Keywords

Introduction

The aim of this chapter is to discuss the relationship between the experience of minority stress and acceptance and the health outcomes of transgender and gender diverse (TGD) youth. We discuss the components of a minority stress model, the expansion of this model to include TGD identities, and the risk and protective factors associated with support (or lack thereof) by parents, schools, peers, and medical and mental health providers. We also include strategies to enhance support and related protective factors with regard to each of these subgroups.

Minority Stress

Social stress is a form of stress related to social processes in the environment. Experiences with stigma, prejudice, and discrimination are among the most prominent examples of social stress that disproportionately affect those who fall into a minority group. Scholars have turned to social stress theory to advance collective knowledge regarding the contributing factors impacting elevated rates of psychological distress among lesbian, gay, bisexual, transgender, queer/questioning, plus (LGBTQ+) individuals, as compared to heterosexual and/or cisgender individuals. In 2003, Meyer published a seminal paper in which he introduced a theoretical framework, termed the minority stress model, wherein he outlined a number of factors that predict elevated rates of psychological distress among lesbian, gay, and bisexual (LGB) communities, all within the context of attending to minority stress processes [1]. The model highlights different types of social stress and coping processes and their impacts on LGB communities. Meyer’s model fostered a new narrative that stands in contrast with outdated theories positing that LGB individuals have greater levels of mental illness due to innate qualities associated with homosexuality – also an antiquated term.

Minority stress is characterized by at least three factors: (1) it is unique to minority communities and exists above and beyond stressors experienced by most members of society, (2) it is chronic, and (3) it is dictated by social forces [1]. Meyer draws from research to identify both proximal and distal stress processes, as well as coping factors, that can impact mental health outcomes in LGB communities. The distal or external objective events and factors include various forms of discriminatory events (e.g., being called derogatory names, hate crimes). The proximal or subjectively focused factors depend on attention and cognitive appraisal. Since the development of the minority stress model, myriad studies have been published supporting the model and highlighting the positive correlation between the distal and proximal minority stress factors and mental health challenges in the LGB community.

A growing number of researchers and clinicians have begun to explore how the minority stress model can be extended to reflect the experiences of TGD individuals. Perhaps most notably, Henricks, Testa, and colleagues [2, 3] have outlined the many ways in which stress and resilience factors exist specifically with regard to a minority gender identity. Testa and colleagues (2015) [3] developed the Gender Minority Stress and Resilience (GMSR) measure , which is an extension of Meyer’s work, aimed at expanding on the theory by attending to stress and resilience factors that are relevant to TGD individuals. The GMSR measure is based on 9 constructs, which include gender-related discrimination, gender-related rejection, gender-related victimization, non-affirmation of gender identity, internalized transphobia, negative expectations for the future, concealment, community connectedness, and pride (see Fig. 5.1). For a more in-depth review of the GMSR measure , see the work of Testa and colleagues [3].

Fig. 5.1
figure 1

Minority stress and resilience factors in TGD individuals. Dashed lines reflect inverse relationships. (Reprinted with author permission [3])

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An explosion of research in the last decade or two has begun to study these distal and proximal stress factors, resilience factors, and their impact on TGD individuals. The negative impact of distal stress factors like discrimination, rejection, victimization, and non-affirmation of gender identity are becoming clearer. For example, stigma and/or perceived discrimination have been correlated with depression, poor overall mental health, suicide attempts, and non-suicidal self-injury (NSSI) [4,11,6]. Gender-related victimization, which can manifest in bullying, harassment, verbal abuse, stalking, and assault, for example, can predict the use of alcohol and illicit substances, avoidant coping styles, disordered eating, and other maladaptive behaviors in TGD adolescents [13,14,9]. Liu and Mustanski (2012) [10] found that homelessness, which is related to parents’ non-affirmation of their children’s gender identity, was predictive of greater NSSI. The increase in attention that the topic of non-affirmation of gender identity has received is highly encouraging, given the significance of this topic. This construct is perhaps most frequently discussed within the context of parents/caregivers; however, it applies to a broad range of individuals who have the chance to affirm (or not affirm) the identity of a TGD individual.

With regard to proximal stress factors, numerous studies have identified the adverse effects of internalized transphobia (negative, internal feelings about being transgender), negative expectations for the future, and non-disclosure. For instance, researchers found that internalized transphobia was predictive of negative mental health outcomes, specifically anxiety and depression [11]. Interestingly, one study found that while the relationships between internalized transphobia and negative psychological outcomes were not significant among participants who engaged in low and mean levels of community activism, there was a significant positive correlation between internalized transphobia and mental health challenges among those involved in a high degree of activism [12]. This is particularly interesting, given that there is often a high degree of community in action-oriented work which, as will be further explained below, appears to be a protective factor in the GMSR model.

Concealment of identity has also been found to predict more psychological distress, especially among transgender women [5]. However, in a study aiming to better understand suicidality in TGD individuals by exploring factors from both the GMSR model as well as Joiner’s [13] interpersonal-psychological theory of suicide, non-disclosure of identity explained only a very small percentage of the variance in SI [14]. One proposed hypothesis for this finding was that non-disclosure does not carry the exact meaning of identity concealment (deciding not to disclose your identity is not the same as feeling as though you need to hide it), which may have more pernicious effects. Also of note, concealment can vary across contexts. It is not uncommon for TGD individuals to modify their gender expression depending on the environment, in part to decrease victimization. Having to be hypervigilant regarding one’s safety and the chance of being victimized can also act as an added stressor and impact behavioral performance and well-being [15]. While youth can certainly benefit in many ways from disclosing their identity by receiving affirmation and support, they also run the risk of experiencing adverse consequences from disclosing their identity, such as feeling discriminated against and victimized [16].

Finally, the GMSR model also calls attention to resilience factors, which can mediate the relationship between the above-mentioned distal stressors and mental health consequences. Pride in one’s identity and community connectedness are the two factors named in the GMSR model [3]. In contrast with internalized transphobia or homophobia, acceptance of, and pride in, one’s gender identity and sexual orientation has been connected to reports of fewer depressive symptoms in adolescents and adults [6, 17]. This illustrates one of many reasons why taking an affirmative stance with TGD youth is critical. Other researchers have identified additional factors that appear to increase resiliency in TGD youth. In a qualitative study of resilience among TGD people of color with trauma histories, Singh and McKleroy [18] found six overall common factors among participants leading to resilience in dealing with their traumatic events: (1) having pride in their gender and ethnic/racial identity, (2) recognizing/negotiating gender and racial/ethnic oppression, (3) relationships with one’s family, (4) access to health care and financial resources, (5) connecting with an activist trans community of color, and (6) sense of spirituality and hope for the future. Thus, those interested in supporting TGD patients or loved ones will likely benefit from considering the ways in which the above-mentioned resilience factors are being encouraged and built upon over time and across contexts.

Intersection of Identities

It is imperative to acknowledge that TGD individuals make up a highly diverse group of individuals living across the world, and that while some carry with them numerous forms of privilege and social capital, others experience various levels of oppression. TGD people who identify with multiple minority identities may experience violence, harassment, and microaggressions more often than both individuals who do not have a minority identity and those who identify with one minority identity. Thus, TGD individuals who carry multiple minority statuses are commonly at a greater risk of experiencing oppression from a number of different angles [19].

In working with TGD youth and their families, it is important to assess the impact of multiple minority statuses on mental health, as well as the ways in which these individuals can be best supported in their communities. Attending to stigma within certain cultural identities regarding acceptance of transgender identity is also key [15]. Furthermore, it is also well advised to understand how victimization and microaggressions may occur within different circles. Some individuals with multiple minority identities may feel an uncomfortable sense of obligation to “choose” with which identity they would like to most identify in order to have a support system [20]. A series of measures by Balsam and colleagues may be of help in assessing for microaggressions endured by LGBTQ+ people of color [21] and minority stress experiences and their effects among LGB and TQ+ adults [22].

In the literature exploring intersectionality and the impact of multiple marginalized statuses, some of the most highly researched identity statuses among TGD individuals include race, socioeconomic status, sexual orientation, and gender identity. A number of studies have highlighted that transgender women, including those with trauma histories, report higher levels of NSSI, HIV, and discrimination than transgender men, [5,28,25]. The higher rates of discrimination can in turn lead to higher levels of depression, PTSD symptoms, and overall stress [25]. Increased rates of suicide attempts, NSSI, and victimization have also been identified among those who are younger and have lower incomes and education [7, 21], although more recent research that suggests younger children who are supported in social and medical transitions early show more positive mental health outcomes than older cohorts [30,31,28]. In addition to transgender women, TGD people of color endorse greater rates of discrimination and victimization [5]. Sexual orientation also plays an important role. One study of TGD youth found that TGD participants who identified as LGB had lower grades than their heterosexual TGD peers, in addition to having more absences from school due to increased depression and/or suspensions [29]. Religious identity can also be highly relevant, given that some individuals who come from religious backgrounds have histories of experiencing prejudice in their communities of worship, to the point of seeking out or being referred to conversion/reparative therapies [30]. Of note, continued research is needed to ensure that the experiences of TGD individuals are being properly assessed and that issues like incidents of violence among different subgroups of the TGD community are being appropriately documented.

Parental Support

A number of studies have pointed to the importance of parental support, as it has been associated with positive health outcomes, higher self-esteem, increased social supports, decreased suicidal ideation and attempts, and a decrease in substance use in LGBTQ+ youth [31]. Parental support has also been associated with lower perceptions of feeling like a burden and higher life satisfaction [32], as well as increased condom use among TGD youth [23]. Some have argued that parental support might be the most protective factor against negative mental health outcomes for TGD youth [4, 33], or specifically suicide attempts [34], while others suggest that parental support is as protective against suicidal ideation and attempts as are protections from harassment, gender affirming medical transitions, and documents that reflect an individual’s preferred name and gender marker [35]. In addition, while observing family members move from a place of non-acceptance to a place of acceptance is a protective factor against suicidal ideation and attempts [36], it is unclear whether or not the support of one parent acts as a protective factor, or if two parents are needed (if there is a two-parent family) [19]. In addition, positive parenting (authoritative style, positive reinforcement, the ability to engage in open discussions about relationships and intimacy), coupled with parental engagement (measured by time spent together, emotional availability), was found to be a protective factor against substance use in LGBTQ+ youth [37]. Interestingly, research with TGD children suggests that if young children are supported in their TGD identities, they have similar reported symptoms of depression and anxiety as their siblings and age-matched cisgender peers [28, 38]. Though direct comparisons are not possible, this is a stark contrast to past cohorts of transgender youth who were not supported in their gender identities, who had higher rates of internalizing psychopathology [39].

Alternatively, low parental support has been associated with increased rates of depression, suicide attempts, substance abuse, and risky sexual behaviors [40], as well as increased feelings of burdensomeness and lower life satisfaction [32]. However, there is some research that suggests that if parents are able to learn how to support their children in adulthood, there are still protective effects from which to benefit [41].

It is important to note that parents may feel that they are “responsible” for their children’s TGD identity, and may worry about the judgments that others place on their parenting [42]. Some parents may also fear that their acceptance of their children’s TGD behavior will have a negative impact, leading to an increase in health concerns [43]. This can lead to a struggle where parents experience pressure to abide by societal norms, while also wanting to affirm their children. Supporting parents as they navigate how to best manage different and challenging situations is imperative. If parents feel supported in their decision-making, their children can also feel more supported. Parents may also be pleased to know that emerging research suggests that early social transition does not increase a child’s cross-gender identification [44]. Interestingly, in a study exploring parental reactions to their children’s coming out process, some parents reported that they had become more flexible and creative in their thinking, which had led to their own individual growth [43].

Other studies have examined the relationship between parental response to their children’s identity as TGD and the subsequent effects on the children. For example, youth who reported that their parents had experienced their TGD identity as a loss perceived this as non-acceptance of their identity [23]. Some research has suggested that fathers are less accepting of their transfeminine children, and may pressure their children at greater rates to conform to their birth-assigned gender, which could manifest in the form of verbal harassment and shaming, leading to mental health issues [19].

Parents – Strategies to Help Build Support

Various factors for increasing parental support for TGD youth have been developed to help parents understand the importance of supporting their children’s identity. Working from the gender-affirmative model as a framework, parents can learn that gender presentations are varied and the expression of gender can unfold over time, allowing children the space for identity exploration, which is associated with increased confidence and self-acceptance [45]. From this frame, parents can understand how support is associated with higher self-esteem and positive health outcomes. Parents can also learn the importance of modeling appropriate responses to harassment and teasing, while also teaching youth how to use humor to diffuse uncomfortable situations [46].

It is possible that when parenting interventions are modified to include a general understanding of the GMSR model in order to better understand the experiences of TGD youth, additional decreases in symptomatology for youth may result. When targeted in parent management and family-based treatment, it is possible to address worries that parents may have about their children’s future relationships, potential victimization, acceptance in society, and medical interventions, while also focusing on normative development (romantic and sexual interests), puberty, fertility, and devices used to mirror normative gendered functioning (e.g., binders, prosthetics) [47]. Parents and youth can also discuss their opinions and fears about medical interventions in a safe setting with an independent observer who can help facilitate communication [48]. Thus, an independent observer can encourage open and productive communication between youth and their parent(s).

One parenting intervention that has been put forward for TGD youth is the Multidimensional Family Approach [49]. According to this approach, parents are guided to move from holding “all or none” viewpoints toward practicing more dialectical “both/and” thinking. For instance, parents learn to hold multiple truths, such that an individual’s identity can be affirmed and there can be recognition that difficulties will lie ahead. This stands in contrast with a common line of thought that children can either be affirmed or safe. Once parents feel more comfortable about affirming their children’s identity, they can focus on how to act as advocates for their children, while also promoting their safety. If parents’ fears can be decreased, they can better support their children, which can ultimately bolster the children’s confidence and lead to increased resilience. While this approach has yet to be empirically validated, it does incorporate discussion of many of the components of the GMSR model and mirrors research that additional support of a child’s identity is associated with better health outcomes [28, 31, 38].

It is also important to help parents work through the multiple emotional reactions they might experience while parenting a TGD youth. For example, parents have reported a number of reactions to their children’s TGD identity, including perceiving a sense of loss, fear of future victimization, their own non-affirmation by peers and family members for supporting their children, and marital discord if there is disagreement regarding how to proceed with social or medical transitions [50]. A space for the parents to discuss the perceived loss of a child has been deemed important, even though the child is still present. One way to help parents understand this phenomenon is by observing this process as an evolution of the youth [51]. In addition, it may be that parents of youth who are more ambiguous in gender presentation (non-binary) have more difficulty with the idea of a loss [52]. For these parents, time to explore cis-normative culture and personal expectations are imperative. It is also important for the family to be aware of how the child is still present in the family, and explore how the family system can include their identity. In addition, the importance of parent support groups has been noted for parents to discuss the pressures of parenting in general, and to share strategies on how to deal with people who are not supportive of TGD youth [46, 49]. These groups can also help members feel valued and respected by their peers, which might not otherwise occur [46]. In addition to groups, parents may feel more equipped to support their children on their gender journeys by accessing reading materials about gender variance, updated guidelines for affirmative treatment, information on school policies, and guidelines on lobbying for the coverage of affirmative medical treatments [53].

Schools

There has been increased attention to TGD students’ experiences in schools. In a recent nationwide survey of students [54], 43% of students reported feeling unsafe in their schools based on their gender expression, 20% reported being physically harassed, and 9% reported being physically assaulted, all due to their gender identity. Sadly, approximately 58% of students reported that they did not report harassment or victimization to school staff, as they did not think either the teachers or administrators would intervene on their behalf. When students disclosed mistreatment to school staff, they reported that nothing was done 64% of the time. Unfortunately, 64% of the students also reported hearing negative homophobic or transphobic comments from teachers and other staff. In addition, TGD youth were also singled out at school; 51% of students reported not being allowed to use their preferred name and pronouns at school; 60% were required to use the bathrooms and locker rooms that corresponded with their birth-assigned gender, and 32% were required to wear clothing congruent with their birth-assigned gender for school photos (36% were required to wear clothing congruent with their birth-assigned gender for graduation). If examining these numbers through the lens of the GMSR model, it is clear that this non-affirmation, victimization, and harassment in school settings could lead to an array of negative health and mental health problems for TGD youth.

Indeed, studies have shown that TGD students who experience harassment and victimization in school have increased days of missed school [29], lower GPAs, fewer plans for post-secondary education [54], higher dropout rates [55, 56], lower self-esteem, increased depressive symptoms, suicidal ideation, problematic drinking, illegal drug use, risky sexual behaviors [57], and more suicide attempts [58, 59]. Students who avoided bathrooms due to feeling unsafe experienced increased incidences of urinary tract infections, kidney infections, and dehydration [55]. Feeling unsafe in restrooms in general has also been associated with missing school field trips, not spending time in public spaces (e.g., malls, stores, and restaurants), and avoiding gyms due to fears of locker rooms [55]. Not only can this fear prevent youth from engaging in normative, developmentally appropriate activities, it can also lead to an increase in isolation and fewer opportunities to create a supportive community of peers – some of the protective factors included in the GMSR model.

Schools – Strategies to Enhance Support

There are a number of protective factors for TGD youth in schools, including a positive connection to school [37], an active Gender and Sexuality Alliance (GSA) [54], school anti-bullying policies that include protections based on gender identity and expression and curricula that are inclusive of LGBTQ+ identities [60]. Students with active GSAs report fewer homophobic or transphobic remarks, and school staff tend to intervene more when negative remarks are made [54]. Conversely, for students without an active GSA, there is an increased risk for the use of cocaine, hallucinogens, and non-prescription drugs [61]. Relatedly, research suggests that having an LGBTQ+-friendly curriculum is associated with youth feeling safer and more supported in school and also feeling more likely to complete high school and pursue post-secondary education [54]. In addition, the use of anti-bullying policies inclusive of gender identity can result in fewer negative remarks by peers and teachers and youth feeling as though their concerns are effectively heard and addressed by administration [54, 62]. Of note, supportive staff appear to have the greatest impact on youth. The more supportive and affirming staff there are in school, the greater the reports of self-esteem, the lower the rates of victimization, the higher the GPAs, and the fewer missed days there are from school [54].

In the 2015 Safe Schools Survey [54], students in middle school reported fewer LGBTQ+ resources – GSAs, LGBTQ+ inclusive curricula, supportive educators, comprehensive policies against bullying – than high school students. Middle school students also reported more homophobic/transphobic remarks and slightly higher experiences of victimization. This points to the importance of having supportive environments and inclusive policies for LGBTQ+ youth in middle as well as high school. When supports are not available in school, it is imperative to help TGD youth find other supportive communities (online or in person) to help them feel more confident and engage in self-advocacy [63].

Schools can also incorporate TGD youth in the creation of school policy to increase self-esteem and feelings of safety, and train advocates in TGD health care, who can follow TGD youth as they progress through the school system [56]. Schools can also host a “Safe Schools Summit” where LGBTQ+ youth can meet with one another, discuss strategies to feel more supported in school, advocate for one another, and model leadership for their school [64].

In addition to supporting TGD youth, schools can build the capacity of their staff. School administration can invest in their staff to become better-trained faculty advisors for the GSAs, and also learn how to effectively intervene when LGBTQ+ harassment occurs [56]. Specifically, teachers can learn to recognize behaviors and statements that are transphobic and homophobic, school psychologists can work with teachers to discuss strategies to decrease bullying, and syllabi can include anti-bullying language with appropriate disciplinary actions laid out [61]. PFLAG [65] also offers guidance for schools to be more inclusive (see Table 5.1). When there are more individuals who are supportive to TGD students, there is higher educational attainment and fewer absences among TGD students, as there is less bullying and victimization, or when there is, staff intervene [60]. Teachers will benefit from acknowledging their potential to have strong, direct impacts. On a broader level, school staff and students can advocate for legislation to protect TGD students. Policies that incorporate anti-bullying and safe school curriculum (curriculum that is supportive and inclusive of LGBTQ+ students) are associated with increased school safety [66]. Additionally, measures of sexual orientation and gender identity can be incorporated into school benchmarks so that inequities of LGBTQ+ students can be identified and properly addressed [66].

