Preventing Transphobic Bullying and Promoting Inclusive Educational Environments: Literature Review and Implementing Recommendations

World Psychiatric Association-Asian Journal of Psychiatry Commission on Public Mental Health

Although there is considerable evidence showing that the prevention of mental illnesses and adverse outcomes and mental health promotion can help people lead better and more functional lives, public mental health remains overlooked in the broader contexts of psychiatry and public health. Likewise, in undergraduate and postgraduate medical curricula, prevention and mental health promotion have often been ignored. However, there has been a recent increase in interest in public mental health, including an emphasis on the prevention of psychiatric disorders and improving individual and community wellbeing to support life trajectories, from childhood through to adulthood and into older age. These lifespan approaches have significant potential to reduce the onset of mental illnesses and the related burdens for the individual and communities, as well as mitigating social, economic, and political costs. Informed by principles of social justice and respect for human rights, this may be especially important for addressing salient problems in communities with distinct vulnerabilities, where prominent disadvantages and barriers for care delivery exist. Therefore, this Commission aims to address these topics, providing a narrative overview of relevant literature and suggesting ways forward. Additionally, proposals for improving mental health and preventing mental illnesses and adverse outcomes are presented, particularly amongst at-risk populations.

Effects of Delivering an Animation-Based Inclusive Sex Education Curriculum for Adolescents in China

Evidence suggests that tailored inclusive sex education can be an effective response to prevent gender-based violence and promote an inclusive educational environment. This study examined the effects of an age-appropriate and animation-based inclusive sex education curriculum among Chinese adolescents. A total of 243 students from one comprehensive vocational high school participated in the study. Attitudes toward homosexuality and relevant knowledge were assessed using Attitudes Toward Lesbians and Gays Scale and researcher-made questionnaires at the preintervention and postintervention. Results indicated that adolescents' attitudes and knowledge showed improvement after intervention; female students showed more positive attitudes toward homosexuals; and the animation-based inclusive sex education was welcomed by most participants. Implications of the findings and directions for future research were also discussed.

Social Support and the Association Between Certain Forms of Violence and Harassment and Suicidal Ideation Among Transgender Women - National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019-2020

Violence and harassment toward transgender women are associated with suicidal thoughts and behaviors, and social support might moderate such association. This analysis explored the association between certain forms of violence and harassment and suicidal ideation and moderation by social support. Better understanding of these associations could guide mental health services and structural interventions appropriate to lived experiences of transgender women. This cross-sectional analysis used data from CDC's National HIV Behavioral Surveillance Among Transgender Women. During 2019-2020, transgender women were recruited via respondent-driven sampling from seven urban areas in the United States for an HIV biobehavioral survey. The association between experiencing certain forms of violence and harassment (i.e., gender-based verbal and physical abuse or harassment, physical intimate partner abuse or harassment, and sexual violence) and suicidal ideation was measured using adjusted prevalence ratios and 95% CIs generated from log-linked Poisson regression models controlling for respondent-driven sampling design and confounders. To examine moderation, the extents of social support from family, friends, and significant others were assessed for interaction with certain forms of violence and harassment; if p interaction was <0.05, stratified adjusted prevalence ratios were presented. Among 1,608 transgender women, 59.7% experienced certain forms of violence and harassment and 17.7% reported suicidal ideation during the past 12 months; 75.2% reported high social support from significant others, 69.4% from friends, and 46.8% from family. Experiencing certain forms of violence and harassment and having low-moderate social support from any source was associated with higher prevalence of suicidal ideation. Social support from family moderated the association between experiencing certain forms of violence and harassment and suicidal ideation (p interaction = 0.01); however, even in the presence of high family social support, experiencing certain forms of violence and harassment was associated with higher prevalence of suicidal ideation. Social support did not completely moderate the positive association between experiencing violence and harassment and suicidal ideation. Further understanding of the social support dynamics of transgender women might improve the quality and use of social support. Policymakers and health care workers should work closely with transgender women communities to reduce the prevalence of violence, harassment, and suicide by implementing integrated, holistic, and transinclusive approaches.

