent police reporting among lesbian, gay, bisexual, clinical work with transgender and gender nonconforming transgender, and queer adults in Colorado: Comparing rates of clients: An adaptation of the Minority Stress Model. Professional cisgender and transgender victimization. Journal of Interpersonal Psychology: Research and Practice, 43(5), 460–467. Violence, 31(5), 855–871. Henry, R. S., Perrin, P. B., Coston, B. M., & Calton, J. M. (2018). Lehrhaupt, L., & Meibert, P. (2017). Mindfulness-based stress reduction: Intimate partner violence and mental health among transgender/ The MBSR program for enhancing health and vitality. Novato, CA: New gender nonconforming adults. Journal of Interpersonal Violence. World Library. https://doi.org/10.1177/0886260518775148 Li, P., Huang, Y., Guo, L., Wang, W., Xi, C., Lei, Y., . . . Lu, C. (2017). Is Hicken, M. T., Lee, H., Ailshire, J., Burgard, S. A., & Williams, D. R. sexual minority status associated with poor sleep quality among (2013). Every shut eye, ain’t sleep: The role of racism-related adolescents? Analysis of a national cross-sectional survey in vigilance in racial/ethnic disparities in sleep difficulty. Race and Chinese adolescents. BMJ Open, 7(12)e017067. https://doi. Social Problems, 5, 100–112. org/10.1136/bmjopen-2017-017067 Hofmann, S. G., Asnaani, A., Vonk, J. J., Sawyer, A. T., & Fang, A. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline (2012). The efficacy of Cognitive Behavioral Therapy: A review of personality disorder. New York, NY: Guilford press. meta-analyses. Cognitive Therapy and Research, 36(5), 427–440. Linehan, M. M. (2014). DBT skills training manual. New York, NY: https://doi.org/10.1007/s10608-012-9476-1 Guilford Press. 644 Shipherd et al.

Livingston,N.A.,Berke,D.B.,Ruben,M.A.,Matza,A.R.,&Shipherd,J.C. adolescents and young adults: The Mount Sinai Adolescent (2019). LGBT veterans’ experiences of identity-related trauma: Health Center approach.Cognitive and Behavioral Practice 26(4) , Unexpected findings and unresolved service gaps at the intersection 603 – 616. https: //doi.org/10.1016/j.cbpra.2018.03.002 of trauma and minority stress. Psychological Trauma: Theory, Research, Pachankis, J. E., Hatzenbuehler, M. L., Rendina, H. J., Safren, S. A., & Practice, and Policy. https://doi.org/10.1037/tra0000464 Parsons, J. T. (2015). LGB-affirmative cognitive-behavioral ther- Livingston, N. A., Christianson, N., & Cochran, B. N. (2016). Minority stress, apy for young adult gay and bisexual men: A randomized psychological distress, and alcohol misuse among sexual minority young controlled trial of transdiagnostic minority stress approach. adults: A resiliency-based conditional process analysis. Addictive Behaviors, Journal of Consulting and Clinical Psychology, 83(5), 875–889. https: 63, 125–131. https://doi.org/10.1016/j.addbeh.2016.07.011 //doi.org/10.1037/ccp0000037 Livingston, N. A., Flentje, A., Heck, N. C., Szalda-Petree, A., & Cochran, Pantalone, D. W., Valentine, S. E., & Shipherd, J. C. (2016). Working B. (2017). Ecological momentary assessment of daily discrimina- with survivors of trauma in the sexual minority and transgender/ tion experiences and nicotine, alcohol, and drugs use among gender nonconforming populations. In K. DeBord, T. Perez, A. sexual and gender minority individuals. Journal of Consulting and Fischer, & K. Bieschke (Eds.), The Handbook of Sexual Orientation Clinical Psychology, 85(12), 1131–1143. https://doi.org/10.1037/ and Gender Diversity in Counseling and Psychotherapy (pp. 183–211). ccp0000252 Washington, DC: American Psychological Association. Maher, M., Rego, S., & Asnis, G. (2006). Sleep disturbances in patients Patterson, C. J., Tate, D. P., Sumontha, J., & Xu, R. (2018). Sleep with post-traumatic stress disorder: Epidemiology, impact and difficulties among sexual minority