Table 5.1 PFLAG’s 10 steps to creating inclusive schools
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Peers

As noted above, TGD youth are victimized at high rates in school. Lack of peer support is associated with isolation, concealment of one’s identity, and negative internalized feelings [67, 68]. Increased bullying and victimization by peers is associated with increased use of alcohol, marijuana, and other illegal drugs, with bullying acting as a mediator for substance abuse [8]. In addition to bullying and verbal and physical harassment, transfeminine youth report increased sexualization and sexual propositioning by peers, which is associated with an increased risk for sexual assault [16]. Interestingly, when divided by identity, non-binary youth reported more symptoms of anxiety and depression than their binary transgender peers did. They also had fewer positive peer relations [38]. This could be due to fewer examples of non-binary people in schools and in society, and only binary choices for restrooms and locker rooms. In addition, pronouns and familial labels can be more complicated, which can make individuals feel more separate and burdensome.

Peers – Strategies to Enhance Peer Support

As peers are an important factor in adolescent development, and belongingness appears to be a protective factor against negative mental health outcomes, it is reasonable that advocating for increased peer support for transgender youth would be beneficial. Promoting group activities (either in person or online) is one way where youth can find support and affirmation from others, while also being able to discuss concerns about transition and general developmental issues. It is in this type of format where youth can question societal and/or cultural norms and expectations and also feel supported in this exploration. Having spaces where youth can feel comfortable being themselves and where they are supported in their identities is associated with less psychological distress [5].

Peer support was found to be a moderator in the relationship between discrimination, harassment and victimization and psychological distress [5]. Relationships with TGD peers has been associated with less anxiety, fewer suicide attempts, less fearfulness, and more comfort in one’s identity [69]. Frequent contact with LGBTQ+ peers has been associated with resilience in the face of victimization, as youth are more able to deal with stress and utilize coping skills when they see peers who have shared experiences coping in a positive manner [33]. The creation of lavender graduation (ceremonies to celebrate LGBTQ+ students and allies and their accomplishments), pink (LGBTQ+) proms, media campaigns, and informing administration on policy in schools are all examples of how LGBTQ+ youth can join with peers for support [68]. However, it is important to note that if victimization does not decrease, peer support does not appear to act as a buffer against psychological distress [70].

As peer support is such an important protective factor for TGD youth, it is also important to think about the impact of romantic relationships. Adolescence is a developmental stage where youth experiment with and learn about romantic and sexual relationships. How relationships impact youth is important, as well as how experiences of harassment and victimization affect relationships. In a study looking at the impact of stigma on romantic relationships, researchers found that stigma associated with being in a romantic or sexual relationship with a TGD person not only negatively affected the TGD individual, but also their partner’s perception of the relationship quality [71]. It appears that negative messages internalized by TGD individuals also may be internalized by their romantic partners. Therefore, it is important to address the stress and related difficulties associated with general relational issues, as well as the impact of harassment and discrimination on both the TGD individuals and their partners.

While peer support is an important protective factor for TGD youth, supportive peers are not always available in person. The availability of supportive peers online has also been noted as an important protective factor, to connect with others and share positive coping strategies including positive self-talk, the importance of being a role model to other TGD youth, exploring meaningful and creative activities, and exploring reasons for living [34, 36]. Importantly, while online role models have been identified as a positive coping support in order to model resiliency, success, and positive self-worth, youth who reported having online role models reported more negative symptomatology [72]. It is unclear whether it is because having only online role models makes it more apparent that there are no positive role models in the community, or if youth who seek out role models online are doing more poorly in general [72]. This points to the potential importance of having both online supports and also allies and role models in the community.

Mental Health and Medical Settings

Medical and mental health providers also play an important role in either helping TGD youth and their families to feel supported and affirmed, or in more unfortunate circumstances, to feel invalidated, stigmatized, and/or discriminated against. Notably, the largest barrier to care, as identified by TGD individuals, is the lack of knowledgeable providers [73]. Research highlights the clinical importance of supporting individuals align their body with their mind. As such, struggling with barriers such as lack of culturally sensitive professionals, coverage denials from insurance companies, and long wait periods are highly problematic for TGD individuals.