Preventing sexual violence in sexual orientation and gender diverse communities: A call to action

Background: Members of the lesbian, gay, bisexual, transgender, queer, and other sexual orientation and gender diverse (SOGD) communities are at disproportionately higher risk for sexual violence compared to cisgender heterosexual people. Despite this elevated risk, relatively few sexual violence prevention efforts effectively reduce these victimization disparities based on sexual orientation or gender identity.Objective: This narrative review provides an overview of the prevalence of sexual violence in the SOGD communities, delineates risk factors for sexual victimization among SOGD community members, and reviews and evaluates existing prevention efforts for the SOGD communities. We outline specific recommendations for ensuring that prevention efforts meet the needs of the SOGD communities.Method: Drawing on ecological systems theory and public health approaches to sexual violence prevention, we outline current approaches and opportunities for preventionists and scholars to push the field forward.Results: There have been promising prevention programmes designed to be implemented within SOGD communities specifically; however, it is important that general primary prevention programmes endeavour to specifically address sexual violence perpetrated against SOGD people. While many packaged programmes that endeavour to prevent sexual violence across all gender identities and sexual orientations are inclusive of SOGD participants, more programming is needed that integrates anti-oppression training to target social norms that perpetuate SOGD-specific rape myths and normalize sexual violence against SOGD community members.Conclusion: Ecological prevention strategies in line with a public health approach for primary prevention may be particularly valuable for reducing victimization disparities based on SOGD status and identity. Comprehensive sexual education and anti-discrimination policies should be considered front-line prevention programming. To assess if these strategies are effective, the implementation of large-scale surveillance surveys that use comprehensive assessments of sexual orientation, gender identity, and sexual violence are needed. Using theoretically grounded implementation strategies for prevention programmes can ensure effective programme delivery.

Violence Against LGBTIQ+ People at Universities: The Need to Uncover a Silent Reality

Violence against LGBT community can manifest in different forms and exists in all spheres of society, including education. The main purpose of this article is to deepen the understanding of the state of the art about violence grounded in sexual orientation or gender identity in higher education in order to identify gaps for further research. The topic of this state-of-the-art literature review is the presence and magnitude of these forms of violence in the Spanish higher education system. For this reason, the inclusion criteria were empirical studies about the prevalence of violence against LGBTIQ+ individuals in the Spanish educational system. After analyzing the 25 articles that met the inclusion criteria, the main findings point that despite the existence of numerous international studies of the presence of violence against LGBTIQ+ people at colleges, little is known about this reality in Spain. The Spanish university system continues to remain hermetic, and violence against LGBTIQ+ people is silenced and hidden. Practice, policy and research implications of the findings are discussed in this article, highlighting the need of further research in this field. In this context, the research project Uni4Freedom, addresses this social and educational problem to contribute to the creation of safer universities for the LGBTIQ+ community and people who support them.

Between Resilience and Agency: A Systematic Review of Protective Factors and Positive Experiences of LGBTQ+ Students

A negative school climate resulting from homophobic and transphobic bias and discrimination is associated with poor well-being and mental health among LGBTQ+ youth. However, protective factors and mechanisms may buffer against the impact of stigmatization. Drawing on the socio-ecological model, minority stress theory, and positive youth development and agency perspectives, we carried out a systematic review of research focusing on factors that can promote the well-being of LGBTQ+ students in educational settings, outlining the primary outcomes from studies published between 2012 and 2022. The PRISMA protocol was used for this review, and 64 articles were scrutinized. The results of the thematic analysis revealed that both external factors (school-inclusive policies and extracurricular activities; social support from school, family, and the community; and school connectedness) and internal factors (psychosocial characteristics and personal agency) promote positive school experiences, such as the exploration of sexual and gender identities in a safe environment. The present findings highlight the need for inclusive school policies and strategies and individual-level interventions that target the well-being and positive mental health outcomes of sexual and gender minority students.

Internalized transphobia predicts worse longitudinal trend of body uneasiness in transgender persons treated with gender affirming hormone therapy: a 1-year follow-up study

BACKGROUND

Given the relationship between interiorized stigma and body image, it could be hypothesized that high levels of internalized transphobia (IT) might predict higher levels of body uneasiness in subjects with gender dysphoria (GD) and worse improvement of body image after gender affirming hormone therapy (GAHT).

