Improving Mental Health Professional Training: The Collaborative Development of a Trans Health Teaching and Testing Tool by 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) Copyright © Sofia I. Melendez Ron, 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. ii 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 iii 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. iv 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 v 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 vi List of Figures Figure 1: Conceptual and Theoretical Frameworks .....................................................................