Unhelpful and invalidating experiences with providers cover a wide spectrum of events, from highly unintentional and well-intentioned actions on the providers’ part that unfortunately do not feel supportive from the patients’ perspective, to more egregious cases. One study [74] of transgender adults captured six themes regarding participants’ reports of problematic behaviors experienced while receiving medical care: (1) gender insensitivity, (2) displays of discomfort, (3) denial of services, (4) substandard care, (5) verbal abuse, and (6) forced care (e.g., being involuntarily committed to psychiatric units or undergoing unnecessary medical examinations). Safer and colleagues [73] also reported that financial challenges, discrimination, lack of provider cultural competence, health systems issues, and socioeconomic issues are additional barriers to accessing care among TGD individuals. Trust is also a highly relevant topic, as certain professionals have taken to discussing and writing about issues pertaining to transgender identity from a lens of mistrust, fostering an “us” (providers) versus “them” (TGD patients) dynamic [75].

Mental Health and Medical Settings – Strategies to Enhance Support

While medical and mental health professionals share an overarching goal of providing effective and supportive care to patients in need of services, it is important to also acknowledge our fallibility. Of great importance is our willingness to recognize and correct missteps when they occur. It is arguable that providers may be more prone to missteps with TGD patients, given a number of factors including limited knowledge of the research, minimal exposure to working with TGD individuals, lack of supervision or mentorship on the topic, and personal biases and belief systems. In reflecting on our practice with TGD individuals, it may be helpful to call to mind the ethical principles of beneficence, non-maleficence, autonomy, and justice. For a more detailed explanation of how to attend to each of these principles while working with TGD individuals, see the work of Hann, Ivester, and Denton [76].

Additionally, there are numerous references that providers can consult to foster affirmative, culturally sensitive work with TGD individuals [81,82,79]. The World Professional Association for Transgender Health (WPATH) provides regularly updated, comprehensive standards of care for working with TGD individuals, including special attention directed to the treatment of TGD youth [79]. Others [80] have also outlined a number of suggestions pertaining to the care of TGD individuals across numerous professional arenas like primary care, mental health interventions, speech and language therapy, surgery, and management of transition care. They also detail the importance of including training on the care of TGD individuals early on in medical training. Additionally, the American Psychological Association has published guidelines for providing psychological services to TGD communities [81]. More recently, factors that TGD youth themselves report they wish their providers would keep in mind when working with them were summarized [82]. This includes language use and communication with TGD patients, education regarding the many ways that TGD youth can experience and express their gender identity, and depathologizing transgender identity, among other topics. Further, other colleagues provide important recommendations for serving LGBTQ+ youth effectively, ensuring to attend to systems-level considerations [83].

With regard to mental health treatment, being apprised of risk and resilience factors is an excellent first step for providers who are new to working with TGD youth and their families. More specifically, it is recommended that while assessing the mental health and safety of TGD youth, clinicians should include questions that assess distal and proximal risk factors as well as resiliency factors noted in the GMSR model. It is also worth noting that clinicians and scholars have begun to develop cultural modifications to standard evidenced-based treatment interventions, such as Cognitive Behavior Therapy. For instance, the Transgender Affirmative Cognitive Behavioral Therapy (TA-CBT) aims to help providers deliver more affirmative CBT interventions to TGD individuals with anxiety, depression, and/or suicide behaviors [84]. The intervention is based on ensuring that the following are addressed in treatment: relevant psychoeducation, thinking styles, social support, and suicide prevention [82]. Thus, among other benefits, therapy can help individuals to attend to their emotional, cognitive, and behavioral responses to experiences with rejection and discrimination, for instance, and subsequently help to reframe unhelpful, biased thoughts that if left unchallenged, could further exacerbate difficulties with shame, internalized transphobia, and hope for the future, among other factors.

Conclusions

TGD youth face a great deal of proximal and distal stress factors that are associated with an increase in health and mental health concerns [4, 11,12,13,14,15,10, 15]. In addition, there are also noted supports (e.g., parents, schools, peers, and medical providers) whose affirmative approach can mediate these negative health outcomes and boost TGD youth and their families’ sense of resilience. It is our hope that providers can utilize the strategies noted above to help affirm TGD youth and inculcate them from environmental stressors. Additionally, it is important for researchers to continue to evaluate the above interventions and use their work to inform future policies aimed at supporting TGD youth.