Improving Mental Health Professional Training: The

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Improving Mental Health Professional Training:

The Collaborative Development of a Trans Health Teaching and Testing Tool

Sofia Isabel Melendez Ron

A thesis submitted to the Faculty of Education

in conformity with the requirements for

the degree of Master of Education

Queen’s University

Kingston, Ontario, Canada

(August 2021)

Abstract

Mental health professionals are ill-equipped to support trans people; the majority of these professionals report having little or no education about trans health. Multiple stakeholders have called for training programs to expand their trans mental health curricula, however, input from trans people is necessary for the development of educational materials. The current study was part of a larger collaborative project with the trans community to develop a trans health teaching and testing tool for mental health professionals. My research aimed to understand the variations in feedback given by expert contributors and showcase the use of Evidence-Centred Design qualitative methods to develop this anti-oppressive psychometric and educational tool. A total of

31 expert contributors took part in multiple stages including construct conceptualization review

(n = 1), a pilot review (n = 1), a modified Delphi (n = 29), and reflexivity meetings (n = 3) to provide feedback on how to improve the tool. Expert contributors included trans mental health professionals (n =2), trans clients (n = 19), cisgender mental health professionals experienced in trans-affirmative care (n = 8), and psychometricians (n = 2). Seven variations of feedback were expressed by expert contributors, with feedback being categorized into seven areas of consensus, five areas of dissensus, and eight discrepant cases which have all informed changes made to the tool. Future directions involve continuing the collaborative development and validation of this tool so it can be used in training courses, self-assessments, and as a psychometric research tool.

This study showcases methods that can be used to develop other anti-oppressive educational and psychometric materials in a manner that gives trans people the agency to transform health professions training.

Acknowledgements

First and foremost, I want to thank all the trans, nonbinary, agender, and genderqueer peoples as this work would not be possible without the expertise, time, and energy they contributed to developing this teaching and testing tool. I hope that the tool we are developing together can give back to the trans community in thanks for all that they have taught me. Thank you also to all the trans-affirmative mental health professionals and psychometricians for their vital contributions in shaping this tool; the COVID-19 pandemic has been a very busy time for professionals, and I do not take their participation for granted.

I am beholden to my supervisor, Dr. Saad Chahine. It is a treasure to find a mentor who devotes so much time for his students. You always have my best interest in mind, and you champion the new ideas I come up with. Thank you for your patience and kindness when my mental health was languishing due to the COVID-19 pandemic. You helped to make my

Master’s experience fulfilling even when I was confronted with barriers.

To my committee members and role models, Dr. Michelle Searle and Dr. Lee Airton: thank you for always pushing me to explore new epistemologies, methodologies, and axiologies.

I adore the humility and passion that guide your approaches to research and mentorship. You have both changed me as a researcher and person; I will take both of your teachings with me in the next stage of my career.

I am indebted to Kel Martin whose contributions to this tool are innumerable. Kel, I cherish your insight, feedback, constant support, and friendship. Thanks to Stephanie Gauvin,

Stephen MacGregor, and Erin Rennie for your support in my applications for funding this research; your feedback, mentorship, and advocacy on my behalf allowed me to be able to compensate the expert contributors involved in this research. This research was funded by the

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Ontario Women’s Health Scholars Award through the Council of Ontario Universities and the

Joseph Armand Bombardier Canada Graduate Scholarship through the Social Sciences and

Humanities Research Council of Canada.

To my parents who gave up their life in Yetapa (so called Guadalajara) and moved our family to a Northern part of Turtle Island to find our dreams, my brother who introduced me to mental health and first encouraged me to become a researcher, and my partner who listened to my ideas and guided me through qualitative methods–gracias, los amo.

Table of Contents Abstract ...... ii

Acknowledgements ...... iii

List of Figures ...... vii

List of Tables ...... vii

Key Terminology ...... viii

Personal Statement ...... xii

Chapter 1: Introduction ...... 1

Chapter 2: Literature Review ...... 5

The Growth, Diversity, and Wellbeing of the Trans Community in North America ...... 5

The Historical Roots of the Gender Binary, Cisnormativity, and Transphobia ...... 6

Systemic Issues for Trans-affirmative Support in the Field of Mental Health ...... 8

Trans Mental Health Education and Clinical Knowledge and Skills ...... 12

Study Purpose ...... 16

Chapter 3: Conceptual and Theoretical Frameworks ...... 19

Initial Conceptual Framework ...... 19

Theoretical Framework for Instrument Development ...... 22

Chapter 4: Methodology ...... 28

Participants ...... 28

Procedures ...... 29

Chapter 5: Results ...... 44

Researcher Reflexivity Statement ...... 44

Construct Conceptualization Results ...... 46

Describing the Sample of Expert Contributors ...... 48

Research Question One: Expert Feedback Variations ...... 52

Research Question Two: Elements of Consensus ...... 57

Research Question Three: Elements of Dissensus ...... 60

Research Question Four: Improving the Tool Based on Feedback Variations ...... 62

Chapter 6: Discussion ...... 65

Educational Contributions ...... 72

Psychometric Contributions ...... 75

References ...... 84

Appendix I: Recruitment Materials ...... 114

Appendix II: Website ...... 120

Appendix III: Construct Conceptualization ...... 124

Appendix IV: Vignettes Removed ...... 126

Appendix V: Ethics Clearance ...... 127

Appendix VI: Teaching and Testing Tool that Expert Contributors Reviewed ...... 129

List of Figures

Figure 1: Conceptual and Theoretical Frameworks ...... 27 Figure 2: Procedural Diagram of Methods ...... 31 Figure 3: Data Analysis Process ...... 40 Figure 4: Construct Conceptualization Summary ...... 48 Figure 5: Sample Size Overview ...... 49 Figure 6: Novel Methods and Approaches to Tool Development ...... 79

List of Tables

Table 1: Vignettes Reviewed by Expert Contributors ...... 32 Table 2: Scoring for Multiple-Choice Items ...... 37 Table 3: Number of Individual Sets of Feedback ...... 50 Table 4: Feedback Variations ...... 53 Table 5: Discrepant Cases ...... 62 Table 6: Vignette Characteristics Overview ...... 64

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Key Terminology

The following table includes an alphabetized list of terms and acronyms that are frequently used throughout this thesis. This list provides the reader with easy access to terms as they are only defined at their first occurrence. Please note that language changes depending on location, culture, time, and other contexts, and these terms are based on our dominant Western culture as of 2021.

Acronym or Term Definition Agender Adjective. Seen as either having no gender identity or as having a nonbinary gender identity. People who identify as agender may conceptualize the word differently (e.g., lacking gender, having no words that fit their identity, not caring for external labels.) For more information, see Gender Wiki. Flag design by Fontana (2014). APA Acronym of a noun. American Psychological Association. Cisgender Adjective. A type of gender modality (Ashley, 2021a). Describes a person whose gender identity aligns with the social expectations of their assigned gender at birth. Cisnormativity Noun. “A hierarchical system of prejudice in which cisgender individuals are privileged above non-cisgender individuals but also, negativity, prejudice, and discrimination may be directed toward anyone perceived as noncisgender” (Worthen, 2016, p. 45). DSM-5 Acronym of a noun. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. Expert contributors Noun. Represents the participants who provided their expertise in this study. Includes transgender people, mental health professionals, and psychometricians. Gatekeeping Verb. This term describes the control that health professionals have over client’s access to gender-affirmative medical resources and processes (Budge, 2015).

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Genderfluid Adjective. A gender identity that varies over time. Sometimes, the strength of gender varies over time. Genderfluid people may identify as multigender, nonbinary, transgender, genderflux, agender, and/or demigender. Flag by Poole (2012). Genderqueer Adjective. An umbrella term that denotes a person whose gender identity is not strictly a man or a woman. Genderqueer identities can include a combination of genders, being agender, moving between genders (genderfluid), and more. To some people, genderqueer is similar to nonbinary and may be used to resist gender norms (Stryker, 2008). For more information, see Gender Wiki. Flag design by Roxie (2011). Gender affirming Adjective. This term is used in healthcare practice to refer to the social recognition, procedures, and infrastructure that support a client’s gender identity and gender expression. It is often used to describe various types of surgeries and healthcare practices. Gender dysphoria Noun. The psychological distress that may occur due to a misalignment between the gender that someone was assigned at birth and their gender identity. It is a type of diagnosis in the DSM- 5 with particular criteria that do not apply to all people who are trans. The term was coined in 1973. For more information, see Ashley, (2019). Gender euphoria Noun. “A distinct enjoyment or satisfaction caused by the correspondence between the person’s gender identity and gendered features associated with a gender other than the one assigned at birth” (Ashley & Ells, 2018, p. 24). Gender modality Noun. The relationship between a person’s gender identity and their gender assigned at birth. It serves as an open-ended category that includes the terms trans and cis, and welcomes the elaboration of more terms that describe people’s experiences (Ashley, 2021a; Salamon, 2010).

Gender identity Noun. A person’s “internal and individual experience of gender. It is their sense of being a woman, a man, both, neither, [nonbinary], or anywhere along the gender spectrum. A person’s gender identity may be the same as or different from their birth-assigned sex.” (Ontario Human Rights Commission, 2012). Gender expression Noun. The way “a person publicly presents their gender. Gender expression may include behaviour and outward appearance such as dress, hair, make-up, body language, [chosen name, pronouns,] and voice” (Ontario Human Rights Code, 2012). Hermeneutical Noun. When a socially disadvantaged group is excluded from injustice knowledge-production about themselves (McKinnon, 2016). Indigiqueer Coined by Whitehead (2017) to represent the forward moving momentum for “Two-Spiritness” and decolonization. The word Indigiqueer is a way of making a space, land, and ceremony for identities that centre queerness and culture. Originally, it was used as a title for Whitehead’s book on poetry, and since then, many Indigenous people use the term as part of their identity. Item Noun. This term refers to a single question or statement within an instrument. LGBTQ+ Acronym for various nouns. Lesbian, gay, bisexual, Transgender, queer, and the plus is meant to be inclusive of additional identities and experiences (e.g., asexual, pansexual). 2SLGBTQ+ and

2SLGBTQI+ are more commonly used acronyms which include Two-Spirit (2S) and intersex (I) peoples. The most recent iteration of the flag is by Vecchietti (2021). Nonbinary Adjective. Denotes a person who is not strictly a man or a woman. They may be partially one, both, neither, or something outside the gender binary. It is also spelled as ‘non-binary.’ Flag by Rowan

(2014). Sex Noun. Categories that are generally based on external and internal reproductive anatomy, chromosomes, hormones, and other physical

characteristics. In dominant Western culture, sex is typically assigned to babies at birth based on genitalia and it typically includes categories such as female, male, and intersex. Trans Adjective. This term is a type of gender modality that is used in this thesis as an umbrella term that describes the range of people whose gender identity differs from the expectations of their assigned gender at birth (e.g., Transgender, nonbinary, genderqueer, agender, and/or genderfluid; Florence, 2021). Transgender Adjective. This term has many meanings (Stryker & Currah, 2014) and Stryker (2008) advocates for it to “refer to the widest imaginable range of gender‐variant practices and identities” (p.19).

For readers new to the field, it may help to view the term as representing a person’s gender identity that differs from the social expectations based on their assigned gender at birth (Airton, 2018). Flag by Helms (1999). Two-Spirit Two-Spirit is a term used by some Indigenous people to describe their diverse gender and/or sexuality which involves cultural and spiritual aspects. Two-Spirit holds a variety of co-existing meanings for people including the following: a connection to Indigenous teachings; a "placeholder term until they find words in their Indigenous languages to describe who they are" (p. 4); and a banner under which Indigenous people can organize politically (Laing, 2018). The term is not used by all Indigenous people with diverse gender and/or sexuality, and it can be used in addition to other terms in the LGBTQ+ acronym. Two-Spirit was first proposed in 1990 at an intertribal Native American/First Nations Gay and Lesbian Conference. It is a literal translation of the Anishinaabemowin term niizh manidoowag. WPATH Acronym of a noun. World Professional Association for Transgender Health.

Personal Statement

I am committed to helping transform mental health training and services to better support, respect, and liberate people in a manner that is gender-transformative and decolonial. My passion for rallying against systems of oppression stems from my lived experiences as a queer Mexican-

Canadian Mestiza woman and migrant, as well as my privileges as a white cisgender non- disabled person and uninvited settler on the lands of the Anishinaabe and Haudenosaunee. My fluid sexual and romantic orientations towards people, regardless of their gender, have always drawn me to reflect on our society’s notions of gender and how institutions treat people who embody their gender in ways outside of the gender binary. During my time working at the Sexual

Health Resource Centre, I gained some insight into the experiences of trans and nonbinary people within health institutions, especially in that few health professionals seemed to compassionately and skillfully support their trans clients. I began talking to my cisgender friends and colleagues in medicine, nursing, clinical psychology, and social work who all described feeling unprepared to care for clients who are trans.

As my career ventured into the field of education, I began to view higher education as a valuable tool that could be leveraged to help healthcare professionals provide better support for trans people. My background in psychology taught me to understand mental health as interrelated with both physical and social wellbeing, and I feel that the mental health education of trans-related health is an important place to target research. As a Master of Education student at Queen’s University, I have dedicated my efforts to facilitate the development of a tool that teaches and tests mental health professionals and trainees about trans health.

Over the past two years of this Master’s, my approaches to research, teaching, and advocacy have shifted dramatically thanks to wonderful mentors, courses, readings, and

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experiences in this field of Transgender Studies. I never thought I would change from my positivist quantitative ways of valuing, knowing, and doing research, but I am thankful to have begun that change. Currently, I am drawn towards critical pedagogy, participatory methods, and relational accountability through the orientations of Feminist and Queer Theories. I now understand the importance of reflecting on and communicating my social positionalities given that I am a cisgender person working in Transgender studies. I dive into these areas within my reflexivity statement (Chapter 5) and I describe methods (Chapter 4) that aimed to expand trans people’s agency and prevent perpetuating systems of oppression within this study.

Moving forward into clinical psychology, I am excited to continue growing and learning in my approaches to researching, teaching, and advocating. I plan to dive deeper into Indigenous social theories as our rigid notions of gender and institutional forms of oppression are rooted in colonialism and racism. I also intend to implement participatory research methods at more levels of my investigations to ensure my work goes beyond ‘inclusion’ and ‘engagement’ by enabling trans people and communities to construct and author their knowledge and define their own actions. I also hope to nurture the connections I formed during this thesis with Rainbow Health

Ontario, Wisdom 2 Action, and Gender GP as well as trans advocacy organizations in Mexico such as Impulso Trans A. C. so that I may collaborate with these trans-affirmative organizations and ensure research findings are immediate resources that benefit communities and build local capacities.

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Chapter 1: Introduction

Across North America, mental health professionals and trainees are ill-equipped to support and provide care for Transgender, nonbinary, and genderqueer (trans1) people (Heng et al., 2018; McCann & Sharek, 2016; O’Hara et al., 2013). Many mental health professionals report having had little or no education about how to care for trans clients, and only one in three clinical psychologists self-report having the clinical competency to treat trans clients (Johnson &

Federman, 2014; Lutz, 2013; Ryu, 2018). A recent study with mental health professionals in

Ireland showed that 47% of the sample felt unconfident in providing care for transgender youth, few considered themselves (15%) or others (5%) to be confident or very confident in this area, and the majority (87%) did not believe they received adequate clinical supports such as training, consultation, and expert clinical supervision (Hodgins et al., 2020). These trends can also be found in older studies of clinical psychologists (American Psychological Association, APA,

2009) and social workers (Erich et al., 2007) who reported lacking familiarity with trans issues and competency in trans health, respectively.

The low rates of mental health professionals’ trans health competency are alarming as it is projected that most mental health professionals are likely to encounter trans clients as the trans community continues to grow and seek mental health services in increasing numbers (APA,

2015; Chen et al., 2016; Goodman et al., 2019). In addition, various studies have shown that mental health professionals’ limited training and experience in trans healthcare may negatively impact and cause harm to trans clients (Mizock & Lundquist, 2016; Mikalson et al., 2012;

1 This term is a type of gender modality that is used in this thesis as an umbrella term that describes the range of people whose gender identity differs from the social expectations of their assigned gender at birth (e.g., Transgender, nonbinary, genderqueer, agender, and/or genderfluid; Florene, 2021). 1

Willging et al., 2006; Xavier et al., 2013). In contrast, there is an association between having a health professional that trans clients perceive to be inclusive of and respectful toward transgender communities, and decreased rates of depression and suicidal ideation, as well as improved mental wellbeing in trans people (Kattari et al., 2016).

To improve trans mental healthcare, a variety of advocates including trans community members, researchers, practitioners, educators, and professional organizations have called for mental health professionals to be better educated about trans health, gender identity, and gender expression as foundational components of mental healthcare practice (Burnes et al., 2010; APA,

2015; Bockting et al., 2006; Coleman et al., 2012; Collazo et al., 2013; Johnson & Federman,

2014; Heng et al., 2018; Lombardi, 2001; Phillips & Fitts, 2017; Singh, 2016). These are broad calls across the literature and within practice to improve mental health professionals’ knowledge and skills related to trans health (e.g., understanding the informed consent model; preventing and responding to misgendering; providing supports that meet the intersectional needs of clients; avoiding damage-centred approaches that view identity as a risk factor.) As such, mental health education programs in clinical psychology, counselling psychology, and social work are ideal for providing trainees in the mental health profession with the foundational knowledge and skills they can further develop in practice.

A long-standing method used in health education to build trainees’ clinical knowledge and skills involves using clinical vignettes (e.g., case studies) that incorporate an assessment and educational feedback based on the vignette. The focus on trans health through this method has recently emerged within the fields of nursing (e.g., Ziegler et al., 2020) and medicine (e.g.,

MacKinnon & Ross, 2019; Royal College of General Practitioners, 2020; The General Medical

Council, n.d.) The educational materials within these fields are excellent for their purposes;

however, they only have one vignette related to trans health which does not capture the diversity of trans people’s experiences and the medical vignettes lack an assessment portion. Further, while the educational materials can provide some helpful education for mental health professionals, none provide the unique knowledge and skills related to psychotherapy, counselling, and clinical social work. An initial review of the available trans health educational materials shows that a vignette-based educational tool is not widely available for mental health- specific training.

The current study was part of a larger project that integrated trans people in collaboratively developing a teaching and testing tool for mental health professionals and trainees to learn about trans health. My research aimed to understand the variations in feedback given by expert contributors and showcase qualitative methods to be used in the design of anti- oppressive psychometric and educational tools. This research is guided by the following exploratory questions:

1. What variations of feedback are expressed by expert contributors to enhance a teaching

and testing tool for mental health professionals and trainees?

2. What are the elements where consensus was found among the feedback of expert

contributors?

3. What are the elements where dissensus was found among the feedback of expert

contributors?

4. How can the teaching and testing tool be improved from feedback variations provided by

expert contributors?

By working collaboratively with members of the trans community, I intended to do the following: (1) include a variety of vignettes that showcase the diversity and intersectionality of

trans people’s experiences within mental healthcare; (2) contain a test portion that can serve as an assessment of learning, assessment for learning, and a psychometric measure; and (3) provide educational anti-oppressive feedback to promote situations where health professionals who answer items incorrectly may recognize the error, reflect on gender and the systemic issues within gender affirmative care, and learn how they can play a role in better supporting trans clients.

This study promotes trans voices steering the transformation of mental health training as we collaboratively developed this teaching and testing tool for training courses, self-assessments, and to be a psychometric research tool. Ultimately, by improving trans health education, mental health professionals may be better positioned to alleviate some major barriers that the trans community faces to accessing and receiving adequate healthcare. Additionally, this research serves as part of the movement to continue enhancing the health and wellbeing of trans communities (Bockting et al., 2013; Grant et al., 2011; Trans PULSE Canada, 2020).

Chapter 2: Literature Review

The Growth, Diversity, and Wellbeing of the Trans Community in North America

In recent decades, the trans community has grown dramatically worldwide, with current prevalence rates ranging between 0.1% to 2% among adults and 1.3% to 2.7% among school- aged children (Goodman et al., 2019). This growth has been accompanied by an increasing number of trans people seeking medical and mental health services (Chen et al., 2016) and an increased focus on trans inclusivity in health research to inform trans-affirmative healthcare practices (see APA, 2015 and Coleman et al., 2012). However, most of this research has a deficit-based approach with extensive documentation of the mental health disparities that some people in the trans community face (Heng et al., 2018; Nobili et al., 2018). For example, a systematic review of 77 studies in the United States between 1997 and 2017 found disproportionately high prevalence rates of depressive symptoms, suicidality, interpersonal trauma exposure, substance use disorders, anxiety, and general distress in trans adults (Valentine

& Shipherd, 2018). Similar results have been documented in the Canadian context in both youth

(Veale et al., 2016) and adults (Trans PULSE Canada, 2020).

These documentations often fail to highlight that many trans people live fulfilling and happy lives, and that the mental health issues they experience result from systemic and historic oppression rather than innate fragility. Notably, research that is trans-led illustrates a more complete picture of the health and wellbeing of trans communities; for example, the Trans

PULSE Canada Project showed that 44% of those surveyed had excellent, very good, or good self-rated mental health, 55% had all their needs met, and 81% had primary healthcare providers.

Importantly, “trans people are not a monolith … [as they] live and desire across an inexhaustible range of gender identities, embodiments, and expressions” (Ashley & Domínguez, in press, p. 5).

Researchers need to prioritize the perspectives of trans people who live at the intersection of multiple axes of marginalization to better understand the wellbeing of trans communities. This involves decentring the sole focus on trans people who are “non-disabled, affluent, skinny, non-

Indigenous, citizens, and white,” among other positionalities (Ashley & Domínguez, in press, p.

5).

The Historical Roots of the Gender Binary, Cisnormativity, and Transphobia

For more than a century, people within the trans community have been fighting for their identities to be depathologized, their intersecting social positions to be recognized, and their voices to be valued by society (Stryker, 2017). With the guidance of trans communities, mental health institutions have the power to help uproot and transform the colonial and rigid binary categories of gender that have led trans people to become an underserved population within

North American healthcare systems (Roberts & Fantz, 2014; Vermier et al., 2018).

Transformation within the field of mental health to adequately support trans people must centre around the field’s deep historical roots of oppression. Within the past 45 years, trans people had to meet the criteria for a psychological disorder before being granted access to gender affirmative care such as hormone therapies and surgeries. For this purpose, the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) introduced Transsexualism and Gender Identity Disorder of Childhood (APA, 1980). Transsexualism was later replaced by

Gender Identity Disorder (APA, 1994), which was then altered to Gender Dysphoria in an attempt to depathologize trans experiences (APA, 2013). Nonetheless, these diagnoses are often not made unless the trans client neatly fits into the categories that mental health professionals expect from trans people. For decades, the purpose of transition—from the perspective of health professionals—was to pass seamlessly as a cisgender woman or man, which reinforced the rigid

categorization of gender and the lack of recognition for diverse expressions and identities of gender. As described by Spade (2003), gender affirming-related “procedures are regulated through a mental health model which promotes regulatory, binary gender expression and denies access to medical procedures to those who fail to perform normative binary gender for their healthcare providers” (p. 18). In line with these harmful practices, trans clients who wanted to access legal documentation like a change to the sex marker on their identity documents had to undergo invasive surgeries—such as hysterectomies for trans men and orchiectomies and vaginoplasties for trans women—that were sometimes not desired by the trans person themself

(Westbrook & Schilt, 2013).

The harmful practices of imposing the gender binary and cisnormativity on clients in the mental health field are intimately tied to colonization and racism (Thomas, 2007). Modern gender categories were developed specifically in the context of the Western empire as a way to naturalize slavery and colonialism. Indeed, our current understanding of gender is a “culturally specific, Western bourgeois social construct” (p. 49) that worked to erase Indigenous knowledge systems and rendered Black people outside of gender and sex categories (Thomas, 2007). In the

18th and 19th centuries, white people were deemed ‘civilized’ while Indigenous and Black peoples were dehumanized through a gender system that justified their captivity and the annihilation of their kinship practices (see The White Man’s Burden by Kipling, 1899, and As We

Have Always Done by Betasamosake Simpson for examples). Despite these historical accounts being widely accessible, Dominant Western culture maintains the fiction that the gender categories of man and woman are universal, fundamental, organizing principles in all societies

(Oyěwùmí, 1997). As such, the field of mental health needs to recognize that our understanding of gender cannot be taken for granted or separated from race, class, and colonization.

Over time, the colonial and racist notions of gender manifested into discriminatory laws, carceral rule, and pathologized states of gender (Stanley, 2014). Between the 1840s and 1920s, it was illegal in some of the United States for visibly gender-nonconforming people to exist in public, for people perceived as men to wear dresses, and for people perceived as women to wear pants (Sears, 2014). These laws were part of prohibitions against “public indecency” that upheld normative expressions of gender and policed anything outside the gender norms (Sears, 2014).

Under the threat of these laws, trans and nonbinary people had to modify their appearance and confine their visibility to private spaces. They were pathologized for their self-knowledge, dismissed as delusional, deemed “criminally insane,” and sent to psychiatric asylums, jails, and/or prisons (Vmenon, 2021). Various records showcase the treatment of trans people like

Mamie Ruble who was sent to an “insane asylum” due to a “hallucination that she should wear men’s clothing” and Jeanne Bonnet who was arrested more than 20 times but declared to the police, “you may send me to jail as often as you please but you can never make me wear women’s clothing again” (p. 142, Sears, 2014). There are also reports of law enforcement assaulting trans and nonbinary people through strip searches, non-consensual medical examinations, and dressing people up for photographs in prison and publishing the photos in newspapers so that people could better identify ‘queer freaks’ (Sears, 2014). With this brief historical overview, it is easier to understand the roots and progression of the systemic discrimination, pathologization, and mistreatment of trans peoples and how current biases and harmful practices came to be.

Systemic Issues for Trans-affirmative Support in the Field of Mental Health

The systemic issues within mental healthcare today result from the historical legacies of colonialism, slavery, incarceration, and pathologization described in the previous section (Koh,

2012). Current issues include access to health services and experiences with healthcare professionals (Robert & Fantz, 2014). In terms of access, it can be challenging for trans people to access gender affirming surgeries, hormone therapy, and psychotherapy based on gatekeeping practices by health professionals (Dickey et al., 2016; Mizock & Lundquist, 2016) including stigma (Hughto et al., 2015), wait times to access care (Heng et al., 2018), the binary organization of healthcare infrastructure (Roberts & Fantz, 2014; Heng et al., 2018), government requirements to access financial support for gender affirming procedures (James et al., 2016;

Koch et al., 2020), and geographical location (Knutson et al., 2018), among other systemic factors. Although not all people who are trans want or need these health services, having access for those that seek the services is related to improved quality of life, and lower mental health concerns including suicidality, depression, generalized anxiety disorder, social anxiety, distress, and body dissatisfaction (Davis & Colton Meier, 2014; Gómez-Gil et al., 2012; Murad et al.,

2010).

A second factor within the healthcare system that impacts the health and wellbeing of trans people involves their experiences with healthcare professionals, including those in the mental health field. Given the present healthcare infrastructure for trans communities in North

America, mental health professionals are a vital component of healthcare as they coordinate with other health professionals to grant or restrict (i.e., gatekeep) access to gender-affirmative medical care (i.e., hormone therapies, surgeries), provide legal documentation changes (i.e., name and gender markers; see Budge, 2015), and support wellbeing through psychotherapy. Trans community members have identified gatekeeping and denial of care as therapy missteps of mental health professionals (Heng et al., 2018; Mizock & Lundquist, 2016) in addition to other negative experiences including over- or under-evaluation of the trans aspect of the client’s

identity (Phillips et al., 2014; Vogel, 2014; Peitzmeier et al., 2014), pathologizing trans identities

(stigmatizing their transgender identity as a mental illness to be treated or cause of all problems), conducting psychotherapy as if all trans individuals are the same, placing the burden of education about trans health on the client, applying restrictive concepts of gender onto trans clients, overlooking other essential aspects of a client’s life apart from gender, avoiding topics related to gender, displaying discomfort with trans clients, enacting substandard care and forced care, restricting treatment pathways, verbal abuse, prejudicial attitudes, over-asserting power, and various other forms of discrimination (James et al., 2016; Heng et al., 2018; Kosenko et al.,

2013; Mizock & Lundquist, 2016).

The missteps mentioned above are unfortunately common as various studies have reported that between 60% to 75% of trans people have had at least one trans-specific negative experience within healthcare (Bauer et al. 2015; Costa et al., 2018; Kosenko et al., 2013). There are many health implications to these missteps by mental health professionals. For example, restricting access to medical transition has led to self-medication and unregulated hormone use

(Rotondi et al., 2013). Trans people’s experiences of denial, delay, or avoidance of healthcare due to discrimination contribute to rates of suicide attempts that exceed 50% (Haas et al., 2014).

Negative experiences in therapy have been shown to be barriers to care, worsen mental health symptoms, and negatively impact future help-seeking behaviour for trans people (Mizock &

Lundquist, 2016; Willging et al., 2006). Experiences where mental health professionals lacked trans health competency resulted in client-initiated therapy termination, client-perceived negative impressions of therapy, and a lack of hope for therapeutic change (Israel et al., 2008). Although some of these studies are dated, the results likely generalize across time as they are dependent on therapeutic practices that are still commonplace today.