adults: Associations with family approaches to management. CNS Drugs, 20(7), 567–590. relationship problems. Psychology of Sexual Orientation and Gender Matsuno, E. (2019). Nonbinary-affirming psychological interventions.Cogni- Diversity, 5(1), 109–116. https://doi.org/10.1037/sgd0000264 tive and Behavioral Practice 2 6(4), 6 17–6 28 . https://doi.org/10.1016/j. Pflum, S. R., Testa, R. J., Balsam, K. F., Goldblum, P. B., & Bongar, B. cbpra.2018.09.003 (2015). Social support, trans community connectedness, and McCauley, J. L., Killeen, T., Gros, D. F., Brady, K. T., & Back, S. E. mental health symptoms among transgender and gender non- (2012). Posttraumatic stress disorder and co-occurring substance conforming adults. Psychology of Sexual Orientation and Gender use disorders: Advances in assessment and treatment. Clinical Diversity, 2(3), 281–286. https://doi.org/10.1037/sgd0000122 Psychology, 19(3). https://doi.org/10.1111/cpsp.12006 Pineles, S. L., Shipherd, J. C., Mostoufi, S. M., Abramovitz, S. M., & McGovern, M. P., & Carroll, K. M. (2003). Evidence-based practices for Yovel, I. (2009). Attentional biases in PTSD: More evidence for substance use disorders. The Psychiatric Clinics of North America, 26 interference. Behaviour Research and Therapy, 47(12), 1050–1057. (4), 991–1010. https://doi.org/10.1016/j.brat.2009.08.001 McLellan, A. T., Kushner, H., Metzger, D., Peters, R., Smith, I., Grissom, G., & Pineles, S. L., Shipherd, J. C., Welch, L. P., & Yovel, I. (2007). The role Argeriou, M. (1992). The Fifth Edition of the Addiction Severity Index. of attentional biases in PTSD: Is it interference or facilitation? Journal of Substance Abuse Treatment, 9,199–213. Behaviour Research and Therapy, 45(8), 1903–1913. https://doi. Meyer, I. H. (1995). Minority stress and mental health in gay men. org/10.1016/j.brat.2006.08.021 Journal of Health and Social Behavior, 36(1), 38–56. Pohar, R., & Argaez, C. (2017). Acceptance and commitment therapy Meyer, I. H. (2003). as stress: Conceptual and measure- for post-traumatic stress disorder, anxiety, and depression: A ment problems. American Journal of Public Health, 93, 262–265. review of clinical effectiveness. CATDTH Rapid Response Report: https://doi.org/10.2105/AJPH.93.2.262 Summary with Critical Appraisal. Retrieved May 30, 2019, from. Miller, L. R., & Grollman, E. A. (2015). The social costs of gender https://www.ncbi.nlm.nih.gov/books/NBK525684/ nonconformity for transgender adults: Implications for discrim- Polusny, M. A., Erbes, C. R., Thuras, P., Moran, A., Lamberty, G. J., Collins, R. ination and health. Sociological Forum, 30(3), 809–831. C., & Lim, K. O. (2015). Mindfulness-based stress reduction for Morin, C. M. (1993). Insomnia: psychological assessment and management. posttraumatic stress disorder among veterans: A randomized clinical New York, NY: Guilford Press. trial. JAMA, 314(5), 456–465. https://doi.org/10.1001/jama.2015.8361 Morrison, M. A., Bishop, C. J., & Morrison, T. G. (2018). What is the Puckett, J. A., Barr, S. M., Wadsworth, L. P., & Thai, J. L. (2019). best measure of discrimination against trans people? A systematic Considerations for clinical work and research with transgender review of the psychometric literature. Psychology & Sexuality, 9(3), and gender diverse individuals. The Behavior Therapist, 41(5), 269–287. https://doi.org/10.1080/19419899.2018.1484798 253–263. Myers, L., Voller, E. K., McCallum, E. B., Thuras, P., Shallcross, S., Puckett, J. A., Cleary, P., Rossman, K., Newcomb, M. E., & Mustanski, B. Velasquez, T., & Meis, L. (2017). Treating veterans with PTSD and (2018). Barriers to gender-affirming care for transgender and Borderline Personality symptoms in a 12-week intensive outpa- gender nonconforming individuals. Sexuality Research and Social tient setting: Findings from a pilot