AIM

We sought to evaluate the relationship between IT and body uneasiness in subjects with GD and the role of IT in moderating the improvement of body image after GAHT.

METHODS

In total, 200 individuals with GD performed the baseline assessment; 99 were re-evaluated 12 months after starting GAHT. At baseline participants were evaluated through a face-to-face interview and filled self-administered questionnaires to evaluate GD (Utrecht Gender Dysphoria Scale [UGDS]), IT attitudes (Attitudes Toward Transgendered Individuals [ATTI] Scale), body uneasiness (Body Uneasiness Test, part A [BUT-A]), and general psychopathology (Symptom Checklist 90-Revised [SCL 90-R]). The same questionnaires, except ATTI, were readministered at follow-ups.

OUTCOMES

Outcomes were based on measures of the associations between IT and baseline characteristics of the sample, the longitudinal trends of GD, body uneasiness, and general psychopathology; and IT as a moderator of the longitudinal trend of body uneasiness.

RESULTS

At baseline, IT correlated with lower level of education, higher GD, and more severe body uneasiness. Longitudinal analyses showed significant improvements in GD, body uneasiness, and general psychopathology during GAHT. Moderation analysis confirmed that participants with more transphobic attitudes showed less improvement after GAHT with regard to body uneasiness (bTime*ATTI = -.002, P = .040). The Johnson-Neyman technique revealed that no significant improvement in body uneasiness was found for participants with ATTI scores lower than 71.14.

CLINICAL IMPLICATIONS

The presence of IT should be investigated in subjects with GD who require gender affirming treatments to provide specific interventions aimed at targeting this dimension.

STRENGTHS AND LIMITATIONS

Strengths of this study include the mixed cross-sectional and longitudinal design and the dimensional evaluation of the investigated constructs. Limitations include the small sample size and the limited follow-up. Furthermore, the effects of gender affirming surgery were not evaluated.

CONCLUSION

The association of IT with both baseline body uneasinessand the longitudinal course of this dimension highlighted the clinical significance of body uneasiness and the importance of making continuous efforts to improve education and information to fight societal stigmas.

Effects of the Prevention Program "HateLess. Together against Hatred" on Adolescents' Empathy, Self-efficacy, and Countering Hate Speech

Currently, there is a lack of empirically evaluated prevention programs targeting hate speech among adolescents. This is problematic because hate speech jeopardizes adolescents' well-being and social integration. To this end, this study aims to evaluate the short-term effects of the newly developed anti-hate speech prevention program, "HateLess. Together against Hatred", on adolescents' empathy, self-efficacy, and counter-speech. Eight hundred and twenty adolescents between 12 and 16 (M = 13.27, SD = 1.04) from 11 German schools participated in this study. More specifically, 567 adolescents participated in the one-week prevention program, and 253 participants were assigned to the control group. Repeated measures ANOVAs showed that HateLess was successful, as there was a significant increase in empathy, self-efficacy, and counter-speech in the intervention group from the pretest (T1) to the posttest (T2) one month after the intervention. In contrast, no changes were found among adolescents in the control group. A multilevel mediation model revealed that the effect of being a member of the intervention group on counter-speech was partially mediated via empathy and self-efficacy. The findings indicate that HateLess is an effective, cost-efficient approach to enhance adolescents' counter-speech directly and indirectly by altering the skills they need to become informed citizens in democratic societies.

Will You Protect Me or Make the Situation Worse?: Teachers' Responses to School Violence Against Students With Disabilities

School violence is a global public health epidemic, with students with disabilities at a significantly greater risk than their non-disabled peers. Students with disabilities are more vulnerable to school violence from peers, teachers, and school staff due to stereotypes and prejudice. Teachers are pivotal in preventing violence and intervening, but literature on the role that teachers play in responding to disability-based violence is limited. Guided by the social-ecological framework of bullying, this qualitative study explored educators' responses to school violence against students with disabilities in Zambia. Data generation included document review, interviews, and focus groups with 33 teachers and 12 parents, and child-friendly methods with 90 students with disabilities. Findings illuminated that students with disabