Aude Henin, Ph.D. PCP ROLE IN Child Cognitive- Behavioral TRANSGENDER Therapy Program Massachusetts CARE General Hospital • Review common terminology • Address common issues AGENDA faced by transgender youth • Detail gender affirming procedures and adaptations to existing psychotherapies

DEFINITION OF “TRANSGENDER”

• It’s a general or umbrella term • Someone whose internal sense of gender does not match the gender they were assigned at birth • “trans” for short

• There is no “ed” at the end of the word: transgender ed • This is a label that is given by the person themselves rather than one that we impose. ADDITIONAL TERMS

• Gender diverse, gender expansive • Gender queer • Gender fluid • Transmasculine; Transfeminine • Gender neutral; agender • Nonbinary • Bi gender • Demi-girl; demi-boy • Pan gender

• Language is changing all the time so please don’t worry about knowing all of these terms. Just ask if unsure. AND A FEW MORE IMPORTANT TERMS.. • Cisgender • Gender dysphoria • Stealth vs out • Social transition; medical transition medical affirmation SEX, GENDER, AND SEXUAL ORIENTATION. AREN’T THEY ALL THE SAME THING?

Gender Sex Identity

Sexual Gender orientation Expression

GENDER IDENTITY DEVELOPMENT

Sense of Ages Self label as gender boy or girl 1.5-3 expression

Awareness of Gender Ages 4- their own identity is more bodies and stable 5 gender roles

Less Sense of Ages 6- stereotypical, gender as fixed more and constant 7 integrated

Peer influences important in Nonconformity Puberty expression TRAJECTORIES OF GENDER NONCOMFORMITY

Transgender Heterosexual teen cis-gender teen

Gender nonconforming behaviors in child

Sexual Gender- minority teen queer teen PERSISTENT CONSISTENT INSISTENT PREVALENCE

• Approx 1.4 Million adults in the US (0.6% of the population, 2015 UCLA study) • More common than Type 1 diabetes • 1:165-1:300 identify as significantly gender variant • 1.6-2% of individuals are intersex (Blackless et al., 2000) • Are numbers increasing? • 0.7% of adolescents identify as transgender (Herman et al., 2017) • 1.2% of Boston high schoolers identified as trans (2006) • 2.7% of Minnesota youth identified as trans or gender nonconforming ( AMERICAN ACADEMY OF PEDIATRICS POLICY STATEMENT (SEPT 2018)

• “Accordingly, research substantiates that children who are prepubertal and assert an identity of TGD know their gender as clearly and as consistently as their developmentally equivalent peers who identify as cisgender and benefit from the same level of social acceptance. This developmental approach to gender affirmation is in contrast to the outdated approach in which a child’s gender-diverse assertions are held as “possibly true” until an arbitrary age (often after pubertal onset) when they can be considered valid, an approach that authors of the literature have termed “watchful waiting.” TRAJECTORY OF GENDER AFFIRMATION

Social and legal Gender Puberty Cross-sex affirmation (hair, affirming blockers hormones dress, name) surgery

3-10 years 9-15 years 14-18 years 16-18 years COMMON ISSUES FACING TRANSGENDER YOUTH PREVALENCE RATES OF PSYCHIATRIC DISORDERS IN TNGC CHILDREN AGES 3-9 YEARS Becerra-Culqui et al., 2018. Pediatrics. 141(5): e20173845 0 Eating Dis 3.7

11.1 Depressive 5.6

Transmasculine Transfeminine 7.8 Conduct 7.5

0 ASD 5

15.6 ADHD 14.9

15.6 Anxiety Dis 11.8

0 2 4 6 8 10 12 14 16 18 PREVALENCE OF PSYCHIATRIC DISORDERS IN TNGC YOUTH AGES 10-17 YEARS SI 10.4 7.5 Becerra-Culqui et al., 2018. Pediatrics. 141(5): e20173845 7 SUD 7.7

8.2 NSSI 2.6 Transmasculine Transfeminine 2.3 Personality Dis 2.3

4.9 Psychotic Dis 4.5

4.3 Eating Dis 4.2

61.5 Depresssive Dis 48.5

5.2 Bipolar Dis 5.4

9 Conduct Dis 14.1

3.7 ASD 7.3

16.2 ADHD 25.1

38.9 Anxiety Dis 37.2

0 10 20 30 40 50 60 70 OR OF PSYCHIATRIC HOSPITALIZATION RELATIVE TO REFERENCE SAMPLES

Vs. Reference Females

Transmasculine Transfeminine

Vs. Reference Males

0 2 4 6 8 10 12 14 16 Becerra-Culqui et al., 2018. Pediatrics. 141(5): e20173845 MINORITY STRESS MODEL (MEYER, 2003)

Coping and Social Support Circumstances in General Stressors the Environment • External Minority Stress Processes Mental Health •Violence Outcomes • Minority Status •Discrimination • Gender identity • Sexual orientation • Race/ethnicity Stress Processes Expectations of rejection • Characteristics of Concealment Minority Identity Internalized transphobia • Prominence Gender dysphoria • Valence Minority Identity • integration (trans, gender diverse) 20

SAFETY RISKS FOR TRANS YOUTH

• 83% report bullying (Reisner et al. 2014) • 55% of trans youth report being attacked or experiencing physical violence • 30% report physical harassment or assault in school • 70% of youth report hearing homophobic or transphobic statements • 7 times more likely to experience physical violence when interacting with police (Garofalo et al., 2006) • 1.7 times more likely to experience sexual violence • 2x more likely to be unemployed as adults • 97% report harassment or mistreatment at work HEALTH DISPARITIES (SEATTLE FOCUS GROUP, 2015)

• Safety issues • lack of safe clinical environments • discrimination by providers • Poor access to physical health services • STIs/HIV • Fertility options • Sex-specific health care • Inadequate mental health resources • Lack of continuity of providers • Insurance denials

• These disparities are especially pronounced for transgender women of color ADDITIONAL TRANS SPECIFIC CONCERNS

• Body dysphoria and body image concerns • Coming out and fear of rejection • “Passing” vs being stealth • Dating and sexuality ENHANCING POSITIVE OUTCOMES FOR TRANSGENDER AND GENDER DIVERSE YOUTH 24 THE BASICS

• Train all clinical and support staff • Explicitly express trans-inclusivity • Be conversant about relevant medical issues • Ensure that forms and questionnaire are appropriate for all gender identities • Routinely ask about gender and sexual identity • Ensure that medical records reflect appropriate gender and name IDENTIFY UNDERLYING BIASES

• Remember, the presence of a bias or preconceived notion doesn’t make you a bad person or a clinician • Only by acknowledging their existence can you change biases • Be compassionate but firm with yourself around unhelpful thinking patterns • Be open to others’ pointing out thoughts or behaviors you hadn’t recognized before ASK AND LISTEN

• Passive versus active acceptance and support • Please the affirming pronoun and name (REALLY, REALLY IMPORTANT!) • If you are unsure, please ask • “What pronoun should we use?” • What name should we use? • When you make a mistake (and you will), acknowledge it and apologize • Remember you don’t need to have all the answers. Do show an interest and willingness to seek information. • Kids are always leading the charge and as an adult you will always be a day late and a dollar short NOTICE GENDERED EXPECTATIONS AND LANGUAGE

• “Man up!”; “Run like a girl” • Differing compliments to girls and boys • Girls are “Cute, pretty, kind, sweet”. Boys are “Brave, tough, smart, curious” • Making broad generalizations that reinforce gender stereotypes • Differing expectations in behavior, play, interaction • Cleaning up, sitting still, sharing feelings, aggressive behaviors • Differences in physical affection and cuddling 28 ENHANCING PARENTAL SUPPORT

• May need to incorporate parent or family sessions to address trans-relevant concerns • Psychoeducation • Address biases and negative thought patterns in parents • Parenting issues and limit setting • Discuss issues specific to social and/or medical transitions • Offer resources for additional parental support FOR PARENTS OF TRANS YOUTH: CREATE AN AFFIRMING HOME ENVIRONMENT • Follow your child’s lead • Listen and respond rather than guide, enforce, or force • Be supportive and positive about your child’s gender identity and expression • Use affirming name and pronoun • Support other changes in gender expression (hair, makeup, clothing) • Praise the child in a genuine manner • Ask frequently about the child’s experiences • Provide unconditional support around their suffering • Have a sense of humor • Continue to set age-appropriate limits • Provide accurate information and clarify unrealistic expectations • Protect your child from harm • No tolerance for transphobia in your home 30 POSITIVE IMPACT OF PARENTAL SUPPORT FOR PREPUBESCENT YOUTH Olson et al., 2016. Pediatrics. 137(3): e20153223