In a more positive light, several cross-sectional studies have identified the critical role of inclusive and respectful healthcare professionals in the mental health and wellbeing of trans people. Kattari and colleagues (2016) found that trans individuals in the United States who had a trans-inclusive health professional reported fewer symptoms of suicidality (29% vs. 48%), depression (38% vs. 54%), and anxiety (51% vs. 57%) in the past year compared to trans clients who did not report having a trans-inclusive health professional. A similar study from Australia found that comfort with, and respect from, general health professionals were positively related to mental wellbeing, and discrimination from the same was negatively related to mental wellbeing

(Riggs et al., 2014). Additionally, health professionals’ comfort with trans clients’ sexual orientation—one aspect of inclusive trans healthcare—was positively related to the psychological wellbeing of trans clients (Stanton et al., 2017). Indeed, simple and necessary changes such as asking for and using a client’s correct pronouns and using their correct name are related to more positive interactions between health professionals and trans clients (Pitts et al.,

2009). Further, trans people who have accessed psychotherapy and care involving mental health professionals have reported enhanced resiliency factors that protect them from developing mental health concerns (Grossman et al., 2011; Valentine & Shipherd, 2018). These factors include providing clients with social support, reparative relationship experiences, and opportunities to be heard and validated, as well as helping clients develop emotion-oriented coping skills (e.g., emotion-focused coping techniques), self-esteem, and positive self-identity2

(Austin & Goodman, 2017; Israel, 2008; Moody et al. 2015; Ryu, 2018). Finally, mental health professionals are often some of the first people with whom trans individuals discuss their gender

2 Self-identity is not a synonym for gender identity. Rather, self-identity is a person’s sense of self that involves their experiences, relationships, memories, and values that exist across time. 11

identity; as such, these professionals must practice with extra sensitivity as they are uniquely positioned to support clients via gender affirming practices (Hamison & Veinot, 2020; Hunt,

2014).

Trans Mental Health Education and Clinical Knowledge and Skills

While mental health professionals can have considerable influences on the mental health and wellbeing of trans people, studies highlight that most mental health professionals are not well-equipped to provide high-quality care. In 2009, the American Psychological Association’s

Task Force on Gender Identity and Gender Variance found that only 27% of clinical psychologists felt familiar with the issues that trans people experience (APA, 2009). More recently, another study found that a minority of clinical psychologists in the United States strongly agreed (6.6%) or agreed (29.6%) that they had the competencies to treat trans clients

(Johnson & Federman, 2014). Similar rates have been found in older studies where social workers self-reported knowledge and competency levels in trans health (Erich et al., 2007). More specifically, this study found that two-thirds of the sample reported having “no knowledge” or

“marginal knowledge,” and 68% reported being “minimally” competent or “not competent at all” to work with members of the transgender community. These trends likely persist as a recent study of mental health professionals—including clinical psychologists and social workers—in

Ireland found similar results (Hodgins et al., 2020). In this study, 47% of mental health professionals felt unconfident in providing care for transgender youth, and few considered themselves (15%) or others (5%) to be confident or very confident in this area. About two in five mental health professionals were unaware of the services and clinical pathways available for trans youth, and only one in five explained a referral pathway. Further, 56% answered incorrectly or were unaware of the current DSM-5 diagnostic term of Gender Dysphoria and

37% did not know about, or believed no professional guidelines existed for working with trans clients. Finally, the majority (87%) did not believe they received adequate training, consultation, and clinical supervision in the care of trans youth.

The past decade has seen explosive growth in research focusing on trans health education to improve the trans-related clinical knowledge and skills of health professionals (Braun et al.,

2017; Eriksson & Safer, 2016; Kidd et al., 2016; Thomas & Safer, 2015; Safer & Pearce, 2013;

Stroumsa et al., 2019; Vance et al., 2017). Among mental health professionals, increased clinical confidence, knowledge, and skills are each positively related to more experience in working with trans clients and education about trans health (Hodgins et al., 2020; Leyva et al., 2014; Riggs &

Bartholomaeus, 2016). Further, the presence of educational content about trans health in social work curricula was associated with a stronger desire to work with trans communities, more knowledge about their health, and higher perceptions of competency to work within trans health

(Erich et al., 2007). Notably, 59% of mental health professionals in one study reported that trans health education (e.g., presentations, workshops, and conferences) was informative and beneficial to their knowledge and skills when working with trans youth (Hodgins et al., 2020). In a semi-structured interview from the same study, all six mental health professionals stated they would benefit from clinical education. Given that knowledge, skills, and confidence in healthcare provision are likely to be related to the quality of service provided, mental health professionals may need to be provided with ongoing education and opportunities to work with consenting trans clients.

Unfortunately, various investigations have found that mental health professionals had little or no education about working with trans clients in their training. One study from the

United States found that about 84% of clinical psychologists experienced a single class or lesson

on trans health in their educational program (Johnson & Federman, 2014). To complement this work, researchers have found that trainees who take elective courses in human sexuality do not have opportunities to discuss or read about trans issues within curricula (Lutz, 2013; Ryu, 2018).

This pattern is consistent in older studies showing that 51% of social workers and 48% of psychologists and clinical graduate trainees did not receive information about the trans community in their educational program (APA, 2009; Erich et al., 2007). These results are likely still relevant as similar rates were recently found in Australia by Riggs and Bartholomaeus

(2016); more specifically, only about a quarter of mental health professionals (including counsellors, mental health nurses, psychiatrists, psychologists, and social workers) had undertaken previous training in working with trans clients. Further, a US study concluded that counsellor programs do not adequately equip trainees to support trans clients (O’Hara et al.,

2013). In my literature search, complementary Canadian-based studies were not found, and the

Canadian context of mental health professionals’ trans-related clinical knowledge and skills seems relatively undocumented.

Numerous organizations have advocated for mental health professionals to be better educated about trans health, gender identity, and gender expression as foundational components of affirmative healthcare practice (Burnes et al., 2010; APA, 2015; Bockting, Knudson, &

Goldber, 2007; Coleman et al., 2012; Collazo, Austin, & Craig, 2013; Lombardi, 2001; Phillips

& Fitts, 2017; Singh, 2016). In addition to organizations, various studies indicate that trans individuals, health professionals, researchers, and educators have started to identify educational initiatives aimed at improving the quality of mental health care that trans clients receive (Heng et al., 2018; Jaffee et al., 2016; Korpaisarn & Safer, 2018; MacKinnon et al., 2016; Safer & Pearce,

2013).

A long-standing method used in health education to build trainee’s clinical knowledge and skills involves using clinical vignettes (e.g., case studies) that incorporate an assessment and educational feedback based on the vignette. The focus on trans health through this method has recently emerged and excellent educational materials of this type exist for nursing trainees to learn about sexual and gender diversity (e.g., Ziegler et al., 2020) and for medical professionals involved in gender-affirmative medicine (e.g., MacKinnon & Ross, 2019; Royal College of

General Practitioners, 2020; The General Medical Council, n.d.). Notably, all educational materials were developed by and/or with trans scholars, professionals, and community members which promotes the role of trans people having agency in the transformation of the education provided to health professionals. However, the nursing and medical educational materials only have one trans health vignette each, and the medical education materials do not include an assessment portion. While all materials provide some useful information for mental health professionals, they do not provide sufficient breadth of the diversity of trans people’s experiences, nor the unique knowledge and skills required for psychotherapy, counselling, and social work related to supporting trans people. An initial review of the available trans health educational materials shows that a vignette-based educational tool is not widely available for mental health-specific training.

The inclusion of an assessment portion in educational tools can serve several purposes including using it in educational contexts to (i) check trainees/professionals’ level of knowledge and skills (assessment of learning) and (ii) enhance the trainees/professionals’ knowledge and skills through feedback on the task (assessment for learning). Indeed, practice tests have been shown to be an effective way to learn content (Dunlosky et al., 2013). Since assessment is closely related to measurement, the assessment portion of the tool can also be used in research or

program evaluation settings to conduct group-level analyses of (i) the current state of trans health knowledge and skills of mental health professionals and (ii) how particular interventions (e.g., integrated instruction of trans health training) improve the knowledge and skills of trainees and professionals. Evidence-Centred Design is an approach from education to develop educational assessments that ensure the “consideration and collection of validity evidence from the onset” and subsequent steps of assessment development (Arieli-Attali et al., 2019, p. 1). However, to the best of my knowledge, Evidence-Centred Designs have not been used in the development of research-based psychometric tools. The development of psychometric instruments typically focuses on collecting validity evidence through quantitative means at the end of the tool development process and not in the item generation or theoretical analysis stages. There is a need for greater focus on collecting validity evidence for psychometric tools from the onset of the tool development process.

Study Purpose

1. A variety of vignettes that showcase the diversity and intersectionality of trans people’s

experiences within mental healthcare;

2. A testing portion that can serve as an assessment of learning, assessment for learning, and

psychometric purposes so that the tool can be used in training, professional development,

and research settings, respectively; and

3. Educational anti-oppressive feedback to promote situations where health professionals

who answer items incorrectly can recognize the error, reflect on gender and the systemic

issues within gender affirmative care, and learn how they can play a role in better

supporting trans clients.

To my knowledge, this will be the first educational tool to focus on helping mental health professionals build knowledge and skills necessary to support trans clients adequately. The development of the teaching and testing tool took a construct discovery-oriented approach that prioritized content validity and focused less on its internal reliability to ensure the instrument covered the full range of constructs involved in clinical knowledge and skills of trans mental healthcare (Clifton, 2019). I followed a development process of (1) construct conceptualization,

(2) the generation of vignettes, assessment items, and educational feedback materials, and (3) theoretical analysis of the tool through one stage of a modified Delphi and reflexivity meetings with expert contributors. My research aimed to understand the variations in feedback given by expert contributors in the theoretical analysis phase and showcase how qualitative methods can be used through the Evidence-Centred Design of anti-oppressive educational and psychometric tools. The following are the major exploratory research questions that guided this research:

1. What variations of feedback are expressed by expert contributors to enhance a teaching

and testing tool for mental health professionals and trainees?

2. What are the elements where consensus was found among feedback from expert

contributors?

3. What are the elements where dissensus was found among feedback from expert

contributors?

4. How can the teaching and testing tool be improved from feedback variations provided by

expert contributors?

Following an exploratory research approach, these questions will be investigated with minimal a priori expectations to develop explanations of these phenomena (Lincln & Guba,

1985). This study promotes trans voices steering the transformation of mental health training as we collaboratively improved the initial tool. Clinical psychologists, clinical social workers, and psychometricians also took part in the first stage of the modified Delphi to enhance its clinical and psychometric components.

My aim is for this tool to be used in training courses, self-assessments, and as a research tool after it has been quantitatively validated in a future study. The teaching and testing tool may contribute to the shift in trans health education that is necessary to align the healthcare systems in

North America with the self-determined values set by the Transgender Professional Association for Transgender Health and laws regarding gender identity and gender expression across at least

15 states3 in the United States and all levels of government in Canada. Ultimately, by improving trans health education, mental health professionals may be better positioned to alleviate some major barriers that the trans community faces to accessing and receiving adequate healthcare.

Additionally, this research serves as part of the movement to continue enhancing the health and wellbeing of trans communities (Bockting et al., 2013; Grant et al., 2011; Trans PULSE Canada,

2020).

3 As of August 2021 in the United States, laws explicitly prohibit discrimination based on gender identity for employment (23 states and 2 territories), housing (22 states and D.C.), public accommodations (21 states), and credit/lending services (15 states). For specifics on each state or territory please consult the Movement Advancement Project (2021). 18

Chapter 3: Conceptual and Theoretical Frameworks

Initial Conceptual Framework

The present investigation was positioned at the junctions of health, education, and gender to carefully integrate the experiences, wellbeing, and values of people in the trans community within the teaching and testing tool. At the outset of the research design, I chose the Health

Equity Promotion Model (Fredriksen-Goldsen et al., 2014) and the Transformative Paradigm

(Mertens, 2009, 2010; Mertens & Wilson, 2012) as two models to guide the conceptual framework of this investigation. They were chosen for their overlapping and complementary foundations that put diverse communities’ health and human rights at the centre of their approach. The frameworks provided a starting point to begin developing the initial tool and designing the research methods. As the research and design evolved, so did my need for more complex and critical frameworks that involved theory. An updated theoretical framework is provided later in this chapter, however I begin by describing the conceptual framework that provided me with a springboard into the design of the tool and this study’s methods.

To begin, the Health Equity Promotion Model was developed by Fredriksen-Goldsen and colleagues (2014) to stimulate more inclusive research of LGBTQ+ communities. Both health and education literatures have overwhelmingly emphasized the suffering of individuals in the

LGBTQ+ community without considering these people’s heterogeneity in experiences, resilience, or structural factors (see Airton, 2013; Fredriksen-Goldsen et al., 2014). The Health

Equity Promotion Model is meant to provide a more accurate and accountable framework than deficit-based research by encouraging researchers to consider the following: (1) strengths, agency, and resiliency of people in a community in addition to their health barriers; (2) the heterogeneity and intersectionality within a community; and (3) the influence of structural,

cultural, and historical contexts of health and healthcare (Fredriksen-Goldsen et al., 2014). This framework was chosen because, unlike other frameworks that focus on LGBTQ+ resilience, it does not ignore structural-level influences on resilience, and it includes intersectionality to recognize the diverse experiences within the LGBTQ+ community (Colpitts & Gahagan, 2016).

Nonetheless, as my research design evolved, I gained a better understanding of the insidious discursive role that resiliency may take in the lives of people in marginalized communities. For example, Ranganathan (2021) writes, “I am tired of being resilient; striving for it exhausts me …

I don’t want to be resilient anymore, coz it then implies I am expected to recover & comeback in some form. I shan’t. I need my time & I deserve to take it.” This sentiment was similarly reflected in the results of my study as one expert contributor said, “I’m not sure we should be supporting resilience; we should be working toward a world where people don’t need to be resilient.” Following the Health Equity Promotion Model, my literature review originally attempted to capture both the wellbeing and disparities within the trans community. However, this initial attempt continued to rely on some deficit-based, damage-centred, and individualized narratives for the rationale of the research. After exposure to more critical theories, I decided to focus my literature review on the social structures and historical legacies related to gender norms that drove the current issues with the mental health system.

The second framework I used in this study was the Transformative Paradigm. It was developed by Mertens (2009, 2010) in the context of program evaluation but can be smoothly transferred into research that looks to promote social accountability. Specifically, it aims to promote approaches within the axiology, epistemology, ontology, and methodology of a project to fight oppression and advance human rights (Alkin, 2013). The Transformative Paradigm follows the first principle of the Health Equity Promotion Model, and adds to it by advocating

that researchers be aware of (1) differences in epistemologies and how to establish relationships between the researchers, participants, and stakeholders, (2) how the results will further human rights and diminish oppression, and (3) how the methods will engage a full range of stakeholders and apply a cyclical, responsive approach (Mertens, 2009, 2010; Mertens & Wilson, 2012).

Critiques of the Transformative Paradigm indicate that it is overly Western-oriented, that it attempts to categorize all research into its four areas (axiology, epistemology, ontology, and methodology), and that it is not conducive to post-positivist orientations (Romm, 2015).

Although these are valid limitations, it helped me to think critically about elements of my research that are commonly overlooked by other health researchers and those who work using a postpositive lens. The relationality and stakeholder engagement aspects of the Transformative

Paradigm remained essential across my study (Alkin, 2013; Coghlan & Brydon-Miller, 2014), but I did not initially recognize my social positionality as cisgender and the need for me to carry out participatory-based methods that went beyond ‘engagement’ so that the tool may centre around trans people’s values and agency.

Further, the major focus on human rights within the Transformative Paradigm stopped being central to my research as I started learning more about Indigenous ways of knowing. The notion of human rights was developed in a Western context (e.g., the Magna Carta from 1215, the Universal Declaration of Human Rights from 1948) but before that time, there already existed many Indigenous Legal Systems on Turtle Island that emphasize responsibilities rather than rights. For example, the Seven Grandfather Teachings from the Anishinaabek honour basic virtues and responsibilities that enable humans to respect and value other humans, the land, and spiritual realms (Edward, 1988). The Seven Grandfather Teachings include dbaadendiziwin

(humility), aakwa’ode’ewin (bravery), gwekwaadziwin (honesty), nbwaakaawin (wisdom),

debwewin (truth), mnaadendimowin (respect), and zaagidwin (love). The notions of responsibility, accountability, and valuing all life align with the aims of the teaching and testing tool: to encourage mental health professionals to value and treat their clients with respect, humility, and love; to acknowledge the wisdom and agency in their clients; to be honest and accountable for their actions; to take responsibility for the power they hold in their positions; and to be brave in going against the discriminatory norms that may be present in mental healthcare practice. I do not claim to have a holistic understanding of the Grandfather teachings, but learning more about them allowed me to see my own work and its aims in a valuable light.

Finally, the knowledge mobilization that is promoted by the Transformative Paradigm (Alkin,

2013) remains as I intend to share the tool and findings through publications, presentations, formal reports, social media infographics, and connecting the results with members of the educational and trans health community.

Theoretical Framework for Instrument Development

To aid in the connectedness and streamlined generation of latent constructs, vignettes, assessment, and educational sections, I drew on specific theories to support the development.

Indeed, DeVellis (2016) outlines the importance of using theory as an aid to enhance the clarity of the phenomena researchers aim to measure. Using theory prevents the amount and organization of content from becoming unruly and disconnected from latent constructs, educational content, the literature, and social movements. The conceptual frameworks of the

Health Equity Promotion Model and the Transformative Paradigm did not provide specifics as to what the content and constructs should include, so I integrated theory stemming from the critical field of Transgender Studies.

Transgender Studies is a dynamic and interdisciplinary field that is “attentive to the lived experiences and material circumstances” (Stryker & Aizura, 2013, p. 609) of trans people while also providing an analytic lens to comprehend what gender means and does, how its understandings have shifted, and how it is normalized, regulated, and surveilled (Stryker &

Whittle, 2006; Stryker & Currah, 2014). The work in this field is broad and can focus on applied topics of transgender people’s encounters with cultural, legal, health, and educational institutions but also on basic topics that re-evaluate our constructions of gender, sex, sexuality, embodiment, and identity. As stated by Stryker and Currah (2014),

Transgender Studies appears an increasingly vital way of making sense of the world we

live in and of the directions in which contemporary changes are trending. Studying

transgender issues is both worthwhile and substantive in its own right and also of

significant interest for what it can teach about broader conditions of life (p. 1).

Transgender Studies was first conveyed in Stone’s (1991) essay, Posttranssexual

Manifesto, and grew with the emergence of the term Transgender in the early 1990s. It emerged in response to critiques of how transgender issues were represented in other fields (e.g., Gay and

Lesbian Studies; Faderman, 2007). Key figures in Transgender studies include Halberstam

(female masculinity, queer failure, and trans or gender variant embodiment and temporality),

Stryker, Currah, and Aizura (editors Transgender Studies Quarterly and The Transgender Studies

Readers), Prosser, Namaste, and Salamon (who build on work by Butler to discuss trans embodiment, trans lives made invisible by theoretical discourses and institutions), Spade (pro- bono legal support for trans people and discussions against theoretical discourse), Serano

(Whipping Girl: A Transsexual Woman on Sexism and the Scapegoating of Femininity), and

Feinberg (history of transgender warriors and consolidating revolutionary movements).

Transgender Studies draws on poststructuralist and postmodernist epistemologies, the domains of Decolonial Studies and Disability Studies, and the theoretical orientations of Queer

Theory and Feminist Theory (Stryker & Currah, 2014). One of the strengths of Transgender

Studies is that it goes beyond the essentialist understandings of identity in Feminist Theory, and also recognizes that destabilizing all social identities, as with Queer Theory, disintegrates the individual’s belonging to a group and the basis for personal and social empowerment (Nagoshi &

Brzuzy, 2010). Transgender Studies acknowledges the limits of the body and social determinants, while also affirming individuals’ fluid construction of gender.

The introduction of Queer Theory and Feminist Theory (through the lens of Transgender

Studies) in this research was imperative in streamlining the generation of learning outcomes and assessed latent constructs, as well as the development of educational feedback of the teaching and testing tool. Queer Theory guided assessment and educational content that discussed breaking down hierarchies, categories, binaries, and languages in which they are portrayed

(Butler, 1990; Sullivan, 2003; Warner, 1993). Feminist theory guided content that focused on intersectionality, power relations, bodily autonomy, feminist coalition politics, and putting trans liberation as central to the liberation from multiple systems of oppression (Crenshaw, 1991;

Koyama, 2001; Scott-Dixon, 2006). Transgender Studies more broadly guided content that used critical perspectives that contest normative practices, knowledge formations, and institutional agendas that consider “transgender phenomena as appropriate targets of medical, legal, and psychotherapeutic intervention” (Stryker & Currah, 2014, p. 4). I integrated this perspective through a critical consciousness approach that provokes learners to value the context of issues, recognize power structures, enact reflexivity, and promote the liberation of communities that experience oppression (Halman et al., 2017).

Another strength of Transgender Studies is that it places trans people as central to the articulation of knowledge to resist transgender phenomena being regarded as “pathological, marginal, invisible, or unintelligible within dominant and normative organizations of power/knowledge” (Stryker & Currah, 2014, p. 9) This argument formed a central part of feedback processes in the content generation, theoretical analysis, and refinement portions of this study. Importantly, these methods resist hermeneutical injustice, or the process of excluding a socially disadvantaged group from knowledge-production about themselves (McKinnon, 2016).

Participants, who were called expert contributors, provided feedback that guided the development and refinement of the teaching and testing tool. Without their feedback and essential contributions, this work would be relationally unethical, languish in terms of building content validity, and unlikely to be used in research and practice.

There do exist critiques of Transgender Studies. For example, Enke argues that transgender studies is limited by “a perception that [it] only or primarily concerns transgender- identified individuals” (Stryker & Aizura, 2013, p. 2). Enke calls for Transgender Studies to “do more flexible work … opening broadly in all directions, … modify[ing] and ... [being] modified by participants whose names we may not even yet know’’ (p. 3). Similarly, Aizura (2012) has indicated that the field needs to move away from identity as the main point of analysis, critique the idea of a “master narrative of transgender identity formation,” and move towards anti-identity schools of thought. These potential shifts in Transgender Studies have implications for the applied work of my research, as the teaching and testing tool focused specifically on the lives of trans people, rather than viewing how gender norms impact the broader population.

Figure 1 displays how the conceptual framework of the Transformative Paradigm and the theoretical framework of Transgender Studies informed the methods of this research study and the content generation of the tool, respectively.

Figure 1. The conceptual and theoretical frameworks for the present research study. 27

Chapter 4: Methodology

The present study used a qualitative orientation to develop a teaching and testing tool for mental health professionals to learn about trans health. In this chapter, I describe the participants and their recruitment, the process for developing the tool (i.e., construct conceptualization, item and content generation, and theoretical analysis through a modified Delphi approach and reflexivity meetings), and the qualitative analysis for the data.

Participants

This study consisted of (N = 31) participants who are referred to as expert contributors throughout this manuscript. They took part in one or more of the following procedures: construct conceptualization review, pilot test, modified Delphi, and reflexivity meetings (see Figure 5 in

Chapter 5 for the breakdown of the expert contributors within each of the three procedures).

Expert contributors were not asked to identify their social positionalities (i.e., intersecting identities), but many voluntarily shared their identities when they expressed interest in participating.

Expert contributors were invited to participate through social media advertisements, email listservs, health organizational websites, and purposive sampling of known experts in the field and trans people with intersecting identities, especially Indigenous trans people and Black trans people (Etikan & Bala, 2017). All recruitment materials (see Appendix I) linked potential expert contributors to a website that described the research study in more detail and introduced my social positionality as a cisgender researcher (see Appendix II). Each expert contributor who expressed interest in participating was sent a unique Qualtrics online survey link that included the letter of information, consent form, and a portion of the teaching and testing tool. Each expert contributor had the opportunity to provide feedback for two out of the ten sections of the tool

through open textboxes; each section contained a vignette, questions with multiple-choice options, and educational feedback. It took expert contributors between 20 and 120 minutes to provide feedback on the two sections they were assigned. Sections were not randomly assigned so that expert contributors who voluntarily self-identified as a particular social positionality could be assigned to a particular section (e.g., an Indigenous trans person assigned a section about Indigenous trans intersectionality).

Procedures

All methods followed Tri-Council guidelines and were submitted to the Education

Research Ethics Board and the Queen’s University General Research Ethics Board. The procedure for developing and validating the teaching and testing tool is synthesized in Figure 2.

This chapter will go through the first five completed phases that focus on developing the tool, and a future study will aim to provide psychometric evidence (e.g., validity, reliability, dimensionality) for the assessment portion of the teaching and testing tool.

Figure 2. A procedural diagram and timeline for the development and validation of the teaching and testing tool. The two phases that have not yet been completed are the procedures to find psychometric evidence for the teaching and testing tool.

Construct conceptualization. The definitions of the constructs, content domains, and knowledge and behaviours that underly the constructs that are being taught and tested in the tool were derived from five major sources: clinical practice guidelines with a focus on those that were developed or co-developed with trans people, empirical findings of best practices and missteps taken by health professionals broadly and mental health professionals when providing health support to trans clients, grey literature written by trans and Indigenous authors, tangential educational and psychometric materials that included trans health, and online trans health community groups on Facebook, Reddit, and Twitter (see Appendix III for specific references from these five sources). Finally, one trans person provided written feedback on the resulting construct conceptualization document.

Content Generation: Vignettes. Based on the constructs from the first phase of the procedure, twelve vignettes were initially developed with an aim to present realistic and common situations of trans clients who have intersecting identities. Two of the vignettes involved

Indigenous trans people to better align with two of the recommendations from the Truth and

Reconciliation Commission of Canada:

Recommendation 22. We call upon those who can effect change within the Canadian

healthcare system to recognize the value of Aboriginal healing practices and use them in

the treatment of Aboriginal patients in collaboration with Aboriginal healers and Elders

where requested by Aboriginal patients (p. 3).

Recommendation 23. We call upon all levels of government to … [p]rovide cultural

competency training for all healthcare professionals.

The vignettes focused on trans people interacting with various sectors of institutions including public schooling, employment, government, mental healthcare, and gender affirmative care.

Based on feedback from committee members, the names of people in vignettes were added so that people would not assume that a lack of name meant the person was white (Cotton et al.,

2014). Popular names from around the world were added to all trans clients in the vignettes by looking up celebrity names from countries around the world and popular 2020 baby names in particular countries. Of the original twelve vignettes, three were removed for two reasons: (1) the constructs involved in the vignette were already integrated into other vignettes and (2) the vignette provided little ambiguity, so it was difficult to create questions that could discriminate between those who have high and low knowledge and skills in trans mental health. See Appendix

IV to view the vignettes that were removed. During the modified Delphi procedure, one expert contributor provided a clear idea for a new vignette, so a new vignette was added at that time

(see vignette number 10 in Table 1).

Table 1 Vignettes Reviewed by Expert Contributors Themes Vignette 1: A trans woman named Li Jing calls a rural clinic •Access where you work looking for therapy for her depressive •Over-evaluation symptoms. After consultation with a senior colleague, Li Jing of the trans aspect is referred elsewhere because your clinic does not focus on of the client’s trans health. Indeed, a previous client who was trans indicated identity that they required more specialized healthcare than what your •Rural healthcare clinic was able to provide. The referral given to Li Jing is to a clinic that specializes in trans health with integrated

healthcare. This clinic is located several hours away, but they offer virtual appointments. Vignette 2: Several months ago, a client named Nola was part •Relationships of your group therapy and indicated they were queer and among health Nádleeh. Recently, you overhear several respected senior professionals colleagues repeatedly using the wrong pronouns for Nola and •Respecting calling them Two-Spirit, but usually only when Nola was not pronouns when not present. in the presence of client •Selective disclosure •Indigeneity Vignette 3: Harkamal identifies as gender non-binary and has •Directing people a chronic pain condition that limits their ability to walk. They to all washrooms ask the receptionist where the accessible washrooms are, and •Avoiding the receptionist points them to the women’s washroom down assumptions about the hall. The receptionist then sees Harkamal more closely someone’s gender and says, “sorry, and the men’s bathroom is right beside it. I •Nonbinary am not sure which you prefer, but both are accessible.” Then identity with a warm smile she says more quietly, “by the way, •Staff education congrats on starting your transition!” Vignette 4: A 9-year old child, Jelani, and her mother, •Hormone Moneshah, come into your clinic. Jelani was assigned male at blockers birth but is starting to ask to shop in the girls’ section for •Supporting clothes, play with the girls at school, and say they wish they gender diverse were born more like their sister because she is a girl. Jelani is children constantly changing their mind on what pronouns to use. •Anti-Black racism During the visit, Moneshah tells you that their family doctor said this was a phase of exploration that was common in many children. Moneshah also expresses that she is deeply fearful of Jelani's future and safety if this continues because

they are Black and have heard about many black trans women facing hate and violence. Vignette 5: You are with a client named Sasha who is •Funding for transfeminine and has been taking hormone replacement surgeries and therapy (HRT) for over a year. She is very happy, physically gatekeeping well, and looking to undergo several gender affirming •Gender dysphoria surgeries. Sasha requires two referral letters from mental assessment health professionals to get funding for the surgeries. She did •Nonbinary not require letters for her HRT prescription because her identity university’s health clinic practiced the informed consent •Hearing voices model.

