Affirming Gender Identity in Clinical Practice

Megan Graham, LMHCMHTTC Webcast

July 31, 2019

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New England MHTTCOur Mission To use evidence-based means to disseminate evidence-based practices across the New England region.

Area of FocusRecovery-Oriented Practices, including Recovery Support Services, within the Context of Recovery-Oriented Systems of Care.

Ensuring Inclusion

New England MHTTC, 2019

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• policy makers

• system leaders

• Administrators

• community stakeholders

• Providers

• researchers

• youth and adults

• family members

from each of the six states to guide our activities.

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Sex & Gender • Sex

• Physical traits, i.e. genitalia, chromosomes, hormones, internal structures, secondary sex characteristics

• Generally assigned at birth• Gender

• Internal mental/emotional/spiritual relationship to identity on the gender spectrum

• Often in relation to masculinity and femininity Often, those match up

• Sex and gender align = cisgender• Not always the case

• Assigned female at birth and identifies as male• Assigned male at birth and identifies as female• Assigned male/female at birth and doesn’t identify as any gender• Assigned male/female at birth and identifies as neither gender, or a

combination of genders

The Binary & Beyond• Binary means “relating to, composed of, of involving two things”• The binary genders are male and female• “Gender nonbinary” is an umbrella term for any gender identity

that is not exclusively male or female and can include:• Gender nonconforming• Genderqueer• Agender• Genderfluid• Genderneutral• Androgyne

• Nonbinary identities fall under the trans umbrella, but nonbinarypeople often consider themselves outside the binary of “trans” and “cis”

How Does Gender Identity Develop?

• Gender identity development is thought to reflect a complex interplay of biologic, environmental, and cultural factors

• Studies that shed light on the biologic underpinnings of gender identity may underscore the concept that, much like sexual orientation, gender identity is not a choice

• Primarily from three biomedical disciplines: endocrine, genetic, and neuroanatomical

Olson-Kennedy et al. Research Priorities for Gender Nonconforming/Transgender Youth: Gender Identity Development and Biopsychosocial Outcomes. Current opinion in endocrinology, diabetes, and obesity 2016

Identities (cont.)• Sex

• Biological markers = genes, hormones, genitalia, secondary sex characteristics

• Often, these align, but not always the case• In intersex individuals, markers of sex do not match/overlap in some

way• Impossible to determine by appearance• Gene evolution• Incidence of intersex differences

• Sexual Orientation• Umbrella term for who a person is

physically/emotionally/romantically attracted to • Nonbinary gender identities expand ways we think about/label

orientations• Pansexual• Polysexual• Skoliosexual

Clinical Considerations• Risk and comorbidities

• Suicide/self-harm, depression/anxiety• Substance use, HIV/STDs, eating disorders• Exploitation, dating violence• Minority stress, homelessness

• Personal bias and knowledge• Pathology and dysphoria• Language• Paperwork and forms • National Transgender Discrimination Survey

• 50 percent had to educate providers• 19 percent had been refused care in the past • 28 percent postponed seeking care

• U.S. Transgender Survey

• Intersection with other aspects of identity • What is actually most clinically pressing? • Privilege • Religion • Life span development and fluidity

Pronouns

Bedard, P. Washington Examiner, 2015

Clinical Considerations• Families

• Being “out”• Names/pronouns• Housing/resources stability • Role shifts• Grief and loss• Parenthood

• Schools• Discrimination and harassment

• Over 55 percent of T/GNC youth K-12 reported verbal harassment• Over 22 percent reported physical harassment• Over 11 percent reported physical assault

• Completion • 15 percent of T/GNC adults reported leaving school early due to

harassment• Access to safe, gender affirming spaces

Clinical Considerations• Economic disparities

• 4x more likely to have a household income of less than $10k • Survey of older adults found that almost half reported household

income at or below 200 percent of poverty line • Employment

• Discrimination and harassment • Potential lack of continuity

• Criminal Justice System • Medical Care• Gender affirming hormones

• Age• Familial role• Impact of hormones and expectations • Late onset puberty • Cognitive development and long term consequences

Clinical Considerations

• Possible Areas of Focus• Self-advocacy • Navigating public spaces• Trauma work• Case management/resource support• Identifying peer support • Interdisciplinary collaboration

Resources• Education

• http://www.apa.org/topics/lgbt/transgender.aspx• https://everydayfeminism.com/2014/03/too-queer-for-your-

binary/?utm_content=buffer8078a&utm_medium=social&utm_source=facebook.com&utm_campaign=buffer

• For Parents• https://www.healthychildren.org/English/ages-stages/gradeschool/Pages/Support-Resources-for-Families-of-Gender-Diverse-

Youth.aspx• https://outmetrowest.org/• https://www.genderspectrum.org/blog/parenting-non-binary-kids/• https://www.dropbox.com/s/rzjkrmsw7iklvh1/Affirming%20vs%20Non-affirming%20Parenting%204.24.17.pdf?dl=0• http://lifeoutsidethebinary.com/post/96149381358/so-your-child-is-nonbinary-a-guide-for-parents• http://gbpflag.org/

• Student Resources• http://www.transstudent.org/• https://www.glsen.org/

• For Clients• https://www.translifeline.org/• https://www.thetrevorproject.org• http://lifeoutsidethebinary.com/• https://outmetrowest.org/• https://jri.org/services/health-and-housing/health/boston-glass

Resources (cont.)• Recommended viewing:

• https://www.allure.com/story/gender-nonconforming-video-jacob-tobia• https://www.youtube.com/watch?v=R8IuxRSqnYw• https://www.youtube.com/watch?v=cIb4WIh5Nj0

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