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

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Trauma Recovery in the Transgender and Gender Diverse Community: Extensions of the Minority Stress Model for Treatment Planning Available online at www.sciencedirect.com ScienceDirect Cognitive and Behavioral Practice 26 (2019) 629 – 646 www.elsevier.com/locate/cabp Trauma Recovery in the Transgender and Gender Diverse Community: Extensions of the Minority Stress Model for Treatment Planning Jillian C. Shipherd, Lesbian, 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, discrimination, and traumatic events that can all be related to their identity. However, conceptualizations of trauma treatment in the context of extensive minority stress are lacking. This paper summarizes the existing literature and offers guidance to mental health providers who are well positioned to address stigma, discrimination, violence, and related symptoms that arise from micro-, mezzo- and macro-level spheres of TGD individuals’ experience. 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 transphobia). 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 Ilan Meyer (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
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