Sasha tells you that she went to a psychiatrist to get the first referral letter but that the questions to diagnose gender dysphoria left her feeling exposed and dehumanized. The psychiatrist made her feel insecure because she did not question her gender when she was younger, still loves some masculine aspects of her expression, and questioned her HRT medication compliance because of her history of hearing voices and diagnosis of psychosis. Vignette 6: You are facilitating a CBT group therapy session, •Neopronouns and you find that you and several of the members repeatedly •Group therapy mix up Çağatay's pronouns (ze/zir) and do not pronounce zir •Reactions to name correctly. The members apologize profusely and fix misgendering each other's mistakes, but the atmosphere seems slightly uncomfortable. Vignette 7: One of your clients named Salma comes into •Legal your therapy session on the verge of tears. From previous documentation sessions, you know that she has identified as a woman for changes most of her adult life but presented herself as a man, which •Anxiety caused her constant emotional stress.

At this session, Salma tells you she began the process of changing her legal documents to reflect her gender. At the government office, the teller said to another co-worker, "he uses she/her pronouns" and "she previously went by Karim,” and none of the personnel knew how to process Salma's requests adequately. She felt lost and had a panic attack at the government offices. Salma has long struggled with social anxiety, and she tells you that she is embarrassed to go back, exhausted with all these processes, and does not want to ask her boss for another day off to repeat the same process. Vignette 8: One of your colleagues is reaching out to you to •Trans athlete consult about a trans client they recently saw. The client, •Relationality Ximena who is a professional weightlifting athlete, was •Gatekeeping, looking to access hormone replacement therapy (HRT). Your gender dysphoria colleague conducted an assessment to diagnose gender assessment, and dysphoria as described in the WPATH guidelines, but it the goal of seemed that Ximena was not being honest as they kept transitioning changing their story and various facts within their narrative did not line up. Your colleague is worried that Ximena was telling the kind of story that would enable them to access HRT, but may not adequately fit the assessment criteria. As such, they think Ximena may regret their choice in the future, and your colleague asks you to consult with the client as well. Vignette 9: Liz, one of your clients moved from a First •Indigeneity Nations reserve in Northern Ontario two years ago to study at •Relationality with a nearby college. After a year of sessions, Liz has begun to community share more openly with you and trust you. Liz is almost going to graduate and is excited to go back to see her little brothers, mom, and aunties. However, she tells you that she has not yet told her family about being Two-Spirit. She is worried about how her mom will react, how she will participate in the

community–especially during ceremonies—and whether people will respect her.* *The initial version of the tool included the following sentence which was removed as it contained a discriminatory stereotype: After more conversation, she also tells you that her brothers have been taken by the Children’s Aid Society for several months because her mom used alcohol to cope with stress. She is worried this news will stress her mom again. Vignette 10: Damini is a cheerful man who loves painting •Aging and spending time with his grandchildren. He was AFAB and •Employment and has begun socially and medically transitioning, but needs labour rights assistance determining how and when to come out at work. •Disclosing He is six years from retirement, and it will eventually become identity/ social clear due to the physical changes of the medical transition. transition at work Damini is very scared of rejection, and has had reoccurring nightmares of being fired, facing backlash, and transphobia at work. Item Generation: Assessment. Once the constructs and vignettes were drafted, questions and multiple-choice items were created to measure the knowledge and skills of mental health trainees and professionals. Higher levels of knowledge were defined as having an increased awareness and accuracy of trans-affirmative information relating to the vignette.

Higher levels of skills were defined as tendencies to behave and reflect in trans-affirmative ways for the vignette. The multiple-choice questions ask the person taking the tool whether they (1) would be likely or unlikely (5-point Likert-scale) to take specific actions or have specific thoughts and (2) agree or disagree with specific statements (5 point Liker-scale; Creighton &

Scott, 2006). There were no wrong multiple-choice items in the initial tool to avoid promoting transphobic behaviours, thoughts, and perceptions. However, my committee and the General

Ethics Review Board suggested I include wrong multiple-choice items to reduce socially desirable responding and increase the representation of realistic behaviours, thoughts, and perceptions that mental health trainees and professionals do and have. Multiple-choice items representing transphobic and harmful behaviours/thoughts/perceptions were added and are reverse scored. An educational feedback segment was developed for each vignette to discourage promoting transphobic behaviours/thoughts/perceptions and promote more supportive behaviours/thoughts/perceptions (see the next section in this manuscript for more details).

Following the content discovery-oriented approach, the following recommendations were followed to increase the validity of this instrument and reduce systematic bias, while acknowledging that this may decrease its internal reliability (Clifton, 2019): the order of multiple-choice items will be randomized so that they can be presented differently for each respondent and reverse-scored items made up roughly half of the questions. See Table 2 for details on the scoring for the multiple-choice items (DeVellis, 2016).

Table 2 Scoring for Multiple-Choice Items

Likert-scale value Score Reverse-score 5 – Strongly agree, extremely likely, extremely 5 1 able, extremely aware, etc. 4 4 2 3 3 3 2 2 4 1 – Strongly disagree, extremely unlikely, not at 1 5 all able, not at all aware, etc. 999 – I prefer not to answer 0 0

Content Generation: Educational feedback. In response to creating multiple-choice items that represented behaviours, thoughts, and perceptions that were not trans-affirmative, the educational feedback portions of the tool were developed. The educational feedback sections outline trans-affirmative skills and knowledge within mental health practice related to the

vignette. Where possible, guidance directly from the trans community and trans advocates was included, linked, and referenced. The use of Queer Theory and Feminist Theory (as part of

Transgender Studies) were imperative in guiding the development of educational feedback (see

Chapter 3). Resources used to build the educational feedback are listed in Appendix III.

Pilot testing. One expert contributor piloted several sections of the tool. They identified as a cisgender mental health professional versed in Indigenous studies (n = 1) and their feedback enabled me to clarify the tool’s instructions and modify sections that involved Indigenous peoples to better align with cultural practices and teachings. The teaching and testing tool was accessed through a Qualtrics link that included questions and text boxes for this contributor to provide feedback (e.g., what to add, remove, modify).

Theoretical Analysis: Modified Delphi Review. An essential process of tool development theoretical analysis is where the content validity of the newly generated tool is evaluated (Arias et al., 2014). This process ensures that the initial item pool reflects the desired latent construct(s). In this study, expert contributors were asked to conduct this theoretical analysis by providing feedback on the vignettes, questions, and educational content through a modified Delphi survey technique (Hasson, 2008). These contributors included trans and/or experienced cis-gender mental health professionals, trans clients, and psychometricians.

Specifically, they were each asked to provide feedback on the following: (1) two sections of the tool that included two vignettes, two sets of questions, and two sections of educational feedback

(what to add, remove, modify); (2) whether any other situations should be included in the tool and if so, to provide a general description; (3) ideas for the name of the tool; and (4) any other information the participants wanted to share anonymously with the research team and other expert contributors about the tool. Expert contributors provided this feedback through an online

survey hosted through Qualtrics that they accessed through a unique link over email. The online survey included relevant sections of the teaching and testing tool along with multiple open text boxes throughout the tool to provide feedback. At the end of the online survey, expert contributors were presented with trans health resources to access support as some of the content may have been triggering (Trans Lifeline, The National Suicide Prevention Lifeline in the US, a list of International Suicide hotlines, and The Trevor Project’s phone line, online messaging, and texting options). All expert contributors from the modified Delphi were entered into a prize draw to win one of two $100 prizes for participating in the study. The winners could choose to donate their prize to Trans Lifeline, a transgender-led organization that connects trans people to the support resources they can use to survive and thrive. This includes a peer support hotline, community resources, and financial support for legal document changes.

Typically, the Delphi model includes multiple rounds of providing feedback, with anonymized feedback summaries being communicated back to all expert contributors between each round (Hasson, 2008). In keeping with the time constraints of the Master of Education program, my committee indicated that I had enough data from the first round of the Delphi to complete my Master’s thesis. Nonetheless, I plan to conduct another cycle of the Delphi that will include (1) a summary report of major changes to the tool based on feedback and areas that did not have consensus among expert contributors, (2) another online survey to provide additional feedback for areas that did not have a consensus, and (3) a copy of the teaching and testing tool with track changes.

Data Analyses

Overview. The analysis of data followed inductive qualitative content analysis with incorporations of procedures from grounded theory (Cho & Lee, 2014). These analysis

methodologies were used to find patterns using within- and cross-case analyses; the cross-case analyses were displayed on matrices to further analyze and represent codes and patterns (Miles et al., 2014). After the initial round of within- and cross-case analyses, I facilitate three separate reflexivity meetings. See Figure 3 for an illustration of this process.

Figure 3. A summary of the data analysis process.

The relationship between Qualitative Content Analysis and Grounded Theory. Both approaches are forms of naturalistic inquiry used to analyze and interpret qualitative data through rigorous coding and pattern identification (Cho & Lee, 2014). Some scholars like Crotty (2003) and Patton (2002) view qualitative content analysis as a method and Grounded Theory as a theoretical framework or methodology. However, Cho and Lee (2014) discuss that many researchers who state they use Grounded theory actually used qualitative content analysis that incorporated some procedures of Grounded Theory. As such, the current study uses qualitative content analysis with the incorporation of Grounded Theory methods. This is because this thesis only includes the first iteration of the modified Delphi, so the following key elements of

Grounded Theory could not be completed: constant comparative analysis, theoretical sampling, and the goal of generating a substantive theory (Glaser & Strauss, 1967; Cho & Lee, 2014).

Nonetheless, as the project moves forward to developing the report of the findings and the second round of the Delphi, these three key elements of Grounded Theory will likely be met.

Constant comparative analysis is likely to be completed as the current data analysis will guide subsequent data collection in round two of the Delphi process (Corbin & Strauss, 1990).

Theoretical sampling has been started as I have begun “recruiting participants with differing experiences of the phenomenon so as to explore multiple dimensions of the social processes under study” and will continue to do this with the second round of the Delphi (Starks & Trinidad,

2007, p. 4).

Coding process. As the approach to this study is exploratory, the qualitative content analysis was inductive, wherein codes and themes were directly drawn from the data (Elo &

Kyngäs, 2008). Following Grounded Theory, the coding process used open coding, axial coding, and selective coding (Corbin & Strauss, 1990). The open and axial coding were conducted during a within-case analysis where a case was represented by one vignette, its questions, and its educational feedback. The selective coding was completed within a cross-case analysis.

Within-case analysis. The within-case analysis looked to deeply understand every section of the tool (each vignette, its questions, and its educational feedback; Miles et al., 2014) through open and axial coding (Corbin & Strauss, 1990). Open coding used descriptive coding to identify the content’s topic (Tesch, 1990; Saldaña, 2013). Axial coding used magnitude coding through symbols to indicate the type of feedback given and its relationship to other codes and among the categories of the vignette, questions, and educational section (Weston et al. 2001;

Saldaña, 2013). The symbols used included the following: (+) for feedback about adding content,

(-) for feedback about removing content, (✓) for feedback about an aspect of the tool that was well done, (X) for feedback about something problematic, (Δ) for feedback about content or

aspects that need to be changed, and (?) for feedback that involved a question about an aspect of the tool. There was also a type of feedback that involved topical comments about the subject matter of the vignettes, questions, and educational feedback (topic). This type of axial coding directly relates to the first research question looking to understand the types of feedback given by expert contributors to improve the tool.

Cross-case analysis. The cross-case analysis of all ten sections of the tool enabled me to have a more generalized understanding of the types of feedback that expert contributors were giving across sections, understand which trans health topics within the tool received feedback without a consensus, understand the methods and considerations that a cisgender researcher could use to integrate the knowledge contributions and values of trans people, and find negative cases to strengthen that framework (Miles et al., 2014). This cross-case analysis used selective coding where several core categories were selected to generate a matrix that connects the cases

(Charmaz, 2006; Corbin & Strauss, 1990). The matrix displays of the cross-case analysis were developed to continue analyzing the relationships among the sections and illustrate the findings of the selective coding (Miles et al., 2014).

Reflexivity processes. Following Charmaz’s (2006) social interaction approach in using grounded theory that emphasizes the researcher’s interaction and involvement with participants in constructing a theory, a reflexivity process was undertaken. Three expert contributors (n = 2 trans people and n = 1 psychometrician) met with me to discuss sensitizing concepts that form the basis of grounded theory to develop a deeper understanding of the findings from the data analysis and, points of uncertainty (Bowen, 2006). One expert contributor met with me after I completed the open coding, the second after the axial coding, and the third expert contributor after I developed the matrices. The meetings took between one and three hours over Zoom. Two

of the expert contributors were members of my committee and the third was a colleague who was compensated $100.00 for their time and effort. During the meeting, detailed notes were taken and condensed through thick description (Geertz, 1973). All expert contributors were sent the detailed notes as a form of member checking. Apart from aligning Charmaz’s (2006) grounded theory approach, this process aided the iterative analysis of data and peer debriefing, helped put the findings in the context of trans people’s lives, and ensured that trans people were given an active role in the results that emerged from this study.

Evaluation of trustworthiness and quality of research. Credibility (truth value), transferability (applicability), and dependability (consistency) have been used to evaluate the trustworthiness of the qualitative inquiry (Guba, 1981) and are applicable for both grounded theory and qualitative content analysis (Cho & Lee, 2014). Evidence of credibility was built by showing coding hierarchy charts in the results section, using quotations from the expert contributors in the results section, peer debriefing in the reflexivity phase, and member checking at the reflexivity process and the report after the first round of the Delphi (Graneheim &

Lundman, 2004). Transferability evidence is necessary as I present various methods, approaches, and considerations that other researchers developing psychometric tools can use to integrate the knowledge contributions and values of trans people (Chapter 6). Further, I provided a thorough narrative literature review in Chapter 2 to establish the context of the study and the tool to allow comparisons to be made (Shenton, 2004). Finally, dependability evidence was built through a meticulous audit trail that includes all records, notes on methodology, as well as the documents produced and edited throughout the research procedure (Cho & Lee, 2014).

Chapter 5: Results

Researcher Reflexivity Statement

I understand that my social positionalities and previous training influence my research philosophies, judgements, and practices which in turn influence the findings of this study

(Finlay, 1998). As such, each stage of this research required me to undertake reflexive processes to become aware of my biases, gain a deeper understanding of how they may influence my research, design methods to diminish them, explicitly communicate my positionalities, collaborate with experts to strengthen knowledge production, create contexts with interactive meaning-making, and to outline lessons learned. There are two major areas to discuss within this statement: my social positionalities and philosophical assumptions.

Social positionalities. One of the most important parts of my Master’s research is reflecting on and communicating my identity as a cisgender, white, non-disabled person and uninvited settler conducting research to support trans people with intersecting identities. Given my social positionalities—especially my cisgender identity—it would be impossible and inappropriate for me to create a trans health educational tool that reflects the diverse experiences and values of trans people; in fact, doing this work alone would likely perpetuate stereotypes and systems of oppression for trans communities. To prevent this, my role in this research was to facilitate a process where trans people could voice their expertise and decide how, through this teaching and testing tool, mental health professionals could learn to adequately support trans people. I diligently educated myself and did some of the “heavy lifting” by carefully crafting an initial teaching and testing tool that could be easily moulded and improved through input from trans people within the study. I also met with trans colleagues while interpreting the data and have been actively listening to the conversation had by trans people and trans scholars on the role

of cisgender people “hold[ing] power in work related to trans people” (Kapit, 2021, source).

Indeed, there is much discussion around the role of cisgender researchers publishing on trans “issues” without trans co-authors (see the following threads for examples: allyship, critique and holding space, lessons learned). As put by Kapit (2021), who is a trans educator, “if you are studying trans people, have a trans person on your research team. Have them LEAD the damn team … If you don’t have trans people involved in your trans related work, you’re doing more harm than good. I promise.” Similarly, I often see members of the trans community asking important questions like whether cisgender researchers are “creating opportunity[ies] for more cisgender people to study us and publish about us rather than centering trans voices in research?”

(Marzo, 2021).

So, as I journey through this field, I am constantly asking myself how I can improve my approaches to have trans people leading the work that I do – especially as a graduate student. I often wonder whether I am taking up space in this field and whether I should go into another field, but I am not yet sure of what I will do. For the time being, I have taken steps to learn about participatory research methods that I plan to further integrate in my future research, regardless of the topic. I have also recognized that since my work deals with intersectionality, since oppression based on gender is intimately linked with colonialism and racism, and since I am an uninvited settler and white person, I must engage further with Indigenous peoples from a variety of nations, Indigenous teachings surrounding gender, and the history and currently lived experiences of Black trans people. Thankfully, I have another Master’s and a Ph.D. to dive into these important topics.

Philosophical assumptions. Coming into this research study, I had only been exposed to quantitative methods that used positivist assumptions through my undergraduate research

training. As I entered the field of Transgender Studies, I learned of various major constraints and misalignments using positivist research assumptions in this field. For example, many of the constructs I wanted to study (gender, teaching, learning) are historically and socially constructed; they are not absolutely true in nature as would be assumed by positivism (Alvesson & Skoldberg,

2009). Positivism also does not directly compare data with theories, does not consider the power dynamics or relationality between researchers and participants, and may view emergent methods as “data peeking” which may inflate Type II error (Sagarin et al., 2014).

To address these limitations of positivism, I searched for epistemological assumptions that better align with my research topic. Some of my course work and mentors pointed me towards critical theories and social constructivism, which have enabled me to better integrate

Feminist Theory and Queer Theory, integrate historical contexts of mental health systems and gender, focus on relational methods, implement emergent data analysis, measure tendencies rather than inevitable practices by mental health professionals, aim to transform the way mental health professionals view gender and identity, and attempt to question oppressive social orders and institutionalization (Alvesson & Skoldberg, 2009). Nonetheless, I am at the beginning of my exploration into philosophies outside of positivism and my research is still creating a tool that looks to measure and quantify mental health professionals’ knowledge and skills which may align with positivist assumptions of truth.

Construct Conceptualization Results

Selecting and defining the constructs that were going to be taught and tested in the tool was a much longer process than expected due to the diversity and complexity of the trans health field. At this stage, 16 constructs were identified, each with two to eight sub-constructs. Each sub-construct had a detailed definition. At the time of construct conceptualization, there were

three main domains that the 16 constructs fit into: knowledge, skills, and awareness/reflexivity.

See Figure 4 for an overview of the domains, constructs, and sub-constructs. After discussion with my committee, the awareness-related constructs were moved into the knowledge domain and reflexivity-related constructs were moved into the skills domain. This resulted in two final main domains (knowledge and skills) that are represented in the teaching and testing tool.

Awareness / Reflexivity (moved to skills in later iterations)

Role as a therapist: Power, influence, and contribution to social change, scope of practice, personal attitudes, critical analysis and application of psychotherapeutic guidelines, self-reflection, clebrating prograss, decolonizing approaches

Role in society: Promote positive and affirmative public dialogue, reaction and support

Knowledge

Foundations: identities, experiences, and language: Terms and definitions, variety in experssion and experience, Intersectionality, inclusive and affirmative language

Supporting Two-Spirit and/or Indigenous peoples with diverse gender: Foundations, Indigenous ways of knowing, impacts of colonialism, resources

Influences and impact: Institutional regulation of gender (historic and present); individual, social, and structural factors; strength, resiliency, and agency

Child and youth development: Affirming children and youth

Mental health support and therapeutic approach: Collaborative approach and referrals, resources, gender dysphoria assessments, WPATH Standards of Care, facilitating access to gender-affirmative care, many ways and goals of transitioning and affirming gender identity

Legal Requirements: Documentation and context

Welcoming and affirming environment: Intake forms and clilent charts, washrooms, inclusive presence

Skills

Communication: Foundations, perception analysis, asking questions in a non- judgemental manner, talking about transition, making mistakes and responding to misgendering

Education: Avoid education burdening, trans narratives as educative, consultation and supervision Psychotherapy and gender: Building a trusting relationship with your client, critical consciousness and healing, strengths-based approach and validating emotions, getting to know your client and their context, psychotherapy foci, transitioning, do not narrow the contsrtuct of gender, checking-in with your client's support person(s) Supporting children and youth: Family support, community support, transitioning

Supporting Two-Spirit and Indigenous peoples who are gender diverse: Building relations with your client, self-determination and culture, involve families and communities, self-expression

Navigating structures as a mental health professional: Your role in helping clients access medical care, letters of referral, advocacy in referrals, educate and advocate in the community, changes in identity documents

Group considerations: Pronoun introductions, handling mistakes from other members or staff

Figure 4. Constructs and sub-constructs conceptualization for awareness/reflection, knowledge, and skills related to trans health.

Describing the Sample of Expert Contributors

Based on 38 people who expressed interest in the study through email, 31 experts contributed to the study. Figure 5 illustrates the proportion of expert contributors in each of the three phases of this study: the pilot test, modified Delphi, and reflexivity meetings. The figure also displays the expert contributor’s social positionality as experts (i.e., their identity).

Figure 5. Sample sizes for each of the three procedures that expert contributors were involved in.

During the modified Delphi, 29 expert contributors provided individual sets of feedback for one to two sections of the teaching and testing tool. The distribution of the 59 sets of feedback across the ten vignettes and expert contributors is depicted in Table 3. As shown in

Table 3, each vignette had between five and six feedback sets, except for vignette two (Nola), which had 11 sets of feedback due to procedural error; the same consent and survey link were sent to more expert contributors than expected. Nonetheless, all expert contributors who participated met inclusion criteria, consented to the study, and qualified for the compensation prize. The majority of feedback sets came from trans clients and the least sets of feedback came from psychometricians and trans mental health professionals.

Table 3 Number of Individual Sets of Feedback

Vignettes Number of

Types of Expert Feedback Contributors 1: 2: 3: 4: 5: 6: 7: 8: 9: 10: Sets Li Jing Nola Harkamal Jelani Sasha Çağatay Salma Ximena Liz Damini

Trans clients 3 8 4 2 3 5 3 4 3 3 38

Trans mental 1 1 1 1 4 health professional Cisgender mental 1 3 2 1 1 2 1 1 1 13 health professional

Psychometrician 1 1 1 1 4

Total completed 5 11 6 5 5 6 5 5 5 6 59

Data saturation for each of the vignettes and for the overall tool was not met as new data produced some changes to the codebook and expert contributors suggested 14 different vignettes that could be included in future iterations of the tool; even the last two feedback sets analyzed included new vignette suggestions. The 14 different vignettes included the following topics with quotations for examples given by expert contributors:

• Trans people who have ASD • More representations of mobility and sensory disabilities in trans people. For example, the client requiring a “support person to communicate, make decisions, [and] attend appointments.” • Agender and/or genderfluid people with the learning outcome of understanding that “gender is a social construct.” • The “harmful rhetoric lately about ‘transtrenders’ or youth transitioning to be cool or fit in or because they feel oppressed as women - which is totally ridiculous, but something that's really rising out of TERF circles in the UK and seeping into the US & Canada.” • Fertility and medical transition • Barriers to medical transition due to BMI • Eating disorders as they “are a prevalent problem among both trans men and trans women” • Suicide as the expert contributor noted that “while it is refreshing to not read a suicide scenario because it is the most known and most commonly cited trans mental health ‘issue,’ it is those things for a reason.” • School counsellors involving “a scenario with family called into the school." • Couples therapy and one partner transitioning. For example, “losing their queer credibility … or perhaps [a] trans person worried about being read as a gay man” • Mental health professionals assuming that trauma led a person to wanting to transition. For example, a client “flee[ing] from a female body” or “assum[ing] a male [man] would take on female [a woman’s] role due to sexual assault.”

• Substance use and transitioning with the expert contributor asking, “do we require someone to be completely clean prior to starting transition, when the substance use may be fueled by dysphoria?” • A trans woman social transitioning in employment dominated by men (e.g., military, police). There are no fixed sizes that determine the required samples for reaching data and thematic saturation (Sebele-Mpofu, 2020), however, Young and Casey (2019) showed that a sample size of six to nine had significant coverage of codes and a sample size of four to six had partial theme representation. These numbers may not apply to this research study as even the vignette that had 11 sets of feedback continued to get new codes with the analysis of the tenth and eleventh feedback sets. Indeed, the trans community is so diverse in perspectives that reaching saturation across all vignettes was not possible after 59 independent sets of feedback in the modified Delphi and two reflexivity meetings. This may be a surprising finding for those that assume that the trans community is a monolith. The second round of the modified Delphi will help to get closer to data saturation as new expert contributors will also take part in the second round and work towards reaching consensus.

From a perspective of utility, the goal is to design a measure that is sensitive to the multitude of trans experiences by providing a breadth of trans representations. It would be unrealistic to propose creating an instrument or educational material that meets all the permutations of trans people’s experiences. Nonetheless, I look forward to integrating new vignettes that represent important topics to trans people and continuing to develop as the fields of

Transgender Studies and trans health evolve.

Research Question One: Expert Feedback Variations

Table 4 illustrates the types of variations of feedback that experts expressed to enhance a teaching and testing tool for mental health professionals and trainees. Variations of feedback

from expert contributors fit into one of the following seven categories: (+) add, (-) remove, (Δ) change, (✓) well done, (X) not well done, (?) question, and topic (Saldaña, 2013). A visual representation of the coding levels is represented in the hierarchy chart in the first column; this chart provides information for the depth of data coded in each vignette. Table 4 is ordered by number of coding references, with the vignette having the most total references listed first and the feedback variation with the most coding references also listed first. The final column of

Table 4 describes the most common feedback for each type of feedback variation. While the descriptions provided are not representative of all relevant data, they provide a sense of the types of feedback given. Table 4 highlights that the majority of feedback variations were related to education-related content that was well done. Jelani’s vignette had the most feedback coding references, likely because it was the longest section of the ten sections of the tool. In contrast,

Ximena’s vignette had the least amount of coding references. Many of the topics displayed in the most common feedback areas moved onto the cross-case analysis phase and are addressed in the discussion section. Interestingly, Liz and Nola’s coding hierarchy charts contained the most complexity and these were both the vignettes related to Indigenous topics.

Table 4 Feedback Variations

Vignette and Coding Feedback # Coding Description of Most Common Hierarchy Chart Variation References Feedback All Vignettes Total 438 ✓ 150 Education: positive sentiments + 139 Education: add resource(s) or particular references Δ 121 Questions & education: improve clarity of wording - 41 Education: make more concise, remove repetitions ? 9 Questions: scoring X 2 Vignette: stereotypical and offensive

Topic 103 Little overlap Total 21 1: Li Jing ✓ 7 Vignette: common and representative issue + 5 Questions: adding multiple- choice responses Δ 9 Questions & education: improve clarity of wording - 0 ? 0 X 0 Topic 3 Additional factors that may reduce the person’s access to mental healthcare Total 68 ✓ 29 Education: general positive 2: Nola sentiments + 23 Vignette: definitions Δ 13 Questions: improve clarity of wording - 6 Question: easy opt-out to discrimination ? 3 Education: cultural appropriation

X 0 Topic 7 Identity labels: umbrella terms, Two-Spirit, selective disclosure

Total 47 ✓ 19 Questions: good balance of 3: Harkamal right and wrong questions + 8 Education: resource suggestions Δ 22 Education: change working to add accuracy - 8 Education: removing an example ? 0 X 0 Topic 13 Assumptions about what a trans person looks like

Total 84 ✓ 22 Education: general or no change 4: Jelani + 30 Education: add resource, diagnosis details, hormone blocker details Δ 27 Questions & education: improve clarity of wording - 6 Education: remove repetitions and reference to Christians ? 1 Questions: how to measure responses

X 0 Topic 17 Pathologization of being trans via institutions 5: Sasha Total 51 ✓ 18 Education: general positive sentiments + 17 Vignette: clarity around medical compliance Δ 13 Questions: formatting consistency - 2 Education: make more concise ? 0 X 0 Topic 20 Gatekeeping Total 50 ✓ 14 Education: general positive 6: Çağatay sentiments + 16 Education: diversity of references Δ 10 Questions: consistent formatting - 6 Education: remove reference to NBD campaign as it does not suit this context ? 3 Vignette: role of content warning X 0 Topic 9 Prevention of and reaction to misgendering

7: Salma Total 27 ✓ 11 Questions: general positive sentiments + 10 Questions & education: add consent and confidentiality Δ 6 Question: make response less vague - 1 Education: make more concise ? 0 Topic 0

8: Ximena Total 21 ✓ 8 Education: general positive sentiments + 5 Education: it is valid for stories to change Δ 7 Questions: improve clarity of wording - 1 Education: remove repetitions ? 0 X 0 Topic 8 Intersection of ableism and transphobia Total 44 ✓ 14 Education: general positive sentiments 9: Liz + 17 Question: add response that clients should not have to educate mental health professionals Δ 5 Question: change wording of Two-Spirit definition - 9 Vignette: remove unnecessary stereotypes ? 0 X 2 Vignette: stereotypical and disrespectful Topic 21 Avoid promoting transphobic & colonial ideas with questions that are wrong

10: Damini Total 26 ✓ 8 Situation: realistic + 8 Situation: define the acronym Δ 9 Questions & education: improve clarity of wording - 2 Questions: therapeutic responses due to variability in approach ? 2 Questions: scoring of responses X 0 Topic 5 Being trans is conceptualized as a young person thing or a trend

Note. Variations of feedback are represented by the following symbols: (+) add, (-) remove, (Δ) change, (✓) well done, (X) not well done, and (?) question.

Research Question Two: Elements of Consensus

To compare the elements of consensus, a qualitative matrix analysis was conducted. The elements of consensus highlight three major areas of consensus displayed in Matrix 1: the role of definitions, terms, and language; representations of thriving trans people; and therapeutic skills.

The qualitative matrix analysis also showed four other elements of consensus, but these are displayed in a separate matrix because they confirm areas of the academic literature that are well established (see Matrix 2). These elements include the following: incorporating vignettes that illustrate situations that are realistic, common, and representative of trans people’s lives; organizing categories by similar topics; expert contributors sharing experiences of gatekeeping by mental health professionals; and the importance of highlighting systemic factors.