program. Journal of Traumatic Policy, 15(1), 48–59. https://doi.org/10.1007/s13178-017-0295-8 Stress, 30, 178–181. Puckett, J. A., & Levitt, H. M. (2015). Internalized stigma within sexual Nadal, K. L. (2013). A brief history of lesbian, gay, bisexual, and transgender people and gender minorities: Change strategies and clinical implica- and civil rights. That's so gay! Microaggressions and the lesbian, gay, bisexual, tions. Journal of LGBT Issues in Counseling, 9(4), 329–349. and transgender community. Washington, DC: American Psychological Radix, A. E., Lelutiu-Weinberger, C., & Gamarel, K. E. (2014). Association, 14–37. https://doi.org/10.1037/14093-002 Satisfaction and healthcare utilization of transgender and gender Nadal, K. L., Skolnik, A., & Wong, Y. (2012). Interpersonal and systemic non-conforming individuals in NYC: A community-based partic- microaggressions toward transgender people: Implications for ipatory study. LGBT Health, 1(4), 302–308. https://doi. counseling. Journal of LGBT Issues in Counseling, 6(1), 55–82. org/10.1089/lgbt.2013.0042 Nadal, K. L., Wong, Y., Issa, M., Meterko, V., Leon, J., & Wideman, M. Reisner,S.L.,Greytak,E.A.,Parsons,J.T.,&Ybarra,M.L.(2014).Gender (2011). Sexual orientation microaggressions: Processes and minority social stress in adolescence: disparities in adolescent bullying coping mechanisms for lesbian, gay, and bisexual individuals. and substance use by gender identity. Journal of Sex Research, 52(3), Journal of LGBT Issues in Counseling, 5(1), 21–46. https://doi. 243–256. https://doi.org/10.1080/00224499.2014.886321 org/10.1080/15538605.2011.554606 Reisner,S.L.,Hughto,J.M.W.,Gamarel,K.E.,Keuroghlian,A.S., Nassif, Y., & Wells, A. (2014). Attention training reduces intrusive Mizock, L., & Pachankis, J. E. (2016). Discriminatory experi- thoughts cued by a narrative of stressful life events: A controlled ences associated with posttraumatic stress disorder symptoms study. Journal of Clinical Psychology, 70, 510–517. among transgender adults. Journal of Counseling Psychology, 63(5), National Sleep Foundation (d). Sleep Hygiene. (n.d.). Retrieved May 31, 509–519 2019, from. https://www.sleepfoundation.org/articles/sleep-hygiene Reisner, S. L., Pardo, S. T., Gamarel, K. E., Hughto, J. M. W., Pardee, D. Ong, J. C., Ulmer, C. S., & Manber, R. (2012). Improving sleep with J., & Keo-Meier, C. L. (2015). Substance use to cope with stigma in mindfulness and acceptance: A metacognitive model of insomnia. healthcare among US female-to-male trans masculine adults. Behaviour Research and Therapy, 50(11), 651–660. LGBT Health, 2(4), 324–332. Oransky, M., Burke, E. Z., & Steever, J. (2019). An interdisciplinary Reisner, S. L., White, J. M., Bradford, J. B., & Mimiaga, M. J. (2014). model for meeting the mental health needs of transgender Transgender health disparities: Comparing full cohort and nested TGD Trauma Treatment 645

matched-pair study designs in a community health center. LGBT Slavish, D. C., & Graham-Engeland, J. E. (2015). Rumination mediates the health, 1, 177–184. relationships between depressed mood and both sleep quality and self- Resick, P. A., Monson, C. M., & Chard, K. M. (2016). Cognitive Processing reported health in young adults. Journal of Behavioral Medicine, 38(2), Therapy for PTSD: A comprehensive manual. New York, NY: Guilford 204–213. https://doi.org/10.1007/s10865-014-9595-0 Publications. Sloan, C. A., & Berke, D. S. (2018). Dialectical Behavior Therapy as a Rood, B. A., Maroney, M. R., Puckett, J. A., Berman, A. K., Reisner, S. treatment option for complex cases of Gender Dysphoria. In M. R. L., & Pantalone, D. W. (2017). Identity concealment in Kauth, & J. C. Shipherd (Eds.), Adult transgender care: An transgender adults: A qualitative assessment of minority stress interdisciplinary approach for training mental health professionals and gender affirmation. American Journal of Orthopsychiatry, 87(6), (pp. 123–139). New York, NY: Routledge. 