Siblings Cis-boys Anxiety Trans-boys Cis-girls Trans-girls

Depression

34 39 44 49 54 59 64 PROTECTIVE EFFECTS OF FAMILY ACCEPTANCE Ryan et al., 2010. J Child Adolesc Psych Nursing; 23(4): 205-13

4 4 3.6 3.5 3.4 3 3 2.8 2.6 2.5 Self-esteem General health 2 1.5 Substance abuse 1.5 1.1 1 0.9

0.5 Low acceptance Moderate acceptance High acceptance MORE OUTCOMES Ryan et al., 2010. J Child Adolesc Psych Nursing; 23(4): 205-13

60 56.8 55 Depression 50 Suicidal thoughts 6 mo 45 Suicide attempt ever 40 38.3 36.1 35 30.9 30

25 23 20.1 18.5 20 16.5 15 10.4 10 Low acceptance Moderate acceptance High acceptance 33 BROADENING SOCIAL SUPPORTS

• Better outcomes for LGBTQ youth who attend schools that have GSAs (St. John et al., 2014) • Less victimization • Decreased truancy • Decreased alcohol/drug use • Greater openness re. sexual and gender identity • Often important to identify trans-focused spaces • Support groups • Summer camps • Conferences • Meet-ups; playdates • Identify role models and champions TRANSGENDER CELEBS FOCUSING ON KNOWN SOURCES OF RESILIENCE • Future orientation • Self-esteem • Autonomy and competence • Adult support • Healthy relationships with peers • Belongingness • GSA in the community • Coping skills • Social connectedness ENHANCING SAFETY AT A BROADER LEVEL • Be aware of legislation affecting trans youth in MA: • Public Accomodations Bill • Conversion Therapy • Be aware of transphobic speech and legislation in other areas • Talk about issues with others who may not be aware RESOURCES: ORGANIZATIONS

In Massachusetts: • Greater Boston PFLAG (gbpflag.org) • Massachusetts Safe Schools for LGBTQ students(doe.mass.edu/sfs/lgbtq) • BAGLY/WAGLY/Umbrella Project (bagly.org; outmetrowest.org) • Camp Aranuti’q (camparanutiq.org) • Children’s Hospital GEMS Program (childrenshospital.org) • Borum Health Center at Fenway Health (sidneyborum.org) • MGH (stay tuned ; massgeneral.org/psychiatry)

Nationally: • Gender Cool Project (gendercool.org) • Gender Spectrum (genderspectrum.org) • GLSEN (glsen.org) • Human Rights Campaign(hrc.org) • Family Acceptance Project (familyproject.sfsu.edu) RESOURCES: BOOKS

• The Transgender Child (Stephanie Brill & Rachel Pepper) • The Transgender Teen (Stephanie Brill & Lisa Kenney) • The Gender Creative Child (Dianne Ehrensaft) • Gender Born, Gender Made (Dianne Ehrensaft) • Trans Bodies, Trans Selves (Laura Erickson-Schroth) • Becoming Nicole: The Transformation of an American Family (Amy Nutt) • Beyond Magenta: Transgender Teens Speak Out (Susan Kuklin) • “Balls”: It Takes Some to Get Some (Chris Edwards) • Man Alive (Thomas Page McBee) • This is How it Always Is (Laurie Frankel) • George (Alex Gino) • Raising my Rainbow: Adventures in Raising a Fabulous, Gender Creative Son (Lori Duron) Illustrated Children’s Books: • I am Jazz (Jessica Herthel & Jazz Jennings) • My Princess Boy (Cheryl Kilodavis) • Red (Michael Hall) • Jacob’s New Dress (Sarah & Ian Hoffman)