Matrix 1: Elements of Consensus

Selective Vignettes

Codes 2: 3: 4: 5: 6: 7: 8: 9: 10: 1: Li Jing Nola Harkamal Jelani Sasha Çağatay Salma Ximena Liz Damini (+) Definitions for gender & transition (+) WPATH acronym as a (Δ) Two-Spirit (Δ) Sample (+) Define (Δ) Wording: question definition (Δ) Gender letter needs Nadleeh in “reframing” (Δ) Wording question identity → gender to be vignette for clarity: (Δ) Wording: Word expression to updated as (✓) Wording to gender is not (+) Define “reframing” to (+) Explanation Semantics better reflect Gender (✓) Nuance a binary SMART promote that lacking a measure meaning Dysphoria acronym autonomy & term for gender and context unconscious bias criteria & (Δ) Wording: authenticity diversity does in Two- without demonizing (Δ) Wording: language “reframing” not mean the Spirit it “reframing” has changed (-) Word “healing” community does Definition over time (Δ) Question to not because ableist in not respect it assume a gender this context binary (✓) View (Δ) Binary (✓) Cisgender feelings of privilege privilege, binary shame / → (✓) privilege (✓) Bureaucratic (+) Navigating mental health greater Barriers to details and barriers to avoid Systemic issues as legibility accessing (+) Gender neutral barriers of legal gatekeeping as a Factors result of of binary mental and accessible documentation mental health societal trans healthcare bathrooms changes professional prejudice, people’s

discrimination gender (+) Staff training (not innate) (Δ) Wording (Δ) assumptions have Nightmares differing impacts on → bad trans people dreams as (✓) Gender trans people Thriving (Δ) Wording; euphoria are not resilience→ represented more fragile empowerment, / lack promote world emotion where people don’t regulation need to be resilient. skills Note. Variations of feedback are represented by the following symbols: (+) add, (-) remove, (Δ) change, (✓) well done, (X) not well done, and (?) question.

Matrix 2: Additional Elements of Consensus that Confirm Concepts Established in the Literature

Selective Vignettes Codes 1: 2: 3: 5: 6: 7: 8: 9: 10: 4: Jelani Li Jing Nola Harkamal Sasha Çağatay Salma Ximena Liz Damini (✓) Situation based on Vignettes: suggestion by a (✓) (✓) realistic, (✓) (✓) Realistic contributor Representative Realistic common, Realistic common common common representative (Δ) Change to AMAB and military work Organize (Δ) Facts vs (Δ) Facts vs (Δ) Facts vs

categories by recommendations recommendations recommendations similar topics (✓) Coordination among health (✓) professionals: Hypervigilation impacts of trans (✓) when health people’s stories Gatekeeping Unintended professionals when seeking gatekeeping switch away gender from affirmative informed medical care consent model (+) Consent: (+) Consent & before confidentiality suggesting (+) Consent & strategies or (+) confidentiality: (+) Avoid (+) Avoid (+) Consent: psychoeducation Confidentiality joining a healing assumptions: assumptions: ask if client Therapeutic circle, lacking a term trans people only is interested (+) Avoid (+) Selective consulting/grievance for gender being younger skills in healing assumptions: disclosure and with government diversity does generations or a circle get client’s confidentiality office, providing not mean the trend input about documentation community possible does not employment respect it complications Note. Variations of feedback are represented by the following symbols: (+) add, (-) remove, (Δ) change, (✓) well done, (X) not well done, and (?) question.

Research Question Three: Elements of Dissensus

The qualitative matrix analysis illustrates five major elements of dissensus between expert contributors. These elements include discussions around the following topics: questions meant to be wrong; the length of educational feedback; vignettes being ambiguous enough to discriminate between mental health experts who have high levels of skill and knowledge in trans health and those with lower levels, but also being clear enough to be able to make informed therapeutic decisions based on the vignette; the inclusion or exclusion of open text boxes; and inclusion of general therapeutic skills. All of these topics are displayed in Matrix 3 through shortened titles (in the same order listed above).

Matrix 3: Elements of Dissensus Selective Codes Vignettes

1: 2: 3: 4: 5: 6: 7: 8: 9: 10: Reflexivity Li Nola Harkamal Jelani Sasha Çağatay Salma Ximena Liz Damini Meetings Jing Questions (-) Culturally (✓) Breadth of (✓) Wrong (+) Provide (- /Δ) Indigenous (✓) Tool relies on meant to be offensive responses that answers immediate concepts may the presence of wrong represent worded education require a different incorrect answers (-) Easy opt-outs mental health well as approach

professionals’ they are (✓) Wrong (+) Limitations (✓) Represents thoughts and things responses (+) Immediate statement about not what mental actions mental help teach feedback engaging deeply health health with Indigenous professionals (+) have profession (✓) Diversity knowledge systems actually do feedback als & breadth of directly address actually responses (Δ) Wording to not questions do deter people from taking rest of tool Length of (+) Key take- (-) Make (-) Make (-) Make (-) Concise (✓) Shorter would educational aways to make more more more suggested only by be too surface- feedback more concise concise concise concise settlers level; this tool fills the gap of in-depth (+) Present (✓) Concise via education into trans feedback more hyperlinks topics engagingly (infographic) (+) Dropdown (+) Major takeaways boxes of feedback

Vignettes – (+) Does Nola (✓) Ambiguity (Δ) (+) Role of (+) What is (+) Specify balance like being called helps to test Pronoun mental Çağatay’s what the ambiguity Two-Spirit? people with low consistenc health reaction? client is and clarity What pronouns knowledge y for profession looking for does Nola use? Is /skills clarity als (✓) it selective Appropriatel discretion? (+) perhaps add y nuanced more context Open text (+) Open text (+) Open (✓) Do not add an responses box text box open text box

(+) Guide for how to use in courses, debriefing Therapeutic (+) Importance (✓) Avoid (+) Avoid (+) Avoid (+) (+) (+) No (-) General (-) skills of proper requesting damage- damage- Importance General universa therapeutic skills Therapeut pronoun use education from centred centred of reaction therape l ic clients approach approach to utic approac (✓) Highlight responses (+) Not about (e.g., (e.g., misgenderin skills h that therapeutic skills due to always getting minority shame is g works variability pronouns right, stress not for all (+) Culturally in but about how model) innate) trans specific approache to respond to people knowledge about s mistakes (+) Include the Indigenous minority community is stress needed assessmen t (+) Identity is person-first before Indigenous Note. Variations of feedback are represented by the following symbols: (+) add, (-) remove, (Δ) change, (✓) well done, (X) not well done, and (?) question.

Research Question Four: Improving the Tool Based on Feedback Variations

Each set of feedback from expert contributors was either integrated fully, integrated partially with reasoning, or not integrated with reasoning to the teaching and testing tool.

Generally, areas of consensus were integrated fully, and areas of dissensus were discussed during two of the reflexivity meetings to make decisions about how to integrate (or not) the feedback.

Appendix VI contains the original tool before the feedback from expert contributors was integrated. The preliminary changes that will be made will receive additional feedback from the second round of the modified Delphi, especially changes regarding areas of dissensus.

Discrepant cases which did not show up across multiple vignettes, but describe important concepts that can be applied to the rest of the tool, are displayed in Table 5. The discrepant cases informed more changes made to the tool. Finally, Table 6 displays novel characteristics of each vignette identified by expert contributors. These novel characteristics will receive feedback in the second round of the modified Delphi and be transformed into learning outcomes afterwards.

Table 5 Discrepant Cases Themes Vignette Description Remove stereotypes 9: Liz (-) Remove alcohol and Children’s Aid Society

(-) Remove since they will have the option not to take the Prefer not to 3: scenario, can just go back and not respond respond Harkamal (Δ) Prefer not to answer → I don’t know Likert Scale 3: (+) Provide more detail as to the relationship between the Instructions Harkamal Likert-scale options and the situation Vignette 10: (+) Add a resolution story for the vignette resolution Damini (+) Add to all situations: “The following vignette discusses Sensitive topic 6: ____. would you like to continue with this situation or move to disclaimer Çağatay the next one?” (-) Remove the neutral option to think about the issue: yes/no, 10: Scoring agree/disagree, likely/unlikely Damini (✓) For research, keep Likert-scale

Presentation of 3: (Δ) Presenting the feedback in alternative ways like a Sway education Harkamal presentation or as an infographic? 3: References (Δ) Use Vancouver style referencing Harkamal Note. Variations of feedback are represented by the following symbols: (+) add, (-) remove, (Δ) change, (✓) well done, (X) not well done, and (?) question.

Table 6 Vignette Characteristics Overview Vignette 1: Li Jing 2: Nola 3: 4: Jelani 5: Sasha 6: Çağatay 7: Salma 8: Ximena 9: Liz 10: Damini Harkamal Key •Access •Relationsh •Directing •Hormone •Funding for •Neopronou •Legal •Trans •Indigeneit •Aging characterist •Over- ips among people to blockers surgeries and ns documentati athlete y •Employme ics evaluation health all •Supporting gatekeeping •Group on changes •Relationali •Relational nt and of the professional washroom gender •Gender therapy •Anxiety ty ity with labour trans s s diverse dysphoria •Reactions •Gatekeepin community rights aspect of •Respecting •Avoiding children assessment to g, gender •Disclosing the pronouns assumptio •Anti-Black •Nonbinary misgenderi dysphoria identity/ client’s when not in ns about racism identity ng assessment, social identity the someone’s •Hearing and the goal transition at •Rural presence of gender voices of work healthcare client •Nonbinar transitionin •Selective y identity g disclosure •Staff •Indigeneity education Novel •Unintend •Terms and •Therapeu •Pathologizat •Consent and •Preventing •Consent •Consent •Therapeut •Avoiding characterist ed definitions tic skills ion of being confidentialit misgenderi and and ic skills to assumptions ics gatekeepi •Therapeuti to build trans via y ng confidential confidential build trust : being trans identified ng c skills to trust institutions •Representati ity ity •Relational conceptualiz by expert •Systemic build trust •Well •Parental ons of trans •Bureaucrati •Validity of ity with ed as a contributor barriers to meaning roles people c system clients community young s mental cisgender thriving being , elders, person trend healthcare people uncertain to and Two- •Change in •Privilege begin HRT Spirit peer terms and •Forms of groups DSM (dis)abilit criteria over y time

Chapter 6: Discussion

The current study was part of a larger project that integrated trans people in collaboratively developing a teaching and testing tool for mental health professionals and trainees to learn about trans health. My research aimed to understand the variations in the feedback given by expert contributors and showcase qualitative methods to be used in an

Evidence-Centred Design of anti-oppressive psychometric and educational tools. In this discussion, I will provide an overview of key findings related to feedback variations, outline the modified Delphi and reflexivity meetings as two qualitative methods to be used in an Evidence-

Centred Design of educational and psychometric tools, contextualize the findings in relation to the literature, and outline the limitations and future directions of this work.

There was a great variety of feedback from the 438 codes developed from the feedback of expert contributors including the following: aspects to add (150), remove (41), or change (121) about the tool; aspects that were either well done (139) or not well done (2); comments about topics related to the content (103); and questions about the tool (9). The most common type of feedback involved educational aspects that were well done, followed by suggestions about adding particular resources and references. This set of categorizations enabled me to make systematic enhancements to the tool and find seven major areas of consensus and five major areas of dissensus among expert contributors.

Notably, the process of collaboratively creating this teaching and testing tool unintentionally served as critical inquiry to produce knowledge that relates to the literature.

Many of the findings within the elements of consensus are well established in the literature as influences on, and experiences of, trans people, and provide additional evidence for how to focus on these areas within pedagogy and curricula. One area of consensus was expert contributors

endorsing mental health professionals learning about systemic and structural factors, including systems of oppression, in relation to trans health. This area of consensus aligns with literature promoting the use of education for mental health professionals that trains them in providing anti- oppressive services (Corneau & Stergiopoulos, 2012) as well as critical consciousness. These forms of education help in “illuminating power structures … [and] promoting equity and social justice” (Halman et al., 2017, p. 12) so that mental health professionals understand how systems of power and oppression interact to influence transgender people’s lives (Burnes et al., 2010).

A related element of consensus among trans expert contributors was the importance of representing thriving trans people in the vignettes and educational sections. Expert contributors described the construct of thriving as highlighting that many trans people live fulfilling and happy lives and that the mental health issues they experience are a result of systemic and historic oppression rather than innate fragility. Based on my search, there is a lack of academic references to thriving trans people in the literature; thus, perhaps this construct of thriving provides a new facet of speaking about strengths-based therapeutic models that typically focus on the wellbeing and resilience of a group of people (Burnes et al., 2010) rather than only focusing on their health disparities (Bockting et al., 2004; Singh & Burnes, 2009). Thriving may be a way to describe the state of wellbeing within various areas such as spiritual, mental, emotional, and physical (Medicine Wheel) as well as social, essential, coping, and creativity across multiple contexts including individual, local, global, institutional, and chronometrical

(lifespan) contexts (Avera et al., 2016; Myers & Sweeney, 2008).

The final notable area of consensus from expert contributors was the importance of mental health professionals knowing and using accurate, nuanced, and contextualized terms and definitions, including the terms gender, nonbinary, transition, Nadleeh, Two-Spirit, and bundle.

Indeed, language has played an enormous role in society’s understanding of and orientation toward transgender issues (Zimman, 2017). The introduction of trans-inclusive language and linguistic reform has been essential for the liberation of trans communities and the negotiation of gender (e.g., the introduction of words like nonbinary, cisgender, cisnormativity; Zimman,

2017). Thus, it is logical that trans-inclusive language should play a crucial role in training trans- affirmative mental health professionals. The current study suggests that special considerations are necessary for words that intersect between Indigenous culture and gender; these words seemed to be misunderstood by expert contributors who are settlers or do not self-identify as

Indigenous. Likely, an emphasis on this intersection may be needed in the training of mental health professions to aid in meeting Recommendation 23 of the Truth and Reconciliation report that focused on training health professionals (see pp. 31-32 of this manuscript).

This discussion around terms also ties in with Freire’s (1970) view that words used in dialogue may enable understanding between people, shape how students see the world and history, and support educators in not becoming oppressors by using words as acts of love and humility rather than objectification. Nonetheless, some researchers within queer linguistics resist the notion that language reform will end structural oppression as it is just one of the tools among many for addressing transphobia and cisnormativity (Zimman, 2017). As such, terms and definitions used in the trans community—and the reality that they change over time, have powerful social influences, enable improved understanding in the therapeutic relationship, and can be used to shape trainees’ perceptions of trans people—should be covered as one vital part of mental health training.

There were multiple areas of dissensus among trans health experts suggesting that these experts are not a monolith and have different approaches and perspectives about trans health and

how it should be taught. Many times, areas of dissensus did not have identifiable patterns related to the expert contributor’s identity (e.g., cisgender or trans), however there were distinctions between groups. Firstly, mental health professionals tended to recommend that the educational sections be briefer and more concise as “providers are often very low on training & education time.” In contrast, trans people commented that there exist brief trans health tools which “serve a purpose, but what is missing is an in-depth tool [that works to] … humanize trans lives and elaborates on complexities to connect the client’s point of view with the mental health professionals’ jargon.” Both opinions present valid perspectives on the length of education sections, and as a result, I will develop a Major Take-aways portion for each of the educational sections.

The second area of dissensus that had patterns across groups was whether questions meant to be wrong should be included in the tool. In general, settler and non-Indigenous expert contributors tended to value the ‘wrong’ multiple-choice question items because of the following: (1) they represent the breadth of behaviours and thoughts that mental health professionals display and (2) they help to teach. For example, one non-Indigenous trans expert contributor stated the following:

Including more non-trans affirming statements helps those who are learning or hold

those opinions to identify with the content in the tools instead of skimming over them and

just choosing things they may think are more correct. Adding ambiguity helps to teach.

In contrast, in both of the Indigenous-related vignettes, wrong answers were identified by multiple (but not all) Indigenous expert respondents who were also trans as “culturally offensive” or as “offering an ‘easy out’ for people to be disrespectful.” The Indigenous-related vignettes likely require a different approach than the colonial assessment-centred approach taken

with this tool. However, integrating content about trans health (as with other topics) is best when integrated across curricula rather than as “an isolated education island of knowledge and practice” (MacKinnon et al., 2020). Perhaps the questions that Indigenous trans expert contributors identified as problematic can be removed or reframed so that the same construct is tested without making the question wrong. More feedback is required from Indigenous trans expert contributors before this section moves on to the validation phase; it is necessary to determine whether the Indigenous-related vignettes should be removed or how they can shift to more adequately teach mental health professionals about the intersections of gender and

Indigeneity. This is key to avoiding hermeneutical injustice, which defines a socially disadvantaged group being excluded from knowledge-production about themselves (McKinnon,

2016). By engaging specific trans Indigenous people on their own terms, researchers and those in power can position trans Indigenous people as experts within their own therapeutic life (Ashley

& Domínguez, in press, p. 2).

The final noteworthy area of dissensus was about therapeutic knowledge and skills in the testing and teaching portions. The first dissensus within this area was the therapeutic approach: one mental health professional indicated that the minority stress model should be included, while trans clients indicated that the minority stress model is damage-centred, objectifying, and should be avoided at all costs. This is an essential concept for which I will seek feedback from other experts in the second round of the Delphi to further explore the perspectives of mental health professionals and trans people. It seems that the minority stress model continues to be prolifically used in the field of mental health practice and research, as evidenced by several literature reviews (Delozier et al., 2020; Valentine & Shipherd, 2018), the frequent use of Testa and colleagues’ (2015) Gender Minority Stress and Resilience measure, the APA clinical

practice guidelines (APA, 2015), and trauma recovery treatment planning for trans people

(Shipherd et al., 2019). However, several trans expert contributors expressed the following sentiment that is well captured by one of the trans expert contributors:

[The minority stress model is] so far removed from the community, this is how mental

health professionals have done it for a long time, and it is sad because the first thing they

do is calculate the risk and resiliency of the person. This can be damaging, even if the

client sees it or not … That model frames things in a way that the person is to blame

[when in fact] the actual risk is not the person, [rather] the social structures & social

discrimination. … [It is important] not to centre the risk with the person’s identity.

The second dissensus within this therapeutic skills area was whether each vignette's testing and educational sections should include general skills that apply to all clients, including trans clients. Various mental health professionals and trans clients suggested to include the following general skills: validate reactions, naming and processing emotions, building problem- solving skills, avoiding being educated by your clients, knowing how to apologize when you do something wrong, being honest, and learning from your mistakes. In contrast, one mental health professional said the following about general therapeutic skills included:

Most of these look like general practice tips (which providers would have learned in

school and supervision) - these sections might be more helpful if just really focused in on

the issue at hand in the vignette and associated resources.

While the above reason is valid, one of the learning outcomes of this teaching and testing tool is to show mental health professionals that many of the skills they already use to support other clients can be used to support trans clients as well. As put by one trans expert contributor:

I have sought both mental and medical care unrelated to my gender, and when the

provider has understood that I am transgender, has refused to provide care and instead

referred me elsewhere … Being automatically turned away, or referred to specialized

care that is difficult and expensive to access, is a common problem.

Nonetheless, some of the general practice tips may be more relevant and valuable learning aspects for mental health trainees compared to licenced professionals. As such, having a “take- home messages” educational section in each vignette will enable mental health professionals to avoid some general practice tips found in the detailed educational feedback section of each vignette.

The fact that dissensus was a common finding was not surprising given the various approaches to trans-affirmative health (see Ashley’s 2021b paper titled, The Continuum of

Informed Consent Models in Transgender Health, for an example). Further, the notion that opinions from trans people widely vary; as put by Scheim (2021), who is trans and has worked with trans communities for over 17 years, “there was consultation [of trans people] … But ask 10 trans people and you get 11 opinions.” This type of dissensus has implications for creating expert committees and task forces who develop clinical guidelines or standards of care, and the importance of uplifting trans voices within this process. Given the historical domination of pathologizing and paternalistic approaches to trans healthcare that remain today, it is easy for institutional groups to undermine the self-determination of trans people, especially when there is dissensus within the group (Riggs et al., 2019; MacKinnon et al., 2020). Nonetheless, trans communities need to lead the creation of clinical guidelines and standards of care as the abundance of expertise they hold regarding trans healthcare is not yet fully reflected in the first version of the APA’s clinical guidelines or the WPATH’s seventh edition guidelines. This

missing expertise from trans people “translates into ignorance and reliance on mistaken and cisnormative assumptions to fill gaps” (Ashley & Domínguez, in press, p. 3). Thus, it is essential to understand the variance in perspectives among trans people to avoid a one-size-fits-all approach for supporting trans clients.

Educational Contributions

To my knowledge, this will be the first educational tool to help mental health professionals build knowledge and skills necessary to support trans clients. The tool adds to the toolkit of other vignette-based health professions educational materials. For instance, the

Cultural Humility and Racial Microaggressions (CHARM) game, a simulation tool in development to educate nursing students on how racialized nurses can navigate microaggressions from patients (Shu Jin et al., 2021), and the Sexual Orientation and Gender Identity in Nursing

Toolkit that uses video-based vignettes and questions (e.g., Ziegler et al., 2020). It seems that while there are no other widely available educational tools for mental health-specific training in trans health, going over this tool once in a course does not certify that mental health professionals will have sufficient knowledge and skills to support trans people. The teaching and testing tool from this study can be used alongside other valuable educational materials to form explicit curricula about trans health. For instance, the Path to Patient-Centred Care resources website by MacKinnon and Ross (2019) that explains the Informed Consent Model, provides valuable answers to frequently asked questions by health professionals, and offers valuable strategies to help clients access gender affirmative care; a textbook by Singh and Dickey (2017) titled Affirmative Counseling and Psychological Practice With Transgender and Gender

Nonconforming Clients; another textbook by Chang and colleagues (2018) titled, A Clinician's

Guide to Gender-Affirming Care; and a commentary by Ashley and Domínguez (2020) that

provides an overview of community-engaged clinician-advocates and an introduction to other essential readings for mental health professionals.

Mental health professionals’ training is already crowded, so the areas that are typically called ‘cultural competency,’ ‘population health,’ or ‘equity, diversity, and inclusion’ are limited to one course, one section of a course, one lesson, one section of a lesson, or not covered at all.

MacKinnon and colleagues (2021) argue that this approach creates an isolated education ‘island’ for topics like trans health. They advocate for the use of integrated instruction so that health profession trainees are exposed to trans health conceptual knowledge within various areas of their training (course content, practica, internships, professional development, etc.). Integrated instruction enables learners to connect trans health content to other clinical competencies and may support robust learning and transfer. The creation of widely available free educational materials, such as this teaching and testing tool, provides the necessary resources for curriculum developers, program coordinators, and educators to enhance mental health professionals’ training.

The discussion around explicit curricula is only one piece of what needs to be improved.

Implicit curricula–which may include administrative processes, available support services, inter- relationality of the people at the institution, and physical spaces—are another major aspect of mental health training that must be improved to exemplify and model proactive support that mental health professionals should provide their clients. Leaders within mental health training can look to the work by Airton and colleagues (2021) who are providing systematic documentation of how higher education programs can proactively support transgender students within a Bachelor of Education Program. Their action research has focused on the following

areas outside of explicit curricula: application and orientation processes, school practicum placement, career planning, as well as graduation and certification.

One last note within the area of educational contributions is defining the intended uses for the teaching and testing tool. Once it has received validity evidence, the tool would best serve as a formative assessment of learning; this could be a form of self-assessment to recognize what areas may require more training, or as a formative assessment taken after (and perhaps before, if trainees want to view improvements) learning about trans health in training. The tool can also serve as an assessment for learning wherein it serves as a practice test to learn about trans health.

Practice tests have been shown to be an effective way to learn content (Dunlosky et al., 2013), and trainees can complete the tool individually, in pairs, or in small groups for educational purposes. It is recommended for instructors or clinical supervisors to debrief with the trainee after completing the tool.

The teaching and testing tool may also be used for group-level analyses of how integrated instruction improves the knowledge and skills of trainees (e.g., using a pre- post-program evaluation design). Although integrated instruction is preferred over time-limited ‘islands’ of trans health education, it may also be used to see how a particular lesson or course improves the knowledge and skills of trainees. Finally, this teaching and testing tool is not recommended to be used as a large-scale assessment or as a summative assessment as many of the questions may not have ‘black and white’ or ‘wrong and right’ answers, but instead, requires the trainee to think critically and use clinical reasoning. Summative assessments may not promote the self-regulation of learning that is key to providing adequate support for trans clients. Perhaps a summative assessment may be appropriate if a future iteration of the tool includes open-text questions and an appropriate rubric to mark the answers. However, it is recommended that any summative

assessments not be worth a large percentage of a trainee’s grade, as rubrics may not account for all types of answers given.

Psychometric Contributions

At the writing of this manuscript, this teaching and testing tool is also the first instrument to act as both an educational resource and a psychometric tool. This unique ‘double’ purpose of the tool was not part of the original conceptualization for this study; the original plan was to create a psychometric tool so that researchers could measure the trans health knowledge and skills of mental health professionals. Nonetheless, it felt irresponsible and immoral for me to include questions about trans health that were meant to be wrong as these questions could perpetuate stereotypes and discriminatory thoughts and actions by mental health professionals.

These concerns are addressed by ensuring that the development of the instrument is fully informed by people from the trans community—from the integration of Transgender Studies in the theoretical framework to the involvement of transgender people during the theoretical analysis stage using the modified Delphi and reflexivity meetings. Further, the educational section of each vignette originated in response to this dilemma and it was the section that received the most positive feedback from expert contributors. This study provides a strong connection between educational and psychological measurement and showcases the use of qualitative methods to develop a psychometric tool.

The development of psychometric tools is typically made up of three phases: (1) item generation, (2) theoretical analysis, and (3) psychometric analysis. Researchers are often taught to spend the least amount of focus on the theoretical analysis of the tool, some focus in the item generation phase, and most of their time and effort on the psychometric analyses. This is apparent across popular academic works such as DeVellis’ (2016) textbook on scale

development that provides detailed and rigorous quantitative methods for psychometric analysis

(several chapters), brief guidelines about item generation (21 pages), and indistinct information about theoretical analysis (1.5 pages). Similarly, highly cited articles that discuss best practices for scale development research focus on exploratory and confirmatory factor analysis without mention of inquiry tools to assess item generation and theoretical analysis (Clark & Watson,

2019; Worthington & Whittaker, 2006). These examples highlight the notion that the field of instrument development tends to focus primarily on areas that can be assessed through quantitative means, which positivist or postpositivist traditions may deem as the best types of evidence and methodology. For example, Fisher and colleagues (2014) indicate that “research is limited by […] the nature of qualitative research in which the interpretations of one researcher may not reflect those of another” (p. 488). Nonetheless, qualitative methods–such as focus groups, interviews, and expert panels—are occasionally used for item generation (see

Kapuscinski and Masters, 2010 for examples). However, these qualitative methods seem less common because psychometric researchers undervalue their credibility and generalizability due to their perceived ‘subjectivity’ (Morgado et al., 2017).

One significant gap within the literature is that the second phase of scale/instrument theoretical analysis does not involve any form of systematic inquiry or method to complete.

Theoretical analyses typically involve expert “judges” (experts in instrument development or the target construct) or target population “judges” (potential users of the scale; Arias et al. 2014;

Nunnally, 1967). However, qualitative methods, analyses, and results are often not included (or conducted) in published articles within psychometrics. The current study exemplifies the use

Evidence-Centred Design through qualitative methods. Specifically, I used the modified Delphi method and reflexivity meetings (i.e., semi-structured interviews) in the theoretical analysis

phase of psychometric development. Using a modified Delphi in the theoretical analysis requires many considerations including: how experts will be recruited, how many items and how much content they will be assigned to provide feedback on, how that feedback will be analyzed, involving experts in the reflexivity and decision-making process of refining the tool, and ways to systematically integrate the feedback from expert contributors. The use of qualitative methods in the theoretical analysis phase of tool development may improve the content validity for the instrument as increased rigour is added to the theorization, item refinement and selection, and consensus among expert judges is sought. This follows the construct discovery-oriented approach proposed by Clifton (2019) that prioritizes content validity to ensure the instrument covers the full range of constructs involved and focuses less on an instrument’s internal reliability.

Furthermore, this study provides an initial pathway for academics and educators who develop psychometric tools concerning populations that face systemic oppression from institutions. The present study demonstrates the ability to involve community members (trans people) and avoid hermeneutical injustice (McKinnon, 2016) in creating psychometric tools that are relevant to them. Enabling trans people to contribute to and guide this work, models the type and level of relational ethics that psychometricians should be engaging in, while also facilitating improved content validity for the instrument. Theoretical analysis is a stage of developing psychometric tools that researchers can use to adequately integrate the knowledge contributions and values of communities that experience marginalization.

The present study also highlighted the vital nature of measurement planning before the item generation phase of tool development. Many texts make explicit the importance of defining the latent constructs that are meant to be measured (e.g., DeVellis, 2016). However, attention

also needs to be paid to the overarching purpose and uses of the tool, reflexivity processes related to the social positionality and philosophical assumptions of involved researchers and stakeholders, the makeup of the development team, the use of theory to streamline and add clarity to the process, and the creation of learning outcomes and content areas if the psychometric tool also serves as an educational tool.