704–713. https://doi.org/10.1037/ort0000303 Sloan, C. A., Berke, D. S., & Shipherd, J. C. (2017). Utilizing a Salters-Pedneault, K., Vine, V., Mills, M. A., Park, C., & Litz, B. T. (2009). dialectical framework to inform conceptualization and treatment The Experience of Intrusions Scale: A preliminary examination. of gender dysphoria. Professional Psychology: Research and Practice, 48 Anxiety, Stress & Coping: An International Journal, 22(1), 27–37. (5), 301–309. https://doi.org/10.1037/pro0000146 Sánchez, F. J., & Vilain, E. (2009). Collective self-esteem as a coping Sloan, C. A., & Shipherd, J. C. (2019). Trauma recovery and sexual and resource for male-to-female transsexuals. Journal of Counseling gender minority communities: A call to action for providers. Psychology, 56, 202–209. https://doi.org/10.1037/a0014573 Traumatic StressPoints (2019, November). Saunders, J. B., Aasland, O. G., Babor, T. F., de la Fuente, J. R., & Grant, Sobell, L. C., Agrawal, S., Sobell, M. B., Leo, M. I., Young, L. J., M. (1993). Development of the Alcohol Use Disorders Identifi- Cunningham, J. A., & Simco, E. R. (2003). Comparison of a quick cation Test (AUDIT): WHO collaborative project on early drinking screen with the timeline followback for individuals with detection of persons with harmful alcohol consumption-II. alcohol problems. Journal of Studies on Alcohol, 64(6), 858–861. Addiction, 88,791–804. https://doi.org/10.1111/j.1360- https://doi.org/10.15288/jsa.2003.64.858 0443.1993.tb02093.x Sternthal, M., Slopen, N., & Williams, D. R. (2011). Racial disparities in Scheim, A. I., Bauer, G. R., & Shokoohi, M. (2016). Heavy episodic health: How much does stress really matter? Du Bois Review, 8(1), drinking among transgender persons: Disparities and predictors. 95–113. Drug and Alcohol Dependence, 167, 156–162. https://doi. Stotzer, R. L. (2008). Gender identity and hate crimes: Violence against org/10.1016/j.drugalcdep.2016.08.011 transgender people in Los Angeles county. Sexuality Research & Schrock, D., Holden, D., & Reid, L. (2004). Creating emotional Social Policy, 5(1), 43–52. resonance: Interpersonal emotion work and motivational framing Stryker, S. (2004). Transgender activism. In C. J. Summers (Ed.), in a transgender community. Social Problems, 51(1), 61–81. https: GLBTQ: An encyclopedia of gay lesbian bisexual transgender and queer //doi.org/10.1525/sp.2004.51.1.61 culture Retrieved January 28, 2019, from. http://www.glbtq.com/ Shapiro, F. (2005). Eye movement desensitization and reprocessing (EMDR) social-sciences/transgender_activism,3.html#citation training manual. Watsonville, CA: EMDR Institute Sue, D. W. (2010). Microaggressions in everyday life: Race, gender, and sexual Shipherd, J. C., Beck, J. G., Hamblen, J. L., & Freeman, J. B. (2000). orientation. Hoboken, NJ: John Wiley & Sons. Assessment and treatment of PTSD in motor vehicle accident Sue,D.W.,Alsaidi,S.,Awad,M.N.,Glaeser,E.,Calle,C.Z.,& survivors. In L. Vandecreek, & T. L. Jackson (Eds.), Innovations in Mendez, N. (2019). Disarming racial microaggressions: Micro- clinical practice: A source book (pp. 135–152). Sarasota, FL: intervention strategies for targets, White allies, and bystanders. Professional Resource Press. American Psychologist, 74,128–142. https://doi.org/10.1037/ Shipherd, J. C., & Fordiani, J. (2015). The application of mindfulness amp0000296 in coping with intrusive thoughts in cognitive and behavioral Swim, J. K., Pearson, N. B., & Johnston, K. E. (2007). Daily encounters practice. Cognitive and Behavioral Practice, 22(4), 439–446. https:// with heterosexism: A week in the life of lesbian, gay and bisexual doi.org/10.1016/j.cbpra.2014.06.001 individuals. Journal of Homosexuality, 53,18–31. https://doi. Shipherd, J. C., Green, K. E., & Abramovitz, S. (2010). Transgender org/10.1080/00918360802101179 clients: Identifying and minimizing barriers to mental health Testa,R.J.,Habarth,J.,Peta,J.,Balsam,K.,&Bockting,W.(2015). treatment. Journal of Gay and Lesbian Mental Health, 14(2), 94–108. Development of the gender minority stress and resilience measure. https://doi.org/10.1080/19359701003622875 Psychology of Sexual Orientation and Gender Diversity, 2(1), 65–77. Shipherd,J.C.,Kauth,M.R.,Firek,A.F.,Garcia,R.,Mejia,S.,Laski,S.J.,& Testa, R. J., Jimenez, C. L., & Rankin, S. (2014). Risk and resilience Byne, W. (2016). Interdisciplinary transgender veteran care: Training during transgender identity development: The effects of aware- for Veterans Healthcare Administration providers. Transgender Health, 1, ness of and engagement with other transgender people on affect. 54–62. https://doi.org/10.1089/trgh.2015.0004 Journal of Gay & Lesbian Mental Health, 18,31–56. https://doi. Shipherd, J. C., Maguen, S., Skidmore, W. C., & Abramovitz, S. M. org/10.1080/19359705.2013.805177 (2011). Potentially traumatic events in a transgender sample: Timmins, L., Rimes, K. A., & Rahman, Q. (2017). Minority stressors, Frequency and associated symptoms. Traumatology, 17(2), 56–67. rumination, and psychological distress in monozygotic twins https://doi.org/10.1177/1534765610395614 discordant for sexual minority status. Psychological Medicine, 48 Shipherd, J. C., Ruben, M. A., Berke, D. S., & Livingston, N. A. (2018, (10), 1705–1712. https://doi.org/10.1017/S003329171700321X November). Transgender veterans’ trauma recovery and discrim- Tull,M.T.,Trotman,A.,Duplinsky,M.S.,Reynolds,E.K.,Daughters,S.B., ination: Considerations for treatment. In J. Puckett (Symposium Potenza, M. N., & Lejuez, C. W. (2009). The effect of posttraumatic Chair), Minority stress, gender affirmation, and mental health in stress disorder on risk-taking propensity among crack/cocaine users in transgender individuals: Research and clinical perspectives. residential substance abuse treatment. Depression and Anxiety, 26(12), Presented at the 52nd annual meeting of the Association for Behavioral 1158–1164. https://doi.org/10.1002/da.20637 and Cognitive Therapies, Washington, DC. University of New Hampshire, Prevention Innovations Research Shipherd, J. C., Salters-Pedneault, K., & Fordiani, J. (2016). Evaluating post- Center (d). Bringing in the bystander. (n.d.). Retrieved from. deployment training for coping with intrusive cognition: A comparison https://cola.unh.edu/prevention-innovations-research-center/ of training approaches. Journal of Consulting and Clinical Psychology, 84 evidence-based. (11), 960–971. https://doi.org/10.1037/ccp0000136 Valentine, S. E., Peitzmeier, S. M., King, D. S., O'Cleirigh, C., Marquez, Shipherd, J. C., Salters-Pedneault, K., & Matza, A. (2016). Intrusive cognitive S. M., Presley, C., & Potter, J. (2017). Disparities in exposure to content and post deployment distress. Journal of Traumatic Stress, 29(4), intimate partner violence among transgender/gender noncon- 301–308. https://doi.org/10.1002/jts.22113 forming and sexual minority primary care patients. LGBT Health, 4 Singh, A. A. (2016). Moving from affirmation to liberation in (4), 260–267. https://doi.org/10.1089/lgbt.2016.0113 psychological practice with transgender and gender nonconform- Valentine, S. E., & Shipherd, J. C. (2018). A systematic review of social ing clients. American Psychologist, 71(8), 755–762. stress and mental health among transgender and gender non- Skinner, H. A. (1982). The drug abuse screening test. Addictive Behaviors, 7, conforming people in the United States. Clinical Psychology Review, 363–371. https://doi.org/10.1016/0306-4603(82)90005-3 66,24–38. https://doi.org/10.1016/j.cpr.2018.03.003 646 Shipherd et al.

Valentine, S., Woulfe, J., & Shipherd, J. C. (2019). An evidence-based and health in South Africa: Findings from the South Africa Stress approach to conceptualizing trauma responses among transgen- and Health Study. Social Science and Medicine, 67, 441–452. der and gender non-conforming (TGNC) adults. In J. E. Williams, D. R., Yu, Y., Jackson, J. S., & Anderson, N. B. (1997). Racial Pachankis, & S. A. Safren (Eds.), Handbook of evidence-based mental differences in physical and mental health: , health practice with LGBT clients New York, NY: Oxford University stress, and discrimination. Journal of Health Psychology, 2(3), 335–351. Press. Wisco, B. E., Pineles, S. L., Shipherd, J. C., & Marx, B. P. (2013). Walser, R. D., & Westrup, D. (2007). Acceptance and commitment therapy Attentional interference by threat and posttraumatic stress for the treatment of post-traumatic stress disorder and trauma-related disorder: The role of thought control strategies. Cognition and problems: A practitioner’s guide to using mindfulness and acceptance Emotion, 27(7), 497–502. https://doi.org/10.1002/da.22115 strategies. Oakland, CA: New Harbinger Publications. Weathers, F. W., Blake, D. D., Schnurr, P. P., Kaloupek, D. G., Marx, B. P., & Keane, T. M. (2013a). The Life Events Checklist for DSM-5 (LEC-5). Instrument available from the National Center for PTSD The views, opinions, and content of this publication are those of the at. www.ptsd.va.gov. authors and do not necessarily reflect the views, opinions, or policies Weathers, F. W., Blake, D. D., Schnurr, P. P., Kaloupek, D. G., Marx, B. of the Department of Veterans Affairs or the United States P., & Keane, T. M. (2013b). The Clinician-Administered PTSD Government. Scale for DSM-5 (CAPS-5). Interview available from the National Address correspondence to Jillian C. Shipherd, Ph.D., VA Boston Center for PTSD at. www.ptsd.va.gov. Healthcare System, National Center for PTSD Women’s Health Weathers,F.W.,Litz,B.T.,Keane,T.M.,Palmieri,P.A.,Marx,B.P.,& Schnurr, P. P. (2013). The PTSD Checklist for DSM-5 (PCL-5). Scale Sciences Division (116B3), 150 South Huntington Ave., Boston, MA available from the National Center for PTSD at. www.ptsd.va.gov. 02130.; e-mail: [email protected]. Wells, A. (1990). Panic disorder in association with relaxation induced anxiety: An attentional training approach to treatment. Behavior Received: February 2, 2019 Therapy, 21, 273–280. Accepted: June 17, 2019 Williams, D. R., González, H. M., Williams, S., Mohammed, S. A., Moomal, H., & Stein, D. J. (2008). Perceived discrimination, race Available online 5 Ju ly 2019