Figure 6 summarizes the novel methods and considerations that the present study contributes to the field. The layout of the approaches and methods may seem linear, but it is essential to highlight that different topics and projects will need more emergent or cyclic approaches (Mertens, 2009, 2010). The figure lays out elements that should be covered at least once in the development process to promote the development of tools that will genuinely support the community/ies the study or tool intends to support.

Figure 6. Outline of the methods and considerations to develop anti-oppressive educational and psychometric tools. This study showcased the use of these approaches in the context of tool development.

Once this study advances to examine validity evidence for the teaching and testing tool, this tool will be the first to measure the knowledge and skills related to trans health for mental health professionals. Within the mental health literature, various studies developed and used quantitative measures for their studies with little or no psychometric validation (APA, 2009;

Riggs & Bartholomaeus, 2016; Ryu, 2018). Without this type of validated tool, studies that claim to be studying this type of knowledge and skills may not have sufficient backing to warrant their claims (i.e., lacking construct validity; Cook & Campbell, 1979). Many studies have used measures that were not put through a validation study; this included self-report ratings of clinical competency, confidence, comfort, knowledge, familiarity, preparedness, and skills related to

supporting trans clients. The construct validity evidence of these types of measures is unclear, and some studies have demonstrated the issues of using self-report measures of constructs like competency. For example, Johnson and Federman (2014) showed that self-rated competency levels did not align with the levels of training and experience, and O’Shaughnessy and Spokane

(2013) found that self-rated competency and demonstrated competency are not consistently correlated.

In an attempt to use validated measures, various studies in related healthcare fields have used adapted versions of knowledge and skills psychometric tools (Bidell, 2017; Bidell, 2005;

Crisp, 2002; Dillon & Worthington, 2003; Parameshwaran et al., 2016) by changing LGBTQ+ terms to trans-specific terms or using specific items within instruments which were not validated as subscales (see O’Hara, 2013). Pooling both trans and sexually diverse knowledge and skills together may not be useful as the therapeutic needs of trans people differ from the needs of sexual minorities (Israel et al., 2008a; Israel et al., 2011), and mental health professionals are less informed about trans health than sexually diverse health (Johnson & Federman, 2014). Without a validated measure regarding trans-specific mental healthcare knowledge and skills, quantitative studies that examine the impact of training interventions on mental health professionals' clinical knowledge and skills will lag in progress.

Limitations and Future Directions

The next step of the process is to conduct the second round of the modified Delphi with the expert contributors that provided feedback in the first round. They will be asked about the elements of dissensus with the aim of reaching consensus among all expert contributors about how the tool should be modified. Reaching consensus may be a form of reaching data and thematic saturation (Sebele-Mpofu, 2020) that will increase the transferability and external

validity of the teaching and testing tool. Expert contributors will also be shown a revised version of the tool based on feedback that had consensus among expert contributors with a summary of major changes and track changes to show transparency and accountability within this process.

Before the second round of the modified Delphi, the teaching and testing tool will be reviewed by Indigenous peoples (e.g., knowledge keepers, Elders, and/or trans Indigenous peoples) who are experts in teachings about gender in their culture. Having these additional reviewers will be essential in deciding whether vignettes two and nine should be removed or how they should be modified to more respectfully and accurately capture the intersections of gender and Indigeneity. One of the trans Indigenous expert contributors from the first round suggested integrating teachings from the book, As We Have Always Done by Leanne Betasamosake

Simpson (2017). This will be done before recruiting Indigenous peoples for the review. A medical professional will also be recruited to review the tool as medical practices are referenced throughout the tool. An honorarium (between $100 and $150) will be provided to each medical and Indigenous reviewer.

Future studies that look to develop educational and/or psychometric tools should integrate more participatory methods to improve this project's hermeneutical justice and ethical relationality (McKinnon, 2016). Trans people should be involved as co-researchers rather than just expert contributors so that they may have more decision-making power in the initial design of the tool, the theory and methods used, the data analysis, the writing and authorship, and the knowledge mobilization. I learned about participatory methods too late to fully implement this approach, however, I developed the reflexivity meetings with trans people and ensured that each piece of feedback from expert contributors held equal weight and could not be ignored by my biases as a cisgender person. Each expert contributor was given the option to remain anonymous

or add their name as a contributor to the tool and trans expert contributors were also given the option to become more involved with the research process. Two experts have indicated they would be interested in the writing of an academic paper and the dissemination of findings. So, while trans people did not ‘lead’ this first stage of the research, I aimed for them to ‘steer’ and

‘contribute’ to this work in ways that they may find meaningful.

Another major limitation of the teaching and testing tool is the cultural contexts in which it can be used. The tool was developed with a dominant-Western understanding of gender that recognizes and aims to resist its historically racist and colonial roots. Further, the tool is in

English and was developed by people in Canada, the United States, and the United Kingdom. As such, the tool likely will not provide relevant educational and psychometric information in parts of the world that do not partake in a dominant-Western and English-speaking context. It may be appropriate for curriculum developers or educators to modify sections of the educational feedback sections to be more relevant to their national, legal, and clinical contexts.

Once the development phase of the teaching and testing tool is complete, the aim will be to examine validity evidence for the psychometric aspects of the tool. This will be achieved through a quantitative study where mental health professionals and trainees from clinical psychology, clinical social work, and counselling will be asked to complete several sections of the teaching and testing tool. In terms of psychometrics, construct validity evidence will be explored by assessing unidimensionality, as well as calculating factor loadings, internal reliabilities, and test re-test reliabilities. Incremental (predictive) validity will be assessed by calculating the association between demographic variables (levels of experience and education in trans health, as well as gender identity) and scores for knowledge and skills from the tool.

Exploratory sub-population response patterns will also be analyzed.

Conclusion

The current study was part of a project that integrated trans people in collaboratively developing a teaching and testing tool for mental health professionals and trainees to learn about trans health. The findings illustrated the variations in feedback given by expert contributors and used the areas of dissensus, consensus, and discrepant cases to refine the tool. The present study also showcased how qualitative methods and considerations can be used in the measurement planning and theoretical analysis phases of tool development. This study promotes the use of trans voices to guide the transformation of mental health training and will provide a tool to be used in training courses, self-assessments, and psychometrics research. Ultimately, by improving trans health education, mental health professionals may be better positioned to alleviate some major barriers that the trans community faces to accessing and receiving adequate healthcare.

Additionally, this research serves as part of the movement to continue enhancing the health and wellbeing of trans communities (Bockting et al., 2013; Grant et al., 2011; Trans PULSE Canada,

2020).

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Vogel, L. (2014). Screening programs overlook transgender people.

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Westbrook, L., & Schilt, K. (2014). Doing gender, determining gender: Transgender people,

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Appendix I: Recruitment Materials

INSTAGRAM POSTS (shared together in one post)

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Listservs

Email listservs contacted: GLMA LGBTQ Health Digest, Ottawa Academy of Psychology, Social Determinants of Health, Four Directions Indigenous Student Centre Newsletter

Dear Colleagues,

We are seeking trans-affirmative mental health professionals who want to help improve mental health training around transgender-spectrum (trans) health!

Our project aims to develop an educational tool that tests and teaches mental health professionals about trans health through an intersectional and anti-oppressive approach. This stage of the study is a structured feedback process through which

gender diverse people and mental health professionals are helping design the educational tool. It will be used in training courses, self-assessments, and as a research tool. You can find out more information about the tool, the study, and the researcher

facilitating this work at this website.

Your role if you participate:

• Provide feedback on the situations, questions, and educational materials. • Three confidential and anonymous online surveys (20-40 minutes each). • Chance to win one of two $100 prizes. This money can also be donated to

Trans Lifeline. Together, we can transform and enhance mental health training and research! Interested? Email [email protected] Gratefully, Facebook Accounts contacted to ask if they would be willing to share recruitment materials: • Sexual Orientation and Gender Identity Issues Section of the CPA • unSOGII • US Professional Association for Transgender Health • USPATH • Gender Health Training Institute • GenderHealthTraining • International Transgender Health Twitter Accounts contacted to ask to ask if they would be willing to share recruitment materials: • @APA • @GenderGP

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• @RainbowHealthOn • @GLMA_LGBTHealth • @CPA_SCP • @Wisdom@Action Email Email addresses contacted to ask to ask if they would be willing to share recruitment materials: • [email protected] • [email protected] Organizational Website Posted a research listing on the Rainbow Health Ontario’s LGBT2SQ Health Research list (https://www.rainbowhealthontario.ca/research-policy/lgbt2sq-health-research/)

Reddit Contacted:

• r/NonBinary, • r/trans, r/transgender, • r/transeducate, • r/MtF, • r/BlackTransmen, • r/TwoSpirit • r/transvancouver, • r/transgenderUK, • r/genderfluid, • r/truscum, • r/lgbtstudies, • r/TransyTalk Contacted back and allowed to post: r/transeducate, r/transvancouver, r/genderfluid, r/truscum Hello! I am wondering if it would be okay for me to share recruitment materials for a study on r/[THREAD]? In this study, we are developing an educational tool that tests and teaches mental health professionals about trans health in an intersectional and anti-oppressive manner. This study has ethics approval from the Queen’s University General Ethics Board and I want to ensure that trans-spectrum people’s voices are steering this project. Recruiting through r/[THREAD] would help to reach a wider audience and give gender diverse folks the power to help transform education. You can find out more about this study and my

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social positionality as a researcher at this website: https://sofiamelendezron.wixsite.com/transed Thank you so much, Sofia Melendez If allowed to post on reddit thread by moderator of thread, I used the recruitment post and the following script: Study opportunity! Share your voice and help transform mental health training Be part of this study to help develop an educational tool that tests and teaches mental health professionals about trans-spectrum health in an intersectional and anti-oppressive manner. This stage of research is a structured feedback process through which trans, nonbinary, genderqueer, genderfluid, agender, Two-Spirit, Indigiqueer, people from diverse backgrounds and experiences are helping design and steer this tool. This tool, called the Trans Health Educational Tool, is composed of several clinical situations, with multiple-choice questions, and educational feedback. It will be used in training courses, self-assessments, and as a research tool. You can find out more information about the tool, the study, and the researcher facilitating this work at this website. Your role if you participate: • Provide feedback on the situations, questions, and educational materials to help design the tool. • This feedback will be given through three confidential and anonymous online surveys (20-40 minutes each). • Chance to win one of two $100 prizes. This money can also be donated to Trans Lifeline. Interested? Email [email protected] *This study has ethics approval from the General Ethics Research Board at Queen's University. Comment: I like to share with my collaborators that I am cisgender and recognize the need to have trans-spectrum people self-voicing and leading this work. I do not want to take up space, so I am here to facilitate and support the push towards gender- transformative impacts in mental health training. If you are transgender, nonbinary, genderqueer, genderfluid, agender, Indigiqueer, and/or Two-Spirit, I want your voice steering this work! If you want to get more involved in the research process, please email me as I am always looking for collaborators so that trans people can create and author knowledge about their own communities.

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Appendix II: Website

Link: https://sofiamelendezron.wixsite.com/transed

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Descriptions up when you scroll over the images above:

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Appendix III: Construct Conceptualization

References Used to Understand and Add Constructs

(1) Clinical practice guidelines: Almeida, 2018; Burnes et al., 2010; APA, 2015; Bess &

Stabb, 2009; Bockting et al., 2007; Coleman et al., 2012; Collazo et al., 2013;

Creative Kids Canada, n.d.; Gender GP, 2020; Hardacker, Duckeny, & Houlberg,

2019; Lombardi, 2001; MacKinnon & Ross, 2019; Phillips & Fitts, 2017; Sick Kids

Hospital, n.d.; Singh, 2016; Telfer et al., 2020;

(2) Empirical findings: Heng et al., 2018; MacKinnon et al., 2019; Mizock & Lundquist,

2016;

(3) Related grey literature: Airton, 2018; Ashley, 2021b; Ashley & Domínguez, in press;

Ashley & Ells, 2018; Betasamosake Simpson, 2017; Laing, 2018; Native Women’s

Association of Canada, 2020; Native Youth Sexual Health Network, n.d.; Ontario

Federation of Indigenous Friendship Centres, 2020;

(4) Tangential educational and other psychometric materials: Bidell, 2017; Ziegler et al.,

2020; MacKinnon & Ross, 2019; Royal College of General Practitioners, 2020; The

General Medical Council, n.d.;

(5) Online trans health community groups including Facebook (International Transgender

Health), Reddit threads (r/feminineboys, r/FTMfemininity, r/genderfluid,

r/genderqueer, r/NonBinary, r/trans, r/transeducate, r/transgender, r/transgenderUK,

r/TransyTalk, r/TwoSpirit,), and Twitter accounts (@AllAboutTrans,

@APADiv35Sec4, @BlkTransFutures, @BlkTransTravel, @BmcTrans,

@CGSHEquity, @eaglecanada, @CCGSD_CCDGS, @CBRCTweets,

@enchantenetwork, @EuropeanPATH, @friendsofrubyca, @GenderGP, @INQYR_,

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@LGBTQ_Research, @LGBTYouthLine, @Mermaids_Gender,

@MGHTransHealth, @mygenderation, @NWAC_CA, @pointofpride,

@RadTherapistNet, @RainbowHealthOn, @RainbowRailroad, @recogandreform,

@TPATHealth, @TransActualUK, @TransArchives, @TransCareSinai,

@TransEquality, @TransJA, @TransKidsSpeak, @TransLifeline,

@TransLawCenter, @TransNHS, @transpulseca, @TransStudies, @TrevorProject,

@tsqjournal, @USPATH1, @WhatTheTrans, @Wisdom2Action, and @wpath).

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Appendix IV: Vignettes Removed

During an internship, you notice various policies and practices that do not proactively integrate gender inclusivity. For example, requisition forms only include male and female checkboxes for sex and do not mention gender identity, preferred name, or pronouns. While updated names and pronouns are included on client records, this information is hard to find.

You’ve also heard about trans clients who had difficulties getting referrals for cancer screening.

One of your clients that you have had for 5 years discloses to you for the first time that they are trans. They are an active member of their church, and they have a large family with 7 grandchildren. They want to come out to their partner, and eventually their family and church community, but they are very scared of rejection and isolation.

You are talking to a close friend who works as a professor about singular they/them pronouns. Your friend argues that it is grammatically incorrect to use they/them pronouns to refer to a single person. They tell you that they are having to make more of an effort than usual to speak a language they have been speaking since birth. They say they just avoid using pronouns altogether if they ever talk about a person who is trans because they do not want to get in trouble with the law or university.

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Appendix V: Ethics Clearance

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Appendix VI: Teaching and Testing Tool that Expert Contributors Reviewed

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4/29/2021 Qualtrics Survey Software

Letter of Information and Consent Form

Towards Improved Mental Health Support for Transgender Communities: The Development of the Educational Trans Health Tool

Combined Letter of Information and Consent Form

PLEASE NOTE: To print a copy of this letter of information so that you may refer back to it throughout the survey, please select ‘print’ in your browser window now.

Investigators

Sofia I. Melendez, B.Sc.H., Master of Education Student, Faculty of Education, Queen’s University, Canada Saad Chahine, Ph.D., Assistant Professor of Measurement and Assessment, Faculty of Education, Queen’s University, Canada

Study Overview You are being invited to participate in a research study that aims to develop an educational tool that tests and supports transgender-spectrum (trans) healthcare. It is meant to be taken by mental health professionals and students to assess and help improve their knowledge, skills, and reflexivity related to trans health. For now we are calling it the Trans-Ed tool.

Please note: we are using transgender-spectrum (trans) throughout this study as an umbrella term that describes the range of people whose gender identity differs from the expectations of their assigned sex at birth. The term is meant to include people who are trans, nonbinary, genderqueer, agender, and/or genderfluid.

You are an essential part of this research because you hold expertise in trans health, mental healthcare, and/or psychometrics. It is essential to have trans people self-voicing and leading the development of this tool so that it may be strengths-based and have gender-transformative impacts on mental health training and research. With your input, we hope this tool can be used in courses, as a self-assessment, and in research to identify systemic educational gaps. By contributing to these areas, the Trans Health Educational Tool may help mental health professionals to be in a position to better support trans people. The initial tool you will review is based on liberatory psychology, intersectionality, critical consciousness, and strengths-based approaches. This study is funded by the Social Sciences and Humanities Research Council of Canada and the Ontario Women’s Health Scholar award.

https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID=… 1/86 4/29/2021 Qualtrics Survey Software Eligibility. For this research, we are seeking people who have any of the following social positions and/or identities:

Transgender, gender non-conforming, gender non-binary, gender diverse, genderqueer, Two- Spirit, Indigiqueer, and/or having a gender identity that differs from the social expectations of the sex you were assigned at birth. Mental health professionals experienced in affirmative transgender healthcare and involved in therapy (i.e., social worker, clinical psychologist, couples and family therapist, family physician, psychiatrist). A representative of a trans-affirmative mental health organization. An expert in psychometrics.

Nature of Your Participation Your participation would follow in three cycles for a total of 60 to 90 minutes:

1. Initial feedback. Provide feedback about the situations, questions, and multiple-choice options of the Trans Health Educational Tool, which is presented in an online survey format. The survey should about 30 to 40 minutes to complete. 2. First summary. The feedback that all participants provide will be summarized in a way that anonymizes each participant. The purpose is to create consensus among all the experts participating. The summary will be communicated to you through a second online survey. 3. Second feedback. Updating the feedback to the Trans-KSA instrument. After reviewing the summary, you will have the opportunity to provide feedback again through the second online survey. This should take you about 20 to 30 minutes to complete. 4. Second summary. A second summary of responses will be communicated to all participants using the same methods described in (2). 5. Third feedback. Those who wish can provide a third and final round of feedback through the same procedure outlined (3). This final round should take you about 10 to 20 minutes to complete. If there is consensus at the second cycle of feedback, then a third cycle of feedback may not take place.

https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID=… 2/86 4/29/2021 Qualtrics Survey Software

For more information about the research, type of feedback you can give, and the process, please watch this video:

Participation is voluntary and you may discontinue at any time by closing your browser window, selecting decline response for the remaining questions, and/or letting the research team know that you do not wish to participate in future rounds of the process. Your acceptance or refusal will not affect your professional standing. All of the questions on the survey have a ‘decline response’ option. You can go back to previously completed pages by pressing the ‘back’ button.

Compensation

For contributing your expertise, time, and effort to this research, you will be entered in a draw to win one of two $100 prizes. This money can also be donated to Trans Lifeline on your behalf. Trans Lifeline is a transgender-led organization that connects trans people to the support resources they can use to survive and thrive. This includes a peer support hotline, community resources, and financial support for legal document changes. If you do not want to complete any parts of the feedback or choose to skip, you will still be entered in the prize draw. We will also share the final instrument with you once it has been validated.

Confidential Nature of this Study

Confidentiality. Your participation in this study is strictly confidential. The investigators will take all reasonable measures to protect the confidentiality of your records. At no point during the survey do we ask for personal information that can be identifying (e.g., name, gender, address, city). Nonetheless, because we are inviting known experts to contribute, your participation is not anonymous to the research team. We will be communicating with you via email (i.e., sending links to the online surveys), but your email address and identity will not be linked to your responses. Additionally, you will not be identified in any summaries, publications, or reports of this research as data will be anonymized and aggregated in all outputs of this study. However, if you would like to be identified as a contributor to the development of the Trans-ED Instrument, please email [email protected] This is in alignment with the self-voicing principle where research goes beyond ‘inclusion’ and ‘engagement;’ communities construct and author their knowledge and define their own actions. The research team will have access to the data, and the Queen's General Research Ethics Board (GREB) may request access to study data to ensure that the researchers have or are meeting their ethical obligations in conducting this research. GREB is bound by confidentiality and will not disclose any personal information.

Data storage. The study data will be stored in three secure locations: (1) on an encrypted hard drive on a Queen’s University server; (2) on Qualtrics Enterprise Software System, which is the same software you used to complete the survey; and (3) the secure Qualtrics data centre in Toronto, Canada. Back-up data from Qualtrics is stored in the Amazon Web Service, which is stored in https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID=… 3/86 4/29/2021 Qualtrics Survey Software Montreal, Canada. The data will be stored for a minimum of 5 years, and it is only accessible by members of the research team. It is not possible to have your data removed from the survey once you fill out any part of the survey, as all responses are anonymous. You have not waived any legal rights by consenting to participate in this study.

Study participation will not affect your employment or educational status, and others will not know if you participated. This research may be published in academic journals and/or presented at academic conferences. We may include quotes; however, we will never include any real names with quotes.

Advantages and Disadvantages of Participating in this Study

There is a possible emotional risk for participating in the development of this survey. The Trans Health Educational Tool includes several situations about trans clients undergoing challenges and trauma within the healthcare system. Some of the multiple-choice options contain actions and perceptions that are not trans-affirmative and are transphobic. This is so we can understand how mental health professionals and trainees would respond to the situations. These situations and multiple-choice options may be distressing. To address this, we have provided trans-affirmative educational feedback for each situation so that all respondents may learn about anti-oppressive and strengths-based actions and perceptions for each situation. Further, trans-affirmative support resources will be provided at the end of the instrument if you need to debrief or support.

There no direct benefits to you, but you may benefit from having your voice and experiences leading the development of this Trans Health Educational Tool in an anonymous and confidential manner. You may also benefit from reflecting on the situational questions of Tool, and some participants may gain insight into the various educational resources about trans health available.

The resulting instrument from this study may help to identify strengths and gaps in mental health professional’s knowledge, skills, and reflexivity about trans health. Improvements in health professions education can be measured using the Trans Health Educational Tool which may help address systemic educational gaps. Furthermore, educating mental health professionals about trans health may help them better support trans people and communities. We hope that this will indirectly help to improve the health and well-being of trans communities as well as decrease the alarmingly high rates of stigma, discrimination, and health disparities faced by trans communities (Bockting et al., 2013; Grant et al., 2011; Trans PULSE Canada, 2020). Further, participating in this survey may financially support Trans Lifeline, which positively supports the trans community.

Members of the research team will be available by email ([email protected]) and virtual meetings to answer any questions that you may have about the study. We would love to get to know our collaborators and talk about any ideas, concepts, and concerns you have. If you have any ethical concerns, please contact the General Research Ethics Board at 1-844-535-2988 (Toll-free in North America) or [email protected]

I have read the above statements and freely consent to participate in this research:

Yes No

Eligibility Questions https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID=… 4/86 4/29/2021 Qualtrics Survey Software

Do you self-identify as someone with one or more of the following social positions and/or identities:

1. Transgender, gender non-conforming, gender non-binary, gender diverse, genderqueer, Two- Spirit, Indigiqueer, and/or having a gender identity that differs from the social expectations of the sex you were assigned at birth. 2. A mental health professional experienced in affirmative transgender healthcare and involved in therapy (i.e., social worker, clinical psychologist, couples and family therapist, family physician, psychiatrist). 3. A representative of a trans-affirmative mental health organization. 4. An expert in psychometrics.

Yes No

Instructions

Instructions for the Development of the Trans Health Educational Tool

Please watch the following video OR read the text below for instructions.

Instructions for taking the Educational Trans Health Tool - …

In short, you will be shown a portion of the Trans Health Educational Tool:

Three situations from a bank of nine situations. Various questions and multiple-choice options for each situation. https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID=… 5/86 4/29/2021 Qualtrics Survey Software Educational feedback and resources about each situation. The situations are often ambiguous so that test-takers can think critically and deeply about various therapeutic and assessment processes.

Your role:

Provide anonymous and confidential feedback to improve the Trans Health Educational Tool. You can suggest to add/remove/modify the situations, questions, multiple-choice options, and educational feedback. At the end, you can other specific situations and provide general feedback for the instrument as a whole.

Your expertise and collaboration are essential and valued parts of this work!

Before beginning the Trans Health Educational Tool, please consider the following:

TERMS Trans is a term short for transgender-spectrum that we use in the following scenarios to describe the range of people whose gender identity differs from the expectations of their assigned sex at birth. It is meant to be an inclusive term, but we also use more specific terms (e.g., Two-Spirit, gender nonbinary, genderfluid) where applicable.

REPRESENTATION Trans and gender diverse communities are made up of people with diverse experiences, intersecting identities, and unique journeys. The situations in this instrument highlight some lived experiences and trans-related topics, but it is essential to recognize that no one situation can represent all trans peoples' experiences.

VALIDITY Respondents will be asked to answer as honestly as they can. There may be some more socially desirable answers, but respondents will be reminded it is crucial that they answer in a way that represents the actions they would take in each situation. They will also be reminded that their answers are anonymous and confidential.

CAUTION The Trans Health Educational Tool includes several situations about trans clients undergoing challenges and trauma within the healthcare system. Some of the multiple-choice options contain actions and perceptions that are not trans-affirmative. These situations and multiple-choice options may be distressing. To address this, we have provided trans-affirmative educational feedback for each situation so that all respondents may learn about anti-oppressive and strengths-based actions and perceptions for each situation. Further, trans-affirmative support resources will be provided at the end of the instrument if you need to debrief or support.

Situation 1

Situation 1 https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID=… 6/86 4/29/2021 Qualtrics Survey Software A trans woman named Li Jing calls a rural clinic where you work looking for therapy for her depressive symptoms. After consultation with a senior colleague, Li Jing is referred elsewhere because your clinic does not focus on trans health. Indeed, a previous client who was trans indicated that they required more specialized healthcare than what your clinic was able to provide. The referral given to Li Jing is to a clinic that specializes in trans health with integrated healthcare. This clinic is located several hours away, but they offer virtual appointments.

Do you have any feedback about this situation? We are looking for feedback to improve the situation (i.e., remove the situation, modify the situation by adding or removing aspects, etc.)

The following questions and items will be shown to those taking the finalized tool. Because you are helping to develop the tool, you are just meant to provide feedback about the questions and items in the text boxes below. You do NOT have to answer how you would respond to the situation (only shown in bullet points and not multiple choice.)*

*If you are confused or have questions, please do not hesitate to email [email protected] - we can easily have a quick zoom call.

How likely are you to take the following steps? Please answer honestly. Shown in Likert Scale: 1 – Extremely unlikely; 2 – unlikely; 3 – Neutral; 4 – likely; 5 – Extremely likely; 999 - I prefer not to answer

Take the same approach with future clients who are trans. Find out the waitlist times for the specialized trans health clinic. Get to know Li Jing’s context and needs better through a 20-minute phone consultation. Together with Li Jing, determine whether or not you may be a good fit for each other. Talk to your colleagues about whether trans health should be within your scope of care. Work to meaningfully improve your transgender-related clinical skills (i.e., through conferences, books, supervision, etc.) Think about how often this situation happens to people living in rural areas. Think about how Li Jing’s situation is part of the way our healthcare system is set up.

Do you have any feedback about the possible responses (i.e., remove or add a response, modify the wording)?

https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID=… 7/86 4/29/2021 Qualtrics Survey Software

Taking Li Jing on as a client could have been harmful because you do not have the supports available for trans clients. Li Jing may fall through the ‘cracks’ of the system. Specific clinical knowledge about trans health is necessary to support Li Jing. It is not clear if Li Jing’s trans identity is directly relevant to her depressive symptoms. Some mental health professionals over-evaluate the trans aspect of the client’s identity. Seeing Li Jing could have been a way to redraw the boundaries of inclusion in your clinic.

Do you have any feedback about the possible responses (i.e., remove or add a response, modify the wording)?

Additional question How would you rate your current knowledge of referral pathways to trans-affirmative healthcare providers (i.e., therapists, physicians, speech therapists, etc.)?

Not at all knowledgeable

Slightly knowledgeable

Somewhat knowledgeable

Moderately knowledgeable

Extremely knowledgeable

I prefer not to answer

Do you have any feedback about the possible responses (i.e., remove or add a response, modify the wording)?

https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID=… 8/86 4/29/2021 Qualtrics Survey Software

Feedback to be given to the participant at the end of the survey

Skills and Knowledge

Through a free 20-minute virtual/phone consultation, you can determine with your client whether or not you may be a good fit for each other. This is essential for the following reasons: Not all trans people have the same experiences or require the same health supports and treatments. Trans people are very diverse and Li Jing likely has different needs than the previous trans client. Ensure that you are not over-evaluating the trans aspect of the client’s identity and overlooking other essential aspects of the client’s life apart from gender. Perhaps Li Jing’s depression is not directly linked with her trans identity. Ensure that you get to know your client's context and needs. This will help you determine whether (i) Li Jing requires specialized trans health support that impacts their depressive symptoms or (ii) you already have the tools to help them navigate their depressive symptoms. Understand the unique barriers to accessing health services for trans clients in rural areas. Virtual care may not always be the same as in-person care; if there is a mental health crisis virtually, you may have to call the police. Having police respond to mental health crises can have severe consequences for Black, Indigenous, and Latino/a/x people, among other identities.

Reflection and growth

Consider your power and influence as a mental health professional; gatekeeping may occur and cause clients to be neglected from the mental health system. Importantly, you can also help people like Li Jing access quality healthcare services and healing. Think about how the client may feel neglected from healthcare in this situation because of their trans identity. Consider how this is part of larger systemic issues in society: transphobia and cisnormativity (the assumption that all people are cisgender) within healthcare and health education. Recognize that there are many concepts and skills that you can learn which will benefit not only your trans clients, but clients of any gender. Below are some examples: Treating your client as a person and not an object. Avoiding deficits-based narratives while recognizing strength, resiliency, and agency. Having more inclusive intake forms, client charts, and washrooms. https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID=… 9/86 4/29/2021 Qualtrics Survey Software Mirroring language. Building trusting relationships with your client. Understanding intersectionality. Building critical consciousness. Reflecting on your own biases and assumptions.

Do you have any feedback about the educational feedback (i.e., adding a key resource, integrating a different way of knowing, removing irrelevant or potentially problematic aspects)?

Situation 2

Situation 2 Several months ago, a client named Nola was part of your group therapy and indicated they were queer and Nádleeh. Recently, you overhear several respected senior colleagues repeatedly using the wrong pronouns for Nola and calling them Two-Spirit, but usually only when Nola was not present.

Do you have any feedback about this situation? We are looking for feedback to improve the situation (i.e., remove the situation, modify the situation by adding or removing aspects, etc.)

*If you are confused or have questions, please do not hesitate to email [email protected] - we can easily have a quick zoom call.

https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 10/86 4/29/2021 Qualtrics Survey Software It is fair to use the term Two-Spirit for Nola, as this word is meant to be used as an umbrella term for Indigenous peoples with diverse gender and sexual identities. This is not an urgent matter as your colleagues use the correct terms and pronouns when Nola is present. As sexuality and gender are fluid, Nola may have updated their pronouns and the terms they identify with. Misgendering clients between staff may have negative downstream impacts on how other staff interact with trans clients. It is not your position to question senior colleagues. Directly questioning your senior colleagues may indirectly threaten your professional advancement. This situation shows a power imbalance between the client and mental health professionals.

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Consider that perhaps your colleagues have more updated and recent information about Nola than you. Gently ask your colleagues if Nola updated their pronouns and identity. Ensure that the client charts clearly reflect Nola’s pronouns and identity. Avoid conversations around misgendering and pronoun use. If asked about Nola without Nola being present, follow your senior colleagues' lead by mirroring their language. Gently recast or rephrase your colleague’s sentence. For example, “right, they did say they had insurance coverage.” Gently correct your colleagues by saying, “Oh, I think Nola uses they/them pronouns.” Gently and intentionally use Nola’s appropriate pronouns around these colleagues. Consider that perhaps Nola has only shared their pronouns and identities with you and does not want to share that information with other healthcare professionals. https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 11/86 4/29/2021 Qualtrics Survey Software Request to have a teaching session on the intersection of gender diversity and Indigeneity.

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Additional questions Do you know who you can contact to address your colleague’s behaviour if they willfully and continuously misgender a client?

Yes No I prefer not to answer

How would you rate your current knowledge about the origins and use of the term Two-Spirit?

Not at all knowledgeable Slightly knowledgeable Somewhat knowledgeable Moderately knowledgeable Extremely knowledgeable I prefer not to answer

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Feedback to be given to the participant at the end of the survey

Language in general https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 12/86 4/29/2021 Qualtrics Survey Software Use language that is inclusive and affirms a person’s gender identity, even when they are not around. This shows accountability and respect. Show leadership by introducing yourself with your name and pronouns. Apologize for misgendering whether the person is present or not. Know how to apologize for misgendering (say sorry, rephrase, move on).

Language and society

Be aware of the historical and persistent regulation of gender through institutions. For example, historical oppression in mental healthcare can occur through invalidating language and misgendering.

Language and clinical practice

Using people's correct pronouns is a way to show respect and build a trusting therapeutic relationship. Your clients should feel open to express themselves without fear of judgement or discrimination. Advocate for intake forms that allow clients to self-identify their gender, pronouns, whether they are trans, and if the name they use is different from the name used on their legal documents. An example of an intake form can be found here. It is important to know with whom you can use a client's pronouns, identities, and name(s). Your client may only be 'out' or use their pronouns, identities, and name around specific people; they may not share this information with other healthcare professionals, family members, educational systems, among other people and institutions. In the situation with Nola, it is not clear if they have disclosed this information to other mental health professionals. Ideally, you can ask on intake forms or during a session with whom you can and cannot use their name and pronouns. If not, a conversation with other mental health professionals who have a close relationship with Nola may help you figure out how to approach this situation.

Language and Indigeneity

Nádleeh (sometimes spelt Nádleehí or Nádleehé) is a term that is used by the peoples of the Navajo (Diné) nations. Read more here. And watch this video starting at 0:30 until 2:00. Understand that the term Two-Spirit is not used by all Indigenous people with diverse gender and/or sexuality.

https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 13/86 4/29/2021 Qualtrics Survey Software Two-Spirit is a term used by some Indigenous people to describe their diverse gender and/or sexuality which involves cultural and spiritual aspects. Two-Spirit holds a variety of co-existing meanings for people including the following: a connection to Indigenous teachings; a "placeholder term until they find words in their Indigenous languages to describe who they are" (p. 4); and a banner under which Indigenous people can organize politically (Laing, 2018). The term is not used by all Indigenous people with diverse gender and/or sexuality, and it can be used in addition to other terms in the LGBTQ+ acronym. Two-Spirit was first proposed in 1990 at an intertribal Native American/First Nations Gay and Lesbian Conference. It is a literal translation of the Anishinaabemowin term niizh manidoowag. If the client identifies as Two-Spirit, Indigiqueer, or another traditional Indigenous term, ask them what it means for them (Laing, 2018). Reflection (Ontario Federation of Indigenous Friendship Centres, OFIFC, 2020) Involve yourself in authentic, relational, and reflective learning as a mental health professional. This follows teachings that show learning is cyclical, reciprocal, and a healing process for yourself to better serve your clients. Assess your assumptions about what you think Indigenous peoples need. Reflect on what is already in your bundle that you can use to build relationships with Two-Spirit and Indigenous peoples who have diverse gender identities. Reflect on what you need to include in your bundle moving forward. The word bundle is used figuratively here to get you to reflect on the resources, relations, networks, knowledge, and teachings that you have to better support Indigenous peoples. The literal word for bundle refers to a pouch that carries sacred items that can be used personally (to help you develop, items that have brought teachings, items given by elders or family members) or used as a group (to bring healing and vision to a whole nation).

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Situation 3

Situation 3 Harkamal identifies as gender non-binary and has a chronic pain condition that limits their ability to walk. They ask the receptionist where the accessible washrooms are, and the receptionist points them to the women’s washroom down the hall. The receptionist then sees Harkamal more closely and says, “sorry, and the men’s bathroom is right beside it. I am not sure which you prefer, but both are accessible.” Then with a warm smile she says more quietly, “by the way, congrats on starting your transition!”

Do you have any feedback about this situation? We are looking for feedback to improve the situation (i.e., remove the situation, modify the situation by adding or removing aspects, etc.)

*If you are confused or have questions, please do not hesitate to email [email protected] - we can easily have a quick zoom call.

It is difficult to avoid making assumptions about people’s gender. When asked about the washrooms’ location, staff should direct people to multiple types of bathrooms (i.e., gender neutral, men’s, women’s, and accessible, when available). The receptionist is gender affirmative. The receptionist’s comment about Harkamal’s transition was an honest mistake. Bringing up a client’s transition as a receptionist is likely inappropriate. Someone in leadership should privately address the comment about Harkamal’s transition with the receptionist.

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If you had your own clinic, how much would the following be a priority? Please answer honestly. 1 – Not a priority; 2 – Low priority; 3 – Medium priority; 4 – High priority; 5 – Essential; 999 - I prefer not to answer

Having a gender neutral and accessible washroom available. Signage about what utilities (i.e., sink, urinal, toilet, change table) are in each bathroom instead of using gendered signs. If bathroom keys are needed, making them gender neutral or discrete if they are gendered. Teach staff about the types of gendered assumptions that may be harmful to clients. Having professional development sessions with all staff about gender diversity and anti- oppression.

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Think that issues around gender diversity are exaggerated. Consider why and how often you may assume that people’s gender is binary (man or woman). Think about the specific systemic and historical obstacles faced by non-binary people who have disabilities face. Think about your privilege in the spaces you use and the way people speak to you. Reflect on how maintaining the status quo may collude with oppression and work against healing. Consider ways to empower and support the resilience of people like Harkamal. Think that it is unrealistic to be well educated on every social issue (i.e., gender, homelessness, racism, colonization, substance use, sexuality, etc.) https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 16/86 4/29/2021 Qualtrics Survey Software

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Additional questions

When asked about the location of washrooms, do you usually direct people to the washroom that best matches their gender expression? For example, if someone looks feminine or like a woman, you direct them to the women’s washroom.

Yes No I prefer not to answer

When you see a trans person, do you unintentionally consider how well they 'pass' as a woman or man?

Never Almost never Sometimes Often Every time I prefer not to answer

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Clinic washroom best practices (Airton, 2018)

Post signage about what utilities (i.e., sink, urinal, toilet, change table) are in each washroom instead of using gendered signs.

Ensure that your clinic has a gender neutral and accessible washroom available. Direct people to all washrooms if asked (i.e., do not assume what bathroom they will use). Ideally, avoiding the use of keys for bathrooms. However if they must be used, ensure they are gender neutral or discrete if they are gendered.

Related Knowledge

Gender is nonbinary and fluid. Someone’s gender may not align with the social expectations of their sex assigned at birth. Due to systems of oppression (transphobia, cisnormativity, ableism), client’s intersecting identities and abilities (i.e., being trans and having a disability) may interfere with their ability to access spaces and meet their necessities. Avoid saying or asking about preferred spaces (i.e., washrooms), pronouns, or names. Instead, ask about spaces, pronouns, or names that the client uses. Preferred reinforces the perception that these are a matter of preference, and thus can be ignored. Spaces that are gender binary are part of the historical and persistent regulation of gender by institutions.

Reflection and Growth

Taking feedback with grace (Airton, 2019) When a trans person gives you feedback or corrects you, that is an act that they care and trust you. Giving feedback all the time to each person that makes a mistake can be exhausting. So when your client corrects you it may be a sign that they respect you and want to continue a relationship with you. Recognize and challenge your biases (Almeida, 2018; American Psychological Association, 2015; Bess & Stabb, 2009; Rachlin, 2002)

https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 18/86 4/29/2021 Qualtrics Survey Software Across many cultures and systems of oppression, we are socialized to hold automatic ideas, assumptions, and biases about gender and other identities/experiences. As mental health professionals, the assumptions that you make can be deeply harmful to your clients. Therefore, it is essential to reflect regularly so you may challenge these assumptions. How to challenge your assumptions:

1. Recognize you made an assumption. Be honest with yourself. 2. Reflect on how maintaining the status quo may collude with oppression and work against healing. 3. Reframe your thought/perspective/question to disrupt and remove the assumption. 4. Think about where the assumption comes from (professional education, ethics guidelines or standards of practice, families or caregivers, media, culture, etc.). Doing this will help you challenge the assumption based on the root issue. Do not use this as an excuse for complacency and harm to clients. 5. Celebrate your small steps and successes progression in the process of learning and becoming a more inclusive and affirmative professional (Airton, 2018). Look forward to future learning and growth.

Examples of assumptions in dominant Western culture: Assumption: knowing a person’s gender based on how they look or talk. Challenge yourself: it seems I might be trying to figure out if that person fits into the man or woman categories. I know gender is non-binary and fluid, so there is no need to categorize them. Assumption: that person looks feminine, so why are they in the men’s bathroom? Challenge yourself: I should not be assuming the washroom that someone will use based on how they look. I’ll make sure to not stare, and if they look my way, I can give them a small, warm smile. Assumption: that person seems to just have started their transition because they don’t look very masculine yet. Challenge yourself: oh I forgot – many people express themselves in a way that channels masculinity and femininity, or neither. They might not be trans, and if they are, they might be non-binary. Assumption: Do you have a wife? Challenge yourself: I guess that questions assumed that all people are cis-

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Perception analysis to help you remove harmful assumptions (Luctkar-Flude et al., 2020) There are three levels of perception analysis: (1) description, (2) interpretation, and (3) evaluation. As a mental health professional, your perceptions, questions, and answers should aim to be within the description level. As a mental health professional, it is important to be curious, feel genuine emotions for client’s situations, and to support them. However, these elements must be done in an inclusive way that removes assumptions which may harm the client.

Level of Example: someone asks, "where Definition perception are the accessible washrooms?" Perceptions, You answer, "the gendered questions, and washrooms are down the hall to Description answers are based the right, and a gender-neutral on what you see or accessible bathroom is right what is present beside the entrance there." Perceptions, You think, “this client probably has Interpretation questions, and a physical disability if they asked answers are based about accessible washrooms.” on what you think Perceptions, questions, and You feel sorry for the client Evaluation answers are based because you think they likely have on what you feel or a physical disability. value

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Situation 4

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Situation 4 A 9-year old child, Jelani, and her mother, Moneshah, come into your clinic. Jelani was assigned male at birth but is starting to ask to shop in the girls’ section for clothes, play with the girls at school, and say they wish they were born more like their sister because she is a girl. Jelani is constantly changing their mind on what pronouns to use.

During the visit, Moneshah tells you that their family doctor said this was a phase of exploration that was common in many children. Moneshah also expresses that she is deeply fearful of Jelani's future and safety if this continues because they are Black and have heard about many black trans women facing hate and violence.

Do you have any feedback about this situation? We are looking for feedback to improve the situation (i.e., remove the situation, modify the situation by adding or removing aspects, etc.)

*If you are confused or have questions, please do not hesitate to email [email protected] - we can easily have a quick zoom call.

This is a normal part of growing up and exploring self-identity; only if it persists into adulthood should the decision be made to pursue it further. Youth with gender dysphoria are a psychologically vulnerable population. Social transition may reduce a child’s distress and improve their emotional functioning and self- worth. Gender dysphoria often resolves once puberty begins. It is difficult for young people to draw conclusions about their gender identity during a universally tumultuous stage of life. Children who experience some form of gender identity challenge later come to endorse the gender they were raised as.

https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 21/86 4/29/2021 Qualtrics Survey Software Conversion therapy may cause lasting damage to a child’s social and emotional health and wellbeing. Ideally, trans people express aspects of their gender from an early age. The following is a cisnormative practice (assuming all people are cis-gender): suggesting to wait until after the onset of puberty to begin puberty blockers so clinicians can ensure that the client’s gender dysphoria does not go away. The effects of puberty blockers may not be reversible. Jelani is currently in Tanner Stage I, and she would not be able to start puberty blockers until Tanner Stage II. You have the potential to influence the internalized attitudes of Jelani and Moneshah.

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Assess Jelani for gender dysphoria based on the DSM-V criteria. Ensure all avenues are patiently explored to see if gender transitioning is necessary or desirable for Jelani. Due to Jelani’s young age, advise Moneshah to gently discourage Jelani from behaving in ways that contradict their assigned gender. In an age-appropriate way, explain to Jelani and Moneshah that gender can be nonbinary and fluid. Suggest that Jelani be given ample room to explore various options for gender expression. Honour Jelani’s flexible definition of their gender and gender expression. Offer to work with Jelani's family members to develop a shared understanding of Jelani's experience.

Explain the costs and benefits that transition can bear upon individuals. Suggest that Jelani may still be too young to make any decisions about their gender. https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 22/86 4/29/2021 Qualtrics Survey Software Suggest that Moneshah and any other caregivers support Jelani’s gender identity exploration over time. Explain that you cannot promise transition is “the right thing to do” for every client. Indicate that a non-judgemental, safe, and supportive environment for Jelani will allow for optimal outcomes. Advise that the consequences of diagnosing and treating a child could last a lifetime. Indicate that social transition does not have to take an all or nothing approach. Suggest that if Jelani wants to transition in their day-to-day life, that Jelani should lead their social transition. Ensure that Jelani has ready access to puberty blockers by connecting them with a physician or nurse practitioner. Advise that medical transition should be a last resort until Jelani is an adult.

Provide support for Moneshah and her family over time to enable a safe, supportive, and affirming home environment. Compassionately discuss the realistic challenges that Jelani could face as a Black trans girl and woman. Educate and advocate for Jelani to ensure gender affirming support is provided in school and extracurricular activities. Help Moneshah unpack her fear and emotions about Jelani’s future and safety. Encourage Moneshah to reframe the way she views Jelani's story in a way that celebrates Jelani's strengths and unique contributions to their family/community/etc. At another session, explore movie, music, or spoken word clips that will help you and Moneshah discuss various topics (i.e., how black trans women navigate life, how institutions have historically restricted gender diversity, being gender non-binary, etc.) Explore with Jelani and Moneshah in a child-friendly way how trying to restrict gender diversity is a broader social and historical pattern. Bring several of your clients together to help empower each other through this and other situations.

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Additional questions

How would you rate your current knowledge of gender affirming resources that can help support others like Jelani and their family (i.e., local support groups and organizations)?

Not at all knowledgeable

Slightly knowledgeable

Somewhat knowledgeable

Moderately knowledgeable

Extremely knowledgeable

I prefer not to answer

How would you rate your current ability to provide anti-racist and intersectional psychological support to Jelani, Moneshah, and their family?

Not at all able

Slightly able

Somewhat able

Moderately able

Extremely able

I prefer not to answer

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Feedback to be given to the participant at the end of the survey

The following are flexible recommendations for gender affirmative mental healthcare for gender https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 24/86 4/29/2021 Qualtrics Survey Software diverse children and youth.

Getting to know your client and their context (adapted from Telfer, 2020)

Developmental history and family/caregiver dynamic. This can help you understand (i) how the child and their family communicates, (ii) how they cope with stressors, (iii) the source of psychological or social issues, (iv) important cultural components in their family, (v) their social positions and access to supports, and (vi) areas of strengths and growth of your client. Social functioning (i.e., educational, extracurricular, friends). These are important parts of my people’s livelihood, including children. However, institutions and social spaces may place unique barriers in the lives of trans children (especially those who are black, feminine, and/or non-binary). Importantly, these spaces can also be pockets of support and actualization. Understanding the child's social supports and networks can help you tailor referrals. Health and wellbeing. Co-existing physical, mental, spiritual, and emotional aspects of a child’s life may interact with gender and gender diversity. Many of these aspects can be strengthened to build resiliency and agency in children. Some of these aspects uniquely intersect with being trans: having mobility aids and requiring an accessible and gender neutral washroom; having autism and navigating social situations involving others enforcing gender binaries; self- acceptance as some who is trans and also Christian, body trust for trans people who are fat; etc. Identify circumstances that may require more intensive psychotherapy and/or referral. Social positions. Understanding the social barriers and facilitators that impact the client's wellbeing and their access (e.g., financial and geographic) to gender affirmative care. Understand the oppressive systems that impact your client's life (i.e., transphobia, cisnormativity, fatphobia, racism, etc.). Intersecting identities (i.e., being trans and black) within systems of oppression (transphobia and anti-black racism) interfere with people's ability to achieve their goals, desires, and/or necessities.

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Initial steps/gender exploration

https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 25/86 4/29/2021 Qualtrics Survey Software Advocate for parent(s)/caregiver(s) to support their child’s gender identity exploration over time. This involves respecting children and youth’s choices for gender identity, pronouns, and expression related to gender while recognizing that this may change and that is okay. Give ample room for the child to explore various ways to express their gender. Provide clinically relevant education about gender identity (fluid, non-binary) and information regarding local support groups and organizations to support the client, siblings, parents, and/or carers. For example, in this short video, Schuyler Bailar who is a trans athlete, explains gender nonbinary for children. If desired, counsel children/youth and their parent(s)/caregiver(s) on transition and gender affirmative processes. Usually the goal of transitioning is to find better alignment between one’s gender identity, body, and other ways of relating in everyday life (Airton, 2018). Transition is not in terms of passing as a member of a particular gender category; nonbinary children/youth, in addition to those who are gender binary and trans, may seek out transitioning (social and/or medical) (Airton, 2018). Transition is not black-and-white, open-or-shut, or linear for many people (Airton, 2018). Discuss options for social and medical transition available to children and youth. Typically, children can undergo social transition including gender expression and legal document changes with consent from their parent/legal guardian. They can usually also access puberty blockers around the onset of puberty (jurisdiction dependent). Typically, adolescents can undergo social transition and may access some medical transition processes (puberty suppressing hormones, hormone replacement therapy, and gender affirming surgeries). They may not need consent from their parent/guardian to access legal document changes, puberty blockers, and hormone replacement therapy (depending on their age and the laws/policies in their jurisdiction).

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Social transition

Social transition "should be led by the child and does not have to take an all or nothing approach. It may occur broadly across different social contexts such as within the home and school environments, or be kept to selective environments should the child wish to do so" (Telfer et al., 2020, p. 9). A “non-judgemental, safe, and supportive environment for the child and their parents or caregivers allows optimal outcomes from care provision” (Telfer et al., 2020, p. 9) Benefits: social transition has been shown to reduce a child's distress and improve their emotional functioning and self-worth (Olson et al., 2016; Durwood et al., 2017) Conversion therapy or reparative therapies (attempting to change a person’s gender identity to be aligned with their sex assigned at birth) “lack efficacy, are considered unethical, and may cause lasting damage to a child or adolescent’s social and emotional health and wellbeing” (Telfer et al., 2020, p. 5) If the child is expressing a desire to live in a role consistent with their gender identity, provide psychological support and practical assistance to the child and their family to facilitate gender affirmation. A diagnosis of gender dysphoria may not be necessary for the child/youth to carry out their social transition.

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Medical transition

https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 27/86 4/29/2021 Qualtrics Survey Software Puberty blockers (hormone blockers) have fully reversible effects. Support children and youth in gaining ready access to puberty blockers. Puberty blockers (i) give youth more time to explore their gender diversity and identity and (ii) may facilitate transition by preventing the development of physical characteristics that are difficult or impossible to reverse if youth continue on to pursue gender affirming surgeries. If possible, collaborate with a physician or nurse practitioner experienced in trans-affirmative support (family physician, pediatrician, pediatric endocrinologist, etc.) to support the child through this process. Ideally, initiate this collaboration at Tanner Stage I which is before the onset of puberty. Details about the Tanner Stages can be found at Healthline (2018), but these stages only describe the experience of boys and girls who are white (notice white supremacy at work?).

To begin puberty blockers, the WPATH guidelines (2011, p. 18) indicate that youth should wait until the onset of puberty (Tanner Stage II) to certify that gender dysphoria emerged or worsened with the onset of puberty. It may be worth questioning this criterion as puberty blockers are fully reversible and the assumption of gender dysphoria needing to worsen may be cisnormative and transphobic. You could consider following different approaches to transition, such as gender euphoria and creative transfiguration. Read page two of Ahsley, (2019) under the subheading Suppressing the Diversitiy of Trans Embodiment for definitions of gender euphoria and creative transfiguration. Age of Consent: in many places of the world, adolescents can provide informed consent at age 16 for puberty blockers. If the adolescent has not reached the age of medical consent, the parent(s), caregiver(s), or guardian(s) have consented to the treatment and are involved in supporting the adolescent throughout the treatment process. Ideally, treatment decisions should be made among the adolescent, the family, and the treatment team.

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Legal documentation https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 28/86 4/29/2021 Qualtrics Survey Software Provide documentation to assist youth clients in changing identity documents to reflect their name and gender.

Continued support

Manage transition and continuation of care from pediatric to adult services in a timely manner (Telfer, 2020). Avoid enabling clients to be neglected by our healthcare system.

Supporting families and caregiver(s) (Telfer, 2020)

Individually check-in with the child or youth’s support person (parent/caregiver). Work together with family members to help develop a common understanding of the child or youth’s experience. Developing a shared understanding allows the child or youth to feel genuinely supported and affirmed in who they are and for the family to make considered and informed treatment decisions in the future, therefore ensuring optimal care. If necessary, provide support for parent(s)/caregiver(s) over time to enable a safe, supportive, and affirming home environment for the child. This may also apply to peers and mentors from the community, who can be another source of social support. The following is a great resource for parents from Gender GP.

Community support (Telfer, 2020)

It may be necessary to advocate for the child or youth and their family to ensure gender affirming support is provided within community environments (i.e., daycare, school, employment, extracurricular activities, youth justice facilities, etc.) For children or youth who are socially transitioning, “providing education about social transition to the child’s daycare/kindergarten or school [and other social contexts] is often necessary to help facilitate the transition and minimize negative experiences such as bullying or discrimination” (p. 9) Children and youth who are engaged in sporting or other activities may also need assistance to allow their transition to occur without exclusion or withdrawal from these groups.

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Healing and psychological support

Help the child and family unpack their emotions/thoughts related to gender identity, gender expression, transitioning, safety, and intersectional issues. Encourage the child and family to reframe the way they view gender diversity. Recognize and celebrate the unique contributions that the child can make to their family/community/world through their strengths. Explore movie, music, spoken word clips, or other art that will help you and the family discuss various topics in a child-friendly way (i.e., the diversity within trans communities, the existence of nonbinary people, the historical role of institutions restricting gender diversity, etc.). Importantly, get the child and family to discuss and understand how their issues are part of broader social and historical patterns. Healing circles: bring several of your clients together to discuss issues which enables them to lend their voice and experience to change the way the child and family carry the load. The group serves to mobilize changes within oppressive systems. Individual paradigms of therapy do not offer this collective empowerment. See the podcast by Hoff & Almeida (2019) for details on how to enact this healing process. Healing may focus on many different areas: Exploring gender identity, gender role, and gender expression Navigating the constraints of gender dysphoria Impact of gender identity in work, school, home, and social environments, including issues related to discrimination and structural challenges Addressing fear of changes Acceptance and affirmation of diversity Alleviating internalized transphobia Addressing the negative impact of gender dysphoria and stigma on mental health Addressing sexual health concerns Enhancing social and peer support Improving body image Promoting resilience

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Knowledge

One of the most comprehensive, affirmative, interdisciplinary, and evidence-based guidelines

is available through AusPATH at the following link. Reference: Telfer, M. M., Tollit, M. A., Pace, C. C., & Pang, K. C.

(2020). Australian standards of care and treatment guidelines for transgender and gender diverse children and adolescents. Medical

Journal of Australia, 209(3), 132-136. For more information regarding transition-related medicine for young people see: Gender Creative Kids Canada and the Transgender Youth Program at Ontario’s Sick Kids Hospital.

Understand and critically appraise the diagnostic criteria for Gender Dysphoria in Children from the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V, 2013). Ask questions like: Does it regulate gender? Does it restrict the conceptualization of trans experiences? When does it gatekeep and when does it enable access to care? Does the assessment process dehumanize and negatively impact the health and wellbeing of trans clients? https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 31/86 4/29/2021 Qualtrics Survey Software Understand how a diagnosis of gender dysphoria, if used flexibly (i.e., Unspecified Gender Dysphoria) along with the information shared by the client and their caregiver(s), may be useful and sometimes necessary for clients to access care (i.e., surgeries) and file insurance claims.

Understand and critically appraise the criteria and guidelines found in The World Professional Association for Transgender Health Standards of Care, 7th version, for various processes involving youth (WPATH, 2011, pp. 19-21) and the roles of mental health professionals in care (WPATH, 2011, pp. 14-17). Is the language used gender affirming and reflective of terms accepted and used by the trans community? Do the criteria and guidelines have an inflated reliance on nonmaleficence? Do the tone and discourse of the guideline promote your role as a gatekeeper of care? What systems of oppression do these criteria uphold?

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Reflection and Growth

Learn about what you can do to promote transition of care and provide optimal support within the healthcare system. Reflect on your potential to influence the internalized attitudes, health, and wellbeing of Jelani and Moneshah. Examine your attitudes and personal values about gender and healthcare practice. Examine your attitudes and personal values about gender and healthcare practice. Identify where these attitudes come from and how they may impact Jelani and Moneshah.

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Situation 5

Situation 5 You are with a client named Sasha who is transfeminine and has been taking hormone replacement therapy (HRT) for over a year. She is very happy, physically well, and looking to undergo several gender affirming surgeries. Sasha requires two referral letters from mental health professionals to get funding for the surgeries. She did not require letters for her HRT prescription because her university’s health clinic practiced the informed consent model.

Do you have any feedback about this situation? We are looking for feedback to improve the situation (i.e., remove the situation, modify the situation by adding or removing aspects, etc.)

*If you are confused or have questions, please do not hesitate to email [email protected] - we can easily have a quick zoom call.

How much do you agree with the following statements? Please answer honestly. Shown in Likert Scale: 1 – Strongly disagree; 2 – Disagree; 3 – Neither agree nor disagree; 4 – Agree; 5 – Strongly agree; 999 - I prefer not to answer https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 33/86 4/29/2021 Qualtrics Survey Software The criteria for gender dysphoria on the DSM-V are too restrictive. The client may be nervous to see you because of previous bad experiences in healthcare. You prioritize promoting trans people’s agency within healthcare. In-depth assessments to explore a client’s gender dysphoria are necessary. Assessments can be restrictive in definitions of gender dysphoria. The current standards of care have an inflated reliance on nonmaleficence. It is inconsistent that gender variance is non-pathological but gender affirmative care requires psychiatric diagnoses. It is inconsistent that gender affirming care is medically necessary, but clients cannot consent to their own care. It is important to think about the historical legacies of trans-related diagnostic materials (i.e., guides, standards, or assessments). It is appropriate to flexibly apply trans-related diagnostic materials (i.e., guides, standards, or assessments).

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If Sasha is hoping for you to write her a reference letter, how likely are you to take the following steps? Please answer honestly. Shown in Likert Scale: 1 – Extremely unlikely; 2 – unlikely; 3 – Neutral; 4 – likely; 5 – Extremely likely; 999 - I prefer not to answer; 777 - I do not conduct assessments

Caution is required, especially as Sasha did not show signs of gender dysphoria at an early age. Combine your clinical expertise with Sasha’s personal insight about her gender and what she needs to find the best way forward. Assess Sasha for persistent, well-documented Gender Dysphoria in Adults (DSM-V), as this is a criterion for gender affirmative surgery outlined by World Professional Association for Transgender Health (WPATH). Figure out if a Gender Dysphoria diagnosis and/or letter of referral is also required by (1) the health jurisdiction and/or (2) for insurance claim purposes. https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 34/86 4/29/2021 Qualtrics Survey Software Ensure that Sasha's symptoms of psychosis are reasonably well controlled, as this is a criterion for gender affirmative surgery outlined by WPATH.

Get to know which gender affirming surgeries Sasha is interested in. Ensure that Sasha’s hopes and expectations align with what procedures are available.

Reach out to Sasha’s clinician who treats her psychosis. Gently explain why you would like to know about her experiences with psychosis as they relate to her gender affirmative treatment. If Sasha struggles with HRT compliance, collaboratively make a plan of how that will be managed. Find alternative supports with Sasha to navigate her experience with hearing voices that do not involve medication.

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In terms of psychological support (outside of assessment), how likely are you to take the following steps? Please answer honestly. Shown in Likert Scale: 1 – Extremely unlikely; 2 – unlikely; 3 – Neutral; 4 – likely; 5 – Extremely likely; 999 - I prefer not to answer

Help Sasha to accept her current situation and work on coping strategies. Help Sasha unpack her emotions about her experiences in this process of accessing gender affirmative surgeries, her gender, and how she has been treated by mental health professionals. Assess Sasha for depression and anxiety to make sure you are fully understanding Sasha's context as a trans person. Look to understand whether Sasha struggles with HRT medication noncompliance. Support Sasha in reframing her stories, emotions, and/or thoughts about her own gender identity, gender expression, and how those aspects fit in with other aspects of her life. https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 35/86 4/29/2021 Qualtrics Survey Software Help Sasha explore why she wants gender affirming surgery. Explore with Sasha how gender is a diverse, non-binary, and fluid concept. Tell Sasha that she is an expert in her own gender. At the next session, find movie clips, music, spoken word, or other art forms that will help you and Sasha deeply explore how her situation is a broader social and historical pattern. Encourage Sasha to think about identifying as non-binary. Think together with Sasha about whether the gender dysphoria and trans health guidelines reflect the non-binary and fluid nature of gender. Talk about strengths-based approaches such as gender euphoria and creative transfiguration. Encourage Sasha to reframe the way she sees and tells her story in a way that shows her strength. Bring several of your clients together to help empower each other through this and other situations. Help Sasha restore personal agency through validation, recognition of her strengths, and hearing about other trans people with psychosis. Think about the specific discrimination that gender diverse people who have schizophrenia face.

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Additional questions

How would you rate your knowledge of what questions to ask and information to collect to put Sasha’s case forward to medical help?

Not at all knowledgeable

Slightly knowledgeable

Somewhat knowledgeable

Moderately knowledgeable

Extremely knowledgeable

I prefer not to answer

I do not conduct assessments https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 36/86 4/29/2021 Qualtrics Survey Software

How would you rate your ability to write a letter of referral when necessary?

Not at all able

Slightly able

Somewhat able

Moderately able

Extremely able

I prefer not to answer

As a mental health professional, how often do you reflect on your potential to gatekeep or provide access to care?

Never

Rarely

Sometimes

Often

Always

I prefer not to answer

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Feedback to be given to the participant at the end of the survey

Knowledge

Variety in expression, experiences, and needs Everyone’s journey with gender varies, and not all trans people experience being trans in the same way.

https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 37/86 4/29/2021 Qualtrics Survey Software All expressions and experiences of being trans are valid, including identifying as trans later on in life, being non-binary, loving masculine and feminine aspects of one’s gender expression, and wanting to undergo gender affirming surgeries. Do not assume that all trans people struggle with their mental health. Trans people are able to thrive, but mental health professionals often assume trans people struggle.

Institutional regulation of gender (historical and present). Your healthcare practices have been shaped by historical legacies (see list below). Without adequate education and consideration, the healthcare you provide may continue to negatively affect how people view gender. The client may be nervous to see you because of the discrimination they may have experienced and/or the historical and current oppression of gender diversity through mental health assessments, treatments, 'interventions,' etc. Historical oppression in mental healthcare has occurred through the following: Invalidating language and misgendering. Spaces and processes that conform to the rigid gender binary. Pathologization of gender diversity. Rigid and unrepresentative conceptualizations of trans experiences within diagnostic assessments. Epistemic violence by necessitating assessments to access healthcare. Forced medical and mental health treatment/procedures to access legal documentation. Gatekeeping of treatment. Prejudice and discrimination by mental health professionals. A lack of trans voices and leadership in creating guidelines, diagnostic manuals, and treatments, etc.

Intersectionality: trans and hearing voices The WPATH (2011) criteria state, "if significant medical or mental health concerns are present, they must be reasonably well controlled." This may negatively impact trans people who hear voices, see visions, or have other unusual perceptions. Our dominant-Western mental health system views these 'unusual' perceptions through a lens of pathologization, control, and epistemic violence. As mental health https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 38/86 4/29/2021 Qualtrics Survey Software professionals, you may have been trained to understand, diagnose, and treat people with 'unusual' perceptions in a way that may (perhaps unintentionally) undermine their agency and humanity. Some find diagnoses (e.g., schizophrenia, psychosis) and treatments (e.g., CBT, neuroleptics) helpful and others find the same diagnoses and treatments to be a barrier to healing. "For some, these experiences can be comforting or inspiring. For example, someone who is lonely may really value a voice that becomes a trusted confidant, or Authors, sometimes talk about how the characters can come to life and write the story for them" (Hearing Voices Network, n.d.) If compliance with medication is an issue with your client, you can collaborate with their other health providers to help your client meet WPATH criteria (which are flexible guidelines and not mandates) by referring them to the Hearing Voices Network. For more information visit their website or listen to this podcast.

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Knowledge (continued)

Assessments Understand the Informed Consent Model (ICM) "ICM offers a more collaborative and patient-centred approach that addresses debates surrounding exactly how and when trans people should access these gender-affirming medical treatments that persist amongst clinicians and researchers. Using ICM in gender-affirming medicine allows for trans people to access hormones and transition-related surgeries with self-determination and autonomy, without the need for: a gender dysphoria diagnosis, mandatory pre-

https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 39/86 4/29/2021 Qualtrics Survey Software transition psychosocial readiness assessments, and unwanted mental health treatments." (MacKinnon & Ross, 2019) Understand and critically appraise the diagnostic criteria for Gender Dysphoria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V, 2013). Ask questions like: Does it regulate gender (i.e., perpetuate the types of gender identities and expressions that are acceptable)? Does it restrict the conceptualization of trans experiences? When does it gatekeep and when does it enable access to care? Does the assessment process dehumanize and negatively impact the health and wellbeing of trans clients? Understand how a diagnosis of gender dysphoria, if used flexibly (i.e., Unspecified Gender Dysphoria) along with the information shared by the client and their caregiver(s), may be useful and sometimes necessary for clients to access care (i.e., surgeries) and file insurance claims. Understand and critically appraise the criteria and guidelines found in The World Professional Association for Transgender Health Standards of Care, 7th version, for Hormone Replacement Therapies and Gender Affirming Therapies for adults. Think about how needing to control “significant medical or mental concerns” may disproportionately affect minority and marginalized groups such as those who have schizophrenia or psychosis. Is the language used gender affirming and reflective of terms accepted and used by the trans community? Do the criteria and guidelines have an inflated reliance on nonmaleficence? Do the tone and discourse of the guidelines promote your role as a gatekeeper of care? What systems of oppression do these criteria uphold? Be aware of concepts such as gender euphoria and creative transfiguration to prevent the dehumanization of trans clients. See the following FAQ page by MacKinnon and Ross (2019) for answers to the following questions: Do I have to follow the WPATH standards of care (SOC) when assessing/referring trans people for hormones and surgeries? Could I be at risk of malpractice if I don’t follow the WPATH-SOC strictly? What if a trans patient regrets their decision for hormones or surgery and wants to de-transition?

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Skills

Healing and psychological support Help Sasha restore personal agency through validation, recognition of her strengths, and hearing about other trans people with psychosis. Encourage Sasha to reframe the way she sees and tells her story in a way that shows her strength. At the next session, find movie clips, music, spoken word or other art forms that will help you, your client, and others (if you are in group therapy) to deeply explore how the client’s situation is a broader social and historical pattern. The diversity within trans communities - all experiences being varied and valid. How some institutions impose a binary view of gender onto our society, harming individuals. Talk about strengths-based approaches such as gender euphoria and creative transfiguration. Discuss issues within mental health care: Rigid and unrepresentative conceptualizations of trans experiences exist within diagnostic assessments. A lack of trans voices and leadership in the creation of guidelines, diagnostic manuals, and treatments. Epistemic violence by necessitating assessments to access healthcare. Pathologization of gender diversity. Gatekeeping of treatment. Prejudice and discrimination by mental health professionals. Healing circles: bring several of your clients together to discuss issues which enables them to lend their voice and experience to change the way client carries the load. The https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 41/86 4/29/2021 Qualtrics Survey Software group also serves to mobilize changes within oppressive systems. Individual paradigms of therapy do not offer this collective empowerment. See this podcast by Hoff & Almeida (2019) for details on how to enact this healing process.

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Skills (continued)

Helping clients access medical care (Gender GP, 2020) Process to avoid gatekeeping and negative health impacts. If the client's physician requires them to be 'assessed' by a mental health professional, you have an essential role to advocate with your client. Current best practices are outlined below: Communicate with the client that they are the expert in their own gender and that your role together is to find the best way forward in a safe and accessible way. Listen to clients who know exactly what they need, and guide those who need a little more guidance. Do not put the client through lengthy assessments to validate their gender. Ask questions and collect information to put the client’s case forward to medical help; you can call this an Information Gathering Session. This involves (1) obtaining informed consent and (2) ensuring that the client’s hopes and expectations fit with what procedures are available. Determine whether a Gender Dysphoria diagnosis and/or letter of referral is required by (1) the health jurisdiction, (2) for insurance claim purposes or financial coverage of surgery by the government, (3) a primary healthcare provider like a physician or a nurse practitioner, or (4) a combination of these options

https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 42/86 4/29/2021 Qualtrics Survey Software (1) If a diagnosis of gender dysphoria is required by the health jurisdiction to access care (i.e., gender affirming surgeries) and/or filing insurance claims, be able to use Unspecified Gender Dysphoria (F64.9) as a flexible form of gender dysphoria with the information the client shared during the Information Gathering Session. (2) If a diagnosis of gender dysphoria is required for insurance of financial coverage of the surgery, be aware that this disproportionately impacts people with lower incomes or financial insecurity. Some surgeries have unspoken or unwritten associated costs - time off work, surgery preparation procedures, transportation, hotel accommodations. For example, phalloplasty requires laser hair removal which can cost $3 000 and may not be financially covered. (3) If the health jurisdiction does not require a diagnosis of gender dysphoria to access medical care, but the primary healthcare provider is requiring the diagnosis or a letter of referral so that the client can access care, you may be able to diagnose Unspecified Gender Dysphoria and/or write a letter of referral for the client using the information the client will share during the Information Gathering Session. If the health jurisdiction does not require a diagnosis of gender dysphoria to access medical care, AND the client is unsure if their physician or nurse practitioner is requiring them to get a letter of referral or diagnosis from you, then you or the client should communicate with the primary healthcare provider as to whether this is necessary. If no diagnosis or letter of referral is necessary—in terms of service provision—you should dedicate your time to psychological support and helping the client navigate other structural barriers rather than writing a letter of referral that is not necessary. Educate other healthcare workers that a letter of referral from a mental health professional is not always needed to access HRT or surgeries (health jurisdiction dependant), where appropriate. Involve your client in the referral process for gender affirming care Often there are few surgeons and physicians who offer gender affirming care (i.e., 2 in Ontario as of 2021). Gender affirming surgeries are meaningful, and various surgeons approach the process differently: some cover costs of travel, accomodation, and do not charge extra for contouring. It is vital that you get feedback from your client about where they want to go so they are not on a https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 43/86 4/29/2021 Qualtrics Survey Software wait-list for years only to have to start the process all over again because the surgeon cannot meet their health needs. Psychosis. Close communication with the psychosis treating health professional(s) may give you more insight into the client’s symptoms and whether it has affected HRT medication compliance. If compliance is impacted, collaborating with the client and the health professional who has been treating the psychosis to create a plan about how to navigate compliance and symptoms. Ensure that the client is valued and believed throughout this process in order to avoid epistemic violence.

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Reflection and Growth

Reflect on the power you hold in your role as a mental health professional and how you contribute towards social accountability and change through advocacy and empowerment at various levels. Consider the following: How can you provide access to gender affirming procedures without gatekeeping? How can your behaviour and systemic barriers lead the client to be neglected within the healthcare system (i.e., falling through the cracks)? How can you influence the internalized attitudes, health, and wellbeing of your clients who are trans ? How can you advocate with and for your client? Reflect on your preparedness to face ethical dilemmas, especially as clinical practices continue to evolve. For example: Do your colleagues or superiors disagree with a gender affirmative approach? By strictly following criteria and guidelines, will you be harming clients? Could you be sued for malpractice by not strictly following WPATH criteria? Would it be ethical for you to flexibly apply criteria to help the client access care? Have you thought about what situations, procedures, actions, or processes are permitted in keeping with the terms of your professional license? https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 44/86 4/29/2021 Qualtrics Survey Software For some help in answering these questions, see https://patient-centred.ca/faq Recognize and challenge your assumptions. For example: Why do we need clients to be distressed about their gender (i.e., gender dysphoria) to access gender affirming care? Where could gender euphoria fit into this model? Do you hold assumptions or attitudes about people with schizophrenia and how that uniquely interacts with their trans identity? Do you conceptualize the client's trans identity as a mental illness to be treated, or a cause of all problems? Do you have a rigid understanding of what it means to be trans? Do you often engage in a deficits-based narrative of the ‘suffering trans people’?

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Situation 6

Situation 6 You are facilitating a CBT group therapy session, and you find that you and several of the members repeatedly mix up Çağatay's pronouns (ze/zir) and do not pronounce zir name correctly. The members apologize profusely and fix each other's mistakes, but the atmosphere seems slightly uncomfortable.

Do you have any feedback about this situation? We are looking for feedback to improve the situation (i.e., remove the situation, modify the situation by adding or removing aspects, etc.)

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*If you are confused or have questions, please do not hesitate to email [email protected] - we can easily have a quick zoom call.

Continue the session and address the issue at the end with Çağatay privately. Ask Çağatay if you can use a nickname for him (that you can pronounce). Avoid using ze/zir pronouns by only using Çağatay’s name. When you mess up, say a quick sorry, rephrase, and move on. After the session, genuinely apologize to Çağatay and explain why this is a little hard for you. Rephrase or recast a sentence when someone else misgenders another person (i.e., ‘yes, like ze was saying’).

Seek to be aware of new terms and definitions within the trans community. Refer Çağatay to trans-specific group therapy, as ze may feel more comfortable there. Model introducing your pronouns in future meetings. Provide the group with name tags in future meetings. Model writing your pronouns on your name tag in future meetings. Allow for voluntary sharing of pronouns in future meetings. Identify times, places, and/or practices where people’s gender is commonly called into question. Strategize concrete actions to anticipate and cool down events where people are misgendered. Practice the use of ze/zir pronouns at home. Practice Çağatay’s name at home.

Do you have any feedback about the possible responses (i.e., remove or add a response, modify the wording)?

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It is remarkable that the group was profoundly apologizing for misgendering. It is not necessary to use they/them pronouns for clients who are clearly cis-gender (i.e., not trans). I am nervous about using gender neutral pronouns. Gender neutral pronouns ignore the vital work that gendered pronouns perform in everyday life. Preferred pronouns and gender pronouns are important. I am not sure why people would use newly made pronouns (i.e., ze/zir, xe/xym) when they/them pronouns already exist. Linguistic change towards gender neutral language is inevitable. I do not see the need for gender neutral words. Using someone’s pronouns can make a big difference in their quality of life. Ze/zir and similar pronouns do not flow naturally into speech or writing. Gender neutral pronouns are a fad. Language is the way it is and has been this way a long time, so it should remain unaltered. There are differences between women and men, and language should reflect these differences. Gender neutral language can feel impersonal and distanced. It is okay if a client uses gender neutral pronouns, but people who enforce these linguistic changes do not align with freedom of speech. People should focus on other vital forms of social injustice rather than language (i.e., the physical violence that trans people experience). This situation should be reflected upon through an intersectional lens.

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Additional question

How often do you reflect after a session on what went well and what could be improved?

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Never

Rarely

Occasionally/Sometimes

Almost every time

Every time

I prefer not to answer

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Feedback to be given to the participant at the end of the survey

Foundational knowledge (Airton, 2018)

Small changes to the way you use language can impact all people, including your trans clients. Respecting someone's pronoun makes them feel good – good enough to make a big difference in their quality of life and wellbeing (Airton, 2012). Terms Pronouns and names: ask about the pronouns and name someone uses rather than “preferred” pronouns or names. The latter reinforces the perception that these are a matter of preference, and thus can be ignored. Additionally, just call them pronouns, not 'gender pronouns' because some people's pronouns are not gendered. There are two types of gender neutral pronouns (or nonbinary pronouns) in English: They/them as a singular pronoun. Neopronouns (i.e., xe/xem and ze/hir, among others).

For people that do not like using they/them pronouns for others

Recognize that their workaround of using people’s names instead of pronouns is an okay way to avoid misgendering people. They/them and neopronouns as singular pronouns may be controversial to some, but just because something is controversial does not make it grammatically incorrect (Airton, 2018). https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 48/86 4/29/2021 Qualtrics Survey Software Using they/them for a single person “has been grammatically correct in English for centuries. What feels new is using it for someone you know" (Airton, 2018, p.193). Be aware that “for linguists, something is 'grammatically correct' when speakers of a language do it. English speakers use singular they [and neopronouns] for this purpose; therefore, it is correct" (Airton, 2018, p. 195). Be aware that “having to work at saying a thing doesn't mean it's grammatically incorrect" (Airton, 2018, p. 195).

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Handling pronoun corrections

When you use the wrong pronoun and realize in the moment:

"Can you pass the paper to him--sorry zirs--thanks." When you use the wrong pronoun and realize later: You are in a position of power and you cannot wait for the client to correct you. Send a short email saying, “I’m sorry, I realized that I used the wrong pronouns for you earlier. I know you use she/her pronouns, and I will make sure I get it right next time.” When other members of group therapy or your colleagues use the wrong pronouns for each other: Rephrase the first student’s sentence to show that you hold the group accountable in referring to each other appropriately. “Right, like they were saying," or "yes, she made a great point.” If a group member willfully continues to misgender someone (or multiple people), address their behaviour outside of the situation (i.e., group therapy). Reference your institution's code of conduct, which likely also references local human rights laws. Be https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 49/86 4/29/2021 Qualtrics Survey Software sure to follow-up with the person who has been misgendered. If you are on placement, bring the situation to your supervisor.

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Preventing misgendering

Model introducing your pronouns: Writing your pronouns on your name tag or display name if you are on a video call. Verbally on the first day of therapy/work. On your website bio, card, CV, etc. Facilitate voluntary sharing of pronouns. Collecting information about your client’s pronouns (Crowley & Melendez, n.d.) As a mental health professional, your role is to provide clients with the space to disclose their pronouns if they choose to do so while simultaneously protecting trans clients who do not wish to out themselves (i.e., disclose their trans identity). Be careful to avoid making assumptions about what pronouns a client might use. Online or written surveys. You may want to include the following questions: What name and pronouns should I use when referring to you? Where and with whom would you like me to use this pronoun? If any of this information changes over the course of the sessions, please feel free to send me an email or talk to me before or after a session. Introduction circles In the first session, write down on a board/PowerPoint what clients may voluntarily share about themselves to the class: name, pronouns, what brings them to therapy, a fun fact. Name tags You and your clients can make name tags and clients can be encouraged (but not required) to include their pronouns on this name tag. https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 50/86 4/29/2021 Qualtrics Survey Software Putting an image in your office/website to let trans and non-binary clients and colleagues know you are someone who is on board to use their pronouns without making it into a big deal (No Big Deal Campaign, Airton, 2016).

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Reflection and growth

Practice Taking feedback with grace (Airton, 2019) When a trans person gives you feedback or corrects you, that is an act that they care and trust you. Giving feedback all the time to each person that makes a mistake can be exhausting. So when your client corrects you it may be a sign that they respect you and want to continue a relationship with you. Continue to practice getting pronouns/names right by practicing with a friend, taking a pause to think about your words, gently correcting others, being real about your own challenges, and embracing change (Airton, 2019). Identify times, places, and/or practices where people’s gender is commonly called into question. Strategize concrete actions to anticipate and cool down events where people are misgendered. Identify your learning needs and be honest with yourself about the challenges that you https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 51/86 4/29/2021 Qualtrics Survey Software face. Commit yourself to action through SMART goals or other goal-setting techniques. Knowledge Language (in general and in the trans community) is continuously evolving and varies from person to person. Seek to be aware of new terms and definitions within the trans community and beyond. For example, consider using words like they/them, partner, sibling, firefighter, etc. Know resources to educate yourself and others about these issues (campaigns, blogs, books, videos, etc.) Reflection Celebrate your small steps and successes in the process of learning and becoming a more inclusive and affirmative mental health professional. After a session, reflect on what went well and what can be strengthened. Ask yourself What power and responsibility do you hold over your clients when you are facilitating group therapy? How you support and/or lead a public dialogue that affirms diversity within gender expression and gender identity?

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Situation 7

Situation 7 One of your clients named Salma comes into your therapy session on the verge of tears. From previous sessions, you know that she has identified as a woman for most of her adult life but presented herself as a man, which caused her constant emotional stress.

At this session, Salma tells you she began the process of changing her legal documents to reflect her gender. At the government office, the teller said to another co-worker, "he uses she/her pronouns" https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 52/86 4/29/2021 Qualtrics Survey Software and "she previously went by Karim,” and none of the personnel knew how to process Salma's requests adequately. She felt lost and had a panic attack at the government offices. Salma has long struggled with social anxiety, and she tells you that she is embarrassed to go back, exhausted with all these processes, and does not want to ask her boss for another day off to repeat the same process.

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Validate Salma’s emotions as what she went through was extraordinarily stressful.

Focus on how to help Salma navigate and cope with social anxiety. Consult with the staff at the government office that the client referred to, and inform them of necessary accommodations to the service they provided. Provide any additional documentation to facilitate Salma in changing documents to reflect her name and gender. Encourage Salma to reframe the way she sees and tells her story in a way that shows her strength. At the next session, find movie clips, music, spoken word, or other art forms to help you and Salma discuss how her situation is a broader social and historical pattern. Bring several of your clients together to help empower each other through this and other situations. Help Salma unpack and reframe her emotions about her experience at the government office and her relationship with her boss.

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There are so few trans people globally, so it makes sense that the staff at the government office were not accustomed to this process. Influencing policies and practices outside of your clinic and institution are not directly part of your scope as a mental health professional. Salma’s experience is a form of systemic discrimination. Using a trans person’s birth name that they no longer use is appropriate in legal and government-related situations and documents. Conflicting gender markers across identity documents has implications for Salma’s privacy and safety. Your clinical education prepared you to help Salma navigate this situation.

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Additional questions

How would you rate your knowledge of the process of legal documentation changes to affirm a person’s gender in your jurisdiction?

Not at all knowledgeable

Slightly knowledgeable

Somewhat knowledgeable

Moderately knowledgeable

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I prefer not to answer

How would you rate your ability to provide psychotherapy for clients navigating social and structural challenges and discrimination?

Not at all able

Slightly able

Somewhat able

Moderately able

Extremely able

I prefer not to answer

How would you rate your awareness of trans-affirming healthcare professionals and community organizations (i.e., endocrinologists, social workers, and trans advocates)?

Not at all aware

Slightly aware

Somewhat aware

Moderately aware

Extremely aware

I prefer not to answer

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Legal considerations (Telfer, 2020)

The frustration of the bureaucratic process Trans people experience barriers to obtaining identity documentation that accurately reflects their gender: birth certificates, healthcare cards, driver's licences, passports, and so on. https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 55/86 4/29/2021 Qualtrics Survey Software Major barriers include the cost, network of changes, literacy access, and time. Cost: the process may not be financially accessible. Sometimes payments do not go through, and people have to begin the process again. Network of changes: in order to change one document (i.e., passport), you need to have other documents changed (birth certificate). The process is repetitive and each time it is just as stressful. If the client is from another country, the process is increasingly complex as the documents must be changed from their country of birth, translated, etc. Once identity documentation is updated, then the client must update information at their bank, school, and for their phone and utility bills. In the context of COVID, many institutions still require in-person attendance to access changes. Literacy access: the paperwork involved can be complex, lengthy (i.e., 23 pages), and require advanced literacy skills. Often, the paperwork is rejected (for things like using the wrong colour ink, not capitalizing a parent's name, etc) and must be started again from the beginning. Sometimes, the changes come back with errors and the paperwork has to be mailed back. Time: for some people, this process can take a few months; for others, it can take years. Difficulties accessing the right documentation have implications for people's rights to privacy and confidentiality when enrolling in school, applying for work, and navigating other institutional structures. Conflicting gender markers across multiple identity documents is also a complicating factor that further disadvantages trans people. The process is stressful, repetitive, and has compounding issues for people with intersectional identities. Seek to understand how legal documents are regulated in your jurisdictions as these processes vary across regions and countries. Understanding the processes will help you provide adequate support for your trans client (in therapy and in helping you know which additional documentation you can provide to facilitate the client in changing documents to reflect their name and gender.) Build strong collaborative networks of trans-affirmative healthcare professionals and community organizations to facilitate high-quality support. Trans advocates, lawyers who are gender affirmative, and community groups could be of great help and guidance in this type of situation. Consult with the staff at the government office and suggest that you help integrate adjustments to provide affirmative service to trans or gender nonbinary people.

https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 56/86 4/29/2021 Qualtrics Survey Software For example, deadnaming (using a trans person's birth name when they no longer use that name) is never appropriate and is a form of discrimination. Instead, people can say, "the name they used before their transition" or "their birth name."

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Healing and psychological support

Assess and treat co-existing mental health difficulties. Understand how social anxiety (or other mental health issues) uniquely interact with the client’s gender identity and other social positions. Help your client restore personal agency through validation, recognition of their strengths, and hearing about other trans people with social anxiety. Encourage clients to reframe the way they see and tell their story in a way that shows their strength. At the next session, find movie clips, music, spoken word, or art forms that will help you, your client, and others (if you are in group therapy) to deeply explore how the client’s situation is a broader social and historical pattern. For example, the historical and persistent regulation of gender through intuitions. Healing circles: bring several of your clients together to discuss issues which enables them to lend their voice and experience to change the way client carries the load. The group also serves to mobilize changes within oppressive systems. Individual paradigms of therapy do not offer this collective empowerment. See this podcast by Hoff & Almeida (2019) for details on how to enact this healing process.

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Reflection and growth

Reflect on the power you hold in your role as a mental health professional and how you contribute towards social accountability and change through advocacy and empowerment at various levels. Reflect on what actions are within your scope of practice within specific situations. How will you meaningfully help your client? Consider how you can influence policies and practices outside of your institution. Think about meaningful ways to advocate with and for your clients.

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Situation 8

Situation 8 One of your colleagues is reaching out to you to consult about a trans client they recently saw. The client, Ximena who is a thriving professional weightlifting athlete, was looking to access hormone replacement therapy (HRT). Your colleague conducted an assessment to diagnose gender dysphoria as described in the WPATH guidelines, but it seemed that Ximena was not being honest as they kept changing their story and various facts within their narrative did not line up. Your colleague is worried that Ximena was just trying to tell the kind of story that would enable them to meet the checkboxes to access HRT. As such, they think Ximena's actual experiences may not fit assessment criteria and that Ximena may regret their choice in the future. Your colleague asks you to consult with the client as well.

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WPATH: World Professional Association for Transgender Health

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Decisions about physical interventions made in mental health professionals' care should arrive after a thorough exploration process. More research is needed on the potential alternatives to gender transition. Misdiagnosis of gender dysphoria can have severe consequences for clients. The discussion about trans people’s experiences does not pay enough attention to the joys of the trans experience and gender diversity. Transition is not an all-or-nothing or linear process. Providing Ximena with HRT when they do not meet the gender dysphoria criteria is an example of malpractice. Trans identity is not a mental illness to be treated. Ximena likely sees you as a gatekeeper. Systematic barriers in gender dysphoria assessment may lead Ximena to be neglected within the healthcare system. Gender dysphoria assessments may harm trans people who do not fit into the woman/man binaries.

Get to know Ximena’s broader context and background. Explore avenues other than gender dysphoria, such as body image issues. Outline that your role together is to find the best way forward in a safe and accessible way. Conduct an in-depth gender dysphoria assessment to be able to compare consistency with your colleague’s notes. Apply the gender dysphoria diagnostic criteria flexibility. Make Ximena aware that some people regret their decision to transition. Make Ximena aware that HRT is only partially reversible. Discuss with Ximena how transitioning may impact their relationships, ability to have children, sexual orientation, and athletic career, among other aspects of life. Discuss Ximena’s hopes and expectations of taking HRT. Talk to your colleague about the informed consent model. Encourage Ximena to tell their story fully as you are there to support them. Communicate with Ximena that you understand assessments of gender dysphoria can be restrictive in conceptualizing trans people’s experiences. Communicate with Ximena that they are the expert in their gender. Ask Ximena whether they will be able to continue competing in weightlifting. Connect Ximena with other trans athletes. Reflect on your biases about trans athletes. Wonder whether dishonesty in gender dysphoria assessments occurs often. Think about why trans people feel they have to be dishonest during gender dysphoria assessments. Have a conversation with your colleague about how Ximena's situation is part of larger systemic issues with the DSM-V. Figure out if a Gender Dysphoria diagnosis and/or letter of referral is required by (1) the health jurisdiction, and/or (2) for insurance claim purposes.

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Knowledge

Variety in expression, experiences, and needs Everyone’s journey with gender varies, and not all trans people experience being trans in the same way. All expressions and experiences of being trans are valid, and clients should not be made to feel like they have to fit into an archetypal narrative of being trans to receive gender affirming mental healthcare.

Assessments Understand and critically appraise the diagnostic criteria for Gender Dysphoria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V, 2013). Ask questions like the following: Does it regulate gender (i.e., perpetuate the types of gender identities and expressions that are acceptable)? Does it restrict the conceptualization of trans experiences? When does it gatekeep and when does it enable access to care? Does the assessment process dehumanize and negatively impact the health and wellbeing of trans clients? Understand how a diagnosis of gender dysphoria, if used flexibly (i.e., Unspecified Gender Dysphoria) along with the information shared by the client, https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 61/86 4/29/2021 Qualtrics Survey Software may be useful and sometimes necessary for clients to access care (i.e., surgeries) and file insurance claims. Understand and critically appraise the criteria and guidelines found in The World Professional Association for Transgender Health Standards of Care, 7th version, for Hormone Replacement Therapies and Gender Affirming Therapies for adults. Think about how needing to control “significant medical or mental concerns” may disproportionately affect minority and marginalized groups. Is the language used gender affirming and reflective of terms accepted and used by the trans community? Do the criteria and guidelines have an inflated reliance on nonmaleficence? Do the tone and discourse promote your role as a gatekeeper of care? What systems of oppression do these criteria uphold? Do you apply the guidelines flexibly and modify them based on an evolving method of handling a common situation? Be aware of concepts such as gender euphoria and creative transfiguration to prevent the dehumanization of trans clients. Read page two of Ahsley, (2019) under the subheading Suppressing the Diversitiy of Trans Embodiment for definitions of gender euphoria and creative transfiguration.

Institutional regulation of gender (historical and present). Your healthcare practices have been shaped by these historical legacies. Without adequate education and consideration, the healthcare you provide may continue to negatively affect how people view gender. Historical oppression in mental healthcare has occurred through the following: Invalidating language and misgendering. Spaces and processes that conform to the rigid gender binary (woman/man). Pathologization of gender diversity. Rigid and unrepresentative conceptualizations of trans experiences within diagnostic assessments. Epistemic violence by necessitating assessments to access healthcare, etc. Forced medical and mental health treatment/procedures to access legal documentation. Gatekeeping of treatment. Prejudice and discrimination by mental health professionals.

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Skills

Build a trusting relationship with your client View your client as a person and not an object or someone to be assessed. Aim to work to heal when you provide therapy or assessment. Understand the client may be nervous to see you because of the previous negative experiences and/or the historical and present oppression of gender diversity through mental health assessments and interventions. Outline to the client that everyone’s journey with gender is different, fluid, and a process. Communicate that you understand assessments can be restrictive in conceptualizing trans people’s experiences and that this is a failing of the system. Encourage them to tell their story fully as you are there to support them (e.g., "I want to hear your honest story without you worrying whether you will meet the check boxes of our flawed assessment process. We will work together to ensure you can access the healthcare that will help you be well").

Healing and psychological support Help your client restore personal agency through validation, recognition of their strengths, and connection/exposure to other trans people who are athletes (i.e., Out Sports; Schuyler Bailar, he/him).

Encourage your client to reframe the way they see and tell their story and gender in a way that shows their strength. https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 63/86 4/29/2021 Qualtrics Survey Software At the next session, find movie clips, music, spoken word, or other art forms that will help you, your client, and others (if you are in group therapy) to deeply explore how the client’s situation is a broader social and historical pattern. Discuss with your client the historical and persistent regulation of gender through institutions: Rigid and unrepresentative conceptualizations of trans experiences exist within diagnostic assessments. A lack of trans voices and leadership in the creation of guidelines, diagnostic manuals, and treatments. Epistemic violence by necessitating assessments to access healthcare. Pathologization of gender diversity. Gatekeeping of treatment. Prejudice and discrimination by mental health professionals. Trans athletes and the systemic barriers they face as well as the strength and resiliency they have shown. Talk about strengths-based approaches such as gender euphoria and creative transfiguration. Healing circles: bring several of your clients together to discuss issues which enables them to lend their voice and experience to change the way client carries the load. The group also serves to mobilize changes within oppressive systems. Individual paradigms of therapy do not offer this collective empowerment. See this podcast by Hoff & Almeida (2019) for details on how to enact this healing process. Assess and treat co-existing mental health difficulties. Understand how mental health issues may uniquely interact with the client’s gender identity and other social positions.

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Skills (continued)

Helping clients access medical care (Gender GP, 2020) https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 64/86 4/29/2021 Qualtrics Survey Software If the client's physician requires them to be 'assessed' by a mental health professional, you have an essential role in avoiding gatekeeping and negative health impacts. Current best practices (which are meant to be applied flexibly) are outlined below: Communication Communicate with the client that they are the expert in their own gender, and that your role together is to find the best way forward in a safe and accessible way. Validate the client’s gender identity. Express (genuine and justifiable) curiosity about the client’s experience so they share their experiences genuinely with you. Identify goals and values together. Transition and gender affirmative care are usually defined in terms of fit or alignment and not in terms of passing as members of a particular gender category. Talk about process fluidity and uniqueness. Transition is not all-or- nothing, open-or-shut, or linear for many people. Listen to clients who know exactly what they need, and guide those who need a little more guidance. Do not put the client through lengthy assessments to validate their gender. Ask questions and collect information to put the client’s case forward to medical help; you can call this an Information Gathering Session. This involves (1) obtaining informed consent and (2) ensuring that the client’s hopes and expectations fit with what procedures are available. Determine whether a Gender Dysphoria diagnosis and/or letter of referral is required by (1) the health jurisdiction, (2) for insurance claim purposes, (3) a primary healthcare provider like a physician or a nurse practitioner, or (4) a combination of these options.

If a diagnosis of gender dysphoria is required by the health jurisdiction to access care (i.e., gender affirming surgeries) and/or filing insurance claims, be able to use Unspecified Gender Dysphoria (F64.9) as a flexible form of gender dysphoria with the information the client shared during the Information Gathering Session. If the health jurisdiction does not require a diagnosis of gender dysphoria to access medical care, but the primary healthcare provider is requiring the diagnosis or a letter of referral so that the client can access care, you https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 65/86 4/29/2021 Qualtrics Survey Software may be able to diagnose Unspecified Gender Dysphoria and/or write a letter of referral for the client using the information the client will share during the Information Gathering Session. If the health jurisdiction does not require a diagnosis of gender dysphoria to access medical care, AND the client is unsure if their physician or nurse practitioner is requiring them to get a letter of referral or diagnosis from you, then you or the client should communicate with the primary healthcare provider as to whether this is necessary. If no diagnosis or letter of referral is necessary—in terms of service provision—you should dedicate your time to psychotherapeutics and helping the client navigate other structural barriers rather than writing a letter of referral that is not necessary. Where appropriate, educate other healthcare workers that a letter of referral from a mental health professional is not always needed to access HRT or surgeries (health jurisdiction dependant).

Build strong collaborative networks of trans-affirmative healthcare professionals and community organizations to facilitate high-quality support.

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Reflection and Growth

Proactively seek consultation from professionals competent with supporting trans people in a trans-affirmative manner (APA, 2015). Consider your assumptions and biases. Reflect on your assumptions about athletes who are trans. Does their positionality as a trans athlete affect the way you approach their care? https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 66/86 4/29/2021 Qualtrics Survey Software Have you ever conceptualized the client's trans identity as a mental illness to be treated or a cause of all problems? Why might clients feel like they have to lie to receive medical care? What is it about our system (and its oppressive structures) that has led to this being a common scenario? Are your actions as a mental health professional working to heal a client or uphold the status quo? Through an assessment, are you negatively influencing the way people view gender? Through an assessment, are we causing people to be neglected from the healthcare system? Why do we need clients to be distressed about their gender (i.e., gender dysphoria) to access gender affirming care? Where could gender euphoria fit into this model? Reflect on your preparedness to face ethical dilemmas, especially as clinical practices continue to evolve. In answering many of the questions above, many of the actions you would want to take to help the client heal may not be accepted by the institutions we work under (psychological associations, guidelines, professional licenses, etc.). In helping people heal, we cannot just do work in therapy so clients can accept themselves and then send them out to a society that will aim to harm them. As mental health professionals with power, we have to advocate outside of therapy as well.

Reflect on the power you hold in your role as a mental health professional and how you contribute towards social accountability and change through advocacy and empowerment at various levels. Reflect on what actions are within your scope of practice within specific situations. How will you meaningfully help and heal your client? Think about meaningful ways to advocate with and for your clients. Consider how you can influence the policies and practices of other mental health professionals.

Do you have any feedback about this portion of the educational feedback (i.e., adding a key resource, integrating a different way of knowing, removing irrelevant or potentially problematic aspects)?

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Situation 9 Liz, one of your clients moved from a First Nations reserve in Northern Ontario two years ago to study at a nearby college. After a year of sessions, Liz has begun to share more openly with you and trust you. Liz is almost going to graduate and is excited to go back to see her little brothers, mom, and aunties. However, she tells you that she has not yet told her family about being Two-Spirit. She is worried about how her mom will react, how she will participate in the community–especially during ceremonies—and whether people will respect her.

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*If you are confused or have questions, please do not hesitate to email [email protected] - we can easily have a quick zoom call.

Refer Liz to someone more knowledgeable about Indigenous culture and Two-Spirit identities. Learn more about the Indigenous peoples living near the areas that you serve as a mental health professional. Ask Liz to tell you more about Two-Spirit identities and Indigeneity. Ask Liz what being Two-Spirit means for her. Help Liz build strong support networks of Indigenous and gender diverse people through warm referrals. Facilitate connecting Liz with knowledge holders to talk about gender and Indigenous teachings. Reflect on what is already in your bundle that you can use to build better relationships with Two- Spirit and Indigenous peoples who have diverse gender identities. Work with Liz in finding a term specific to her culture for gender diversity so that her community will accept with more ease.

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The potential for re-traumatization of Indigenous peoples within healthcare is high. Two-Spirit is a traditional concept that has been passed across many generations in multiple Indigenous groups. Mental health professionals who are not Indigenous should not integrate or use traditional healing practices. Liz is both gender and sexually diverse because she is Two-Spirit.

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Do you have any ideas about additional multiple-choice questions that can test participant's knowledge, skills, or reflection about this situation and trans health?

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Reflection and growth

Recognize and challenge your assumptions and biases (Almeida, 2018; American Psychological Association, 2015; Bess & Stabb, 2009; Rachlin, 2002) Across many cultures and systems of oppression, we are socialized to hold automatic ideas, assumptions, and biases about gender and other identities/experiences. As mental health professionals, the assumptions that you make can be deeply harmful to your clients. Therefore, it is essential to reflect regularly to recognize and then challenge these assumptions. Assess your assumptions on what Indigenous peoples need (Ontario Federation of Indigenous Friendship Centres, 2020). How to challenge your assumptions: 1. Recognize you made an assumption. Be honest with yourself. 2. Reflect on how maintaining the status quo may collude with oppression and work against healing. 3. Reframe your thought/perspective/question to disrupt and remove the assumption. 4. Think about where the assumption comes from (professional education, ethics guidelines or standards of practice, families or caregivers, media, culture, etc.). Doing this will help you challenge the assumption based on the root issue. Do not use this as an excuse for complacency and harm to clients. 5. Celebrate your small steps and successes progression in the process of learning and becoming a more inclusive and affirmative professional (Airton, 2018). Look forward to future learning and growth.

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Reflection and growth (continued)

Commit yourself to action through multiple means such as learning, teaching others, enabling Indigenous peoples to self-voice, building strong relationships with Indigenous peoples and communities, ensuring you are giving back to Indigenous communities, focus your work and advocacy on Indigenous communities' priorities, etc. Consider what is already in your bundle that you can use to better build relationships with Two- Spirit and Indigenous peoples who have diverse gender identities. Think about what you need to include in your bundle moving forward (Ontario Federation of Indigenous Friendship Centres, 2020). Bundle: the word bundle is used figuratively to encourage us to think about resources, relations, networks, knowledge, and teachings that you have to better support Indigenous peoples. The literal word for bundle refers to a pouch that carries sacred items that can be used personally (to help you develop, items that have brought teachings, items given by elders or family members) or used as a group (bring healing and vision to a whole nation). Be honest with yourself about your learning needs and the challenges that you face to learn. If you face a situation that you are not sure how to manage, you can say something like, "that's a new concept/area for me, and I need to learn about it. Can we make a plan to come back to that topic when I’ve learned more about it? Is there anything you need me to know about that today/right now?” (Luctkar-Flude et al., 2019) Aim to educate yourself / seek out education proactively rather than reactively. Involve yourself in authentic, relational, and reflective learning as a mental health professional. This follows teachings that show learning is cyclical, reciprocal, and can be a healing process for yourself to better serve your clients. Seek out the education, perspectives, and personal narratives of Indigenous trans people with intersecting identities (but not your clients) as essential components to fully understanding appropriate support (Heng et al., 2018; Mizock & Lundquist, 2016). This may include the following: Books by trans, Indigenous, and/or Two-Spirit authors

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Knowledge

Indigenous peoples are diverse. Learn more about the specific Indigenous peoples who live in and near the areas you serve as a mental health professional. Be able to use the proper terms when referring to Indigenous people. Learn through this video. Know which Indigenous territories that you live, learn, practice, and heal on. Everyone's experiences with culture and gender diversity are incredibly varied! The intersections of Indigenous self-identity and being Two-Spirit, genderqueer, nonbinary and/or trans are unique for each person. This situation does not represent all Two-Spirit peoples' experiences, so you should take extreme care to understand the specific context and understanding of your client. Ways of knowing Traditional Indigenous knowledge systems already hold knowledge you need to address life situations, including how to respect everyone, including Two-Spirit and gender https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 72/86 4/29/2021 Qualtrics Survey Software diverse peoples. Many of the dominant Western developments that seek to foster equity or equality are actually addressing harms that originate from dominant Western action and thought. The concept of 'equity' needs to be decolonized, and we need to make space for alternative understandings. For example, everyone having a place in the circle, everyone's gifts being recognized and supported, everyone having a place and roles in the community, everyone having responsibilities to all their relations, etc. (Native Women's Association of Canada, 2020). Traditional healing practices can help an individual feel holistically healthy (Native Women’s Association of Canada, Fact sheet) The meanings and creation of the term Two-Spirit Two-Spirit is a term used by some Indigenous people to describe their diverse gender and/or sexuality that involves cultural and spiritual aspects. Two-Spirit holds a variety of co-existing meanings for people including the following: a connection to Indigenous teachings; a "placeholder term until they find words in their Indigenous languages to describe who they are" (p. 4); and a banner under which Indigenous people can organize politically (Laing, 2018). The term is not used by all Indigenous people with diverse gender and/or sexuality, and it can be used in addition to other terms in the LGBTQ+ acronym. Two-Spirit was first proposed in 1990 at an intertribal Native American/First Nations Gay and Lesbian Conference. It is a literal translation of the Anishinaabemowin term niizh manidoowag.

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Knowledge (continued)

Understand the continued impact of colonization, genocide, and residential schools on Indigenous peoples through various structural stressors (Native Women's Association of Canada, 2020; Ontario Federation of Indigenous Friendship Centres, OFIFC, 2020).

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Skills

Building relations with your client (Native Women’s Association of Canada, 2020) Building a trusting therapeutic relationship with your Indigenous clients is essential. It takes time, intentionality, and dedication. Trustworthiness promotes collaboration, equalizes power imbalances, and allows the expression of feelings without fear of https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 74/86 4/29/2021 Qualtrics Survey Software judgment. Notice in this situation that Liz is sharing a lot with the mental health professional. In real-life situations, Indigenous mental health professionals have stated that 7-10 sessions is barely enough for them to establish a relationship of trust. You cannot say ‘this is a safe space’ as that quality needs to be earned and judged by people who attend the space. You can instead call it an ‘accountable space.’ If the client identifies as Two-Spirit, Indigiqueer, or another traditional Indigenous term, ask them what it means for them (Laing, 2018). Self-determination and culture (Native Women’s Association of Canada, 2020) Facilitate opportunities for clients who identify as Two-Spirit and/or Indigenous to connect with their self-determined priorities. Use choice and collaboration to facilitate healing and avoid re-traumatization. Choice increases an individual’s control, self-efficacy, and agency. Create opportunities for clients to rebuild a sense of agency with a purpose to live a fulfilling life directed by them. Acknowledge the needs that individuals who have experienced trauma within the healthcare setting. Recognize that culture heals and saves lives by developing a strong sense of identity and reclaiming land and language. Support the client in their connection with culture, or if applicable, to rediscover their culture. This can be done through support networks and focusing on wellbeing: physical, mental, emotional, spiritual, and relational.

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Skills (continued) Involving families and communities (Native Women’s Association of Canada, 2020)

Families and or communities can sometimes work together with you and your client to accommodate and/or be inclusive, especially when Indigenous advocates are involved. However, it is important to recognize that not everyone may be in a position to do this, especially because of the implications of working with sacred knowledge and practices. https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 75/86 4/29/2021 Qualtrics Survey Software Encourage your client to start conversations with knowledge holders about gender and Indigenous teachings. For example, Indigenous teachings show us that everyone's gifts should be recognized and supported, that everyone should have a place and role in the community, and that everyone has responsibilities to all their relations. They can be encouraged to gently correct others when they misgender someone. For Indigenous mental health professionals who understand and are part of their client's culture, advocacy on behalf of your client within their family or community may be helpful, if appropriate. For settler mental health professionals, this could be inappropriate and considered colonial behaviour, so caution and guidance may be required. Advocacy can be done in many ways: Helping others recognize that that change is traditional and change can be positive. Supporting structural changes (washrooms in a new building, updating forms to be inclusive, etc.) Supporting the role of mediators (i.e., parents) because they may also help to advocate. Work together with family members to help develop a shared understanding of the child's experience. Developing a shared understanding allows the person to feel genuinely supported and affirmed in who they are and for the family to make considered and informed treatment decisions in the future, therefore ensuring optimal care. Self-expression When the client is beginning to explore gender diversity, Indigenous mental health professionals who understand and share their client's culture can encourage the client to experiment with pronouns, expressions, and roles within Indigenous cultures. For example, encouraging them to wear what they want and sit where they want to sit. This may not be appropriate to do for settler mental health professionals as it may be colonial behaviour. Respecting the client’s choices for identity, pronouns, and expression related to gender while recognizing that this may change and that is okay.

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Situation 10 Damini is a cheerful man who loves painting and spending time with his grandchildren. He was AFAB and has begun socially and medically transitioning, but needs assistance determining how and when to come out at work. He is six years from retirement and it will eventually become clear due to the physical changes of the medical transition. Damini is very scared of rejection, and has had reoccurring nightmares of being fired, facing backlash, and transphobia at work.

Do you have any feedback about this situation? We are looking for feedback to improve the situation (i.e., remove the situation, modify the situation by adding or removing aspects, etc.)

Before this survey, did you know the meaning of the acronym AFAB as it is used in trans communities? Please answer honestly. The answer will be shown on the next page.

Yes, I knew the meaning before taking the survey (please indicate below).

No, I did not know the meaning before I took the survey. I prefer not to answer.

AFAB: Assigned female at birth AMAB: Assigned male at birth

*If you are confused or have questions, please do not hesitate to email [email protected] - we can easily have a quick zoom call.

How likely are you to do the following? Please answer honestly. Shown in Likert Scale: 1 – Extremely unlikely; 2 – unlikely; 3 – Neutral; 4 – likely; 5 – Extremely likely; 999 - I prefer not to answer https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 77/86 4/29/2021 Qualtrics Survey Software Suggest to Damini that you can look together at options for early retirement. Ask Damini if he would like for the two of you to write a letter for his employer to understand the situation (example). Ask Damini if he would like for the two of you to reach out to a trans lawyer who works in labour rights and to Damini's union, if he has one. Ask Damini why he has chosen this time to come out to his employer as he is so close to retirement. Ask Damini if he has a diagnosis of gender dysphoria to undergo the medical transition. Ask Damini if he would like to meet with other trans and nonbinary who have had to undergo this type of situation at work. Figure out with Damini if his household will have enough income if he loses his job as a result of this. Ask Damini if he would like to interpret his dreams (i.e., find links to his current context, personal history, and his cultural background). If Damini wants, collaboratively make a self-care plan that he can use during these initial steps in reaching out to his employer. If needed, reaffirm Damini's worth. Give him agency throughout the therapeutic and support processes. Wonder why Damini had not transitioned at a younger age.

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Do you have any ideas about additional multiple-choice questions that can test participant's knowledge, skills, or reflection about this situation and trans health?

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Trans Elders

Variety in expression, experiences, and needs: Everyone’s journey with gender varies, and not all trans people experience being trans in the same way. All expressions and experiences of being trans are valid, including identifying as trans later on in life. Do not make assumptions about Damini's journey with gender (i.e., assumptions may be that he has been trans for many years but not able to come out; that he recently came to the realization that he was trans). It is best to ask your client about their unique journey with gender. If needed, help Damini restore his personal agency through validation, recognition of his strengths, and hearing about other trans people who have transitioned later on in life and at their work. This can also be done by giving Damini agency throughout the therapeutic and support processes. Resources for clients ElderTG: a listserv for trans and nonbinary people over 50 years old to gather to share stories and advice. It also includes some partners and other close family members. To subscribe, send an email stating your age and interest to eldertg- [email protected] Questions can be directed to Robyn ([email protected]) and/or Dan ([email protected]). On Facebook, there are other trans aging-related pages, like The Original Trans Men Over 40. Play with some searches and you will find other social media outlets. Resources for mental health professionals You can join the Transgender Aging Network (TAN). To learn more about various topics related to trans people and aging, see Transgender and Gender Nonconforming Health and Aging (Hardacker, Ducheny, & Houlberg, 2019). It discusses topics including stories of resilience, retirement, honour and celebration at the end of life, caregiving, long-term care, ageing service networks, intersectionality, religion and spirituality, trauma, intimate partner violence, HIV, and more.

Employment

Understanding labour rights in your country and region In the US: https://transequality.org/know-your-rights/employment-general In Canada: https://www.tpsgc-pwgsc.gc.ca/apropos-about/guide-et-te-eng.html

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Summary of all situations

Below is the full bank of the 10 situations, in case you are interested in seeing the breadth of topics covered in this Trans Health Educational Tool. It is not necessary for you to read through each one unless you want to.

Situation Themes

A trans woman named Li Jing calls a rural clinic where you work looking for therapy for her depressive symptoms. After consultation with a senior colleague, Li Access, over- Jing is referred elsewhere because your clinic does not evaluating the focus on trans health. Indeed, a previous client who was trans aspect of 1 trans indicated that they required more specialized the client's healthcare than what your clinic was able to provide. The identity, rural referral given to Li Jing is to a clinic that specializes in healthcare trans health with integrated healthcare. This clinic is located several hours away, but they offer virtual appointments.

Several months ago, a client named Nola was part of your group therapy and indicated they were queer and Language, Nádleeh. Recently, you overhear several respected senior Indigeneity, 2 colleagues repeatedly using the wrong pronouns for Nola power and calling them Two-Spirit, but usually only when Nola differentials was not present.

3 Harkamal identifies as gender non-binary and has a Washrooms, chronic pain condition that limits their ability to walk. They assumptions, ask the receptionist where the accessible washrooms are, (dis)ability, and the receptionist points them to the women’s non-binary washroom down the hall. The receptionist then sees identity Harkamal more closely and says, “sorry, and the men’s bathroom is right beside it. I am not sure which you prefer, but both are accessible.” Then with a warm smile she

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A 9-year old child, Jelani, and her mother, Moneshah, come into your clinic. Jelani was assigned male at birth but is starting to ask to shop in the girls’ section for clothes, play with the girls at school, and say they wish they were born more like their sister because she is a girl. Jelani is constantly changing their mind on what pronouns Supporting to use. gender diverse 4 children, During the visit, Moneshah tells you that their family racism doctor said this was a phase of exploration that was common in many children. Moneshah also expresses that she is deeply fearful of Jelani's future and safety if this continues because they are Black and have heard about many black trans women facing hate and violence.

5 You are with a client named Sasha who is transfeminine Access, DSM and has been taking hormone replacement therapy (HRT) assessment, for over a year. She is very happy, physically well, and epistemic looking to undergo several gender affirming surgeries. violence, non- Sasha requires two referral letters from mental health binary identity, professionals to get funding for the surgeries. She did not hearing voices require letters for her HRT prescription because her university’s health clinic practiced the informed consent model.

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You are facilitating a CBT group therapy session, and you find that you and several of the members repeatedly mix Misgendering, up Çağatay's pronouns (ze/zir) and do not pronounce zir 6 group therapy, name correctly. The members apologize profusely and fix neopronouns each other's mistakes, but the atmosphere seems slightly uncomfortable.

One of your clients named Salma comes into your therapy session on the verge of tears. From previous sessions, you know that she has identified as a woman for most of her adult life but presented herself as a man, which caused her constant emotional stress.

Legal At this session, Salma tells you she began the process of documentation changing her legal documents to reflect her gender. At the changes, 7 government office, the teller said to another co-worker, structural "he uses she/her pronouns" and "she previously went by barriers, Karim,” and none of the personnel knew how to process anxiety Salma's requests adequately. She felt lost and had a panic attack at the government offices. Salma has long struggled with social anxiety, and she tells you that she is embarrassed to go back, exhausted with all these processes, and does not want to ask her boss for another day off to repeat the same process.

8 One of your colleagues is reaching out to you to consult Therapeutic about a trans client they recently saw. The client, Ximena relationships, who is a professional weightlifting athlete, was looking to access, DSM access hormone replacement therapy (HRT). Your assessment, colleague conducted an assessment to diagnose gender trans athlete, dysphoria as described in the WPATH guidelines, but it epistemic seemed that Ximena was not being honest as they kept violence changing their story and various facts within their narrative did not line up. Your colleague is worried that https://queensu.ca1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_aWg6s1S11FrVDbU&ContextLibraryID… 83/86 4/29/2021 Qualtrics Survey Software Ximena was telling the kind of story that would enable them to access HRT, but may not adequately fit the assessment criteria. As such, they think Ximena may regret their choice in the future, and your colleague asks you to consult with the client as well.

Liz, one of your clients moved from a First Nations reserve in Northern Ontario two years ago to study at a nearby college. After a year of sessions, Liz has begun to share more openly with you and trust you. Liz is almost Indigeneity, going to graduate and is excited to go back to see her 9 decolonization, little brothers, mom, and aunties. However, she tells you relationality that she has not yet told her family about being Two-Spirit. She is worried about how her mom will react, how she will participate in the community–especially during ceremonies—and whether people will respect her.

Damini is a cheerful man who loves painting and spending time with his grandchildren. He was AFAB and has begun socially and medically transitioning, but needs Agining, social assistance determining how and when to come out at transition at 10 work. He is six years from retirement and it will eventually work, labour become clear due to the physical changes of the medical rights transition. Damini is very scared of rejection, and has had reoccurring nightmares of being fired, facing backlash, and transphobia at work.

General Feedback

Are there any other situations that should be included in this instrument? If so, please provide a general description.

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Do you have any ideas to improve the name of the instrument? Currently, it is called the Trans Health Educational Tool. Other ideas include the Trans-KSR Instrument (KSR standing for knowledge, skills, and reflexivity), the Trans Education Instrument (Trans-ED), the Educational Trans Health Tool, and the Educational Trans and Nonbinary Tool.

Is there anything else you would like to share anonymously with the research team and other experts about this instrument (i.e., general feedback about the whole instrument, set up of the multiple-choice questions)?

End of Survey

You made it to the end of the survey – congrats!

Compensation We appreciate your time, effort, and energy in sharing your responses and feedback for this first cycle in the expert review of this instrument. You will be entered in a draw to win one of two $100 prizes. You can also choose to donate this money to Trans Lifeline, a transgender-led organization that connects trans people to the support resources they can use to survive and thrive. This includes a peer support hotline, community resources, and financial support for legal document changes. If there are any parts of feedback you do not want to complete, you will still be entered in the draw. We will also share the final instrument with you once it has been validated.

Next Steps We will be sending you an email with a link to a new survey. This new survey will contain (1) a summary of the feedback you and other experts provided in an anonymous manner, (2) changes to the Trans Health Educational Tool based on feedback that had consensus among experts, and (3) a

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Supportive Resources

We recognize that many of the situations in the instrument discussed difficult topics that may have been distressing. Here we provide some trans-affirmative support and crisis resources for you in case you need to debrief or support.

The Trevor Project's 24/7/365 Lifeline at 866-4-U-TREVOR (866-488-7386) or TrevorChat, their online instant messaging option, or TrevorText, a text-based support option. If you are looking for peer support, you can visit TrevorSpace from anywhere in the world. The National Suicide Prevention Lifeline at 800-273-TALK (8255) in the US;

For a list of international suicide hotlines visit International Suicide Hotlines. Trans Lifeline at 877-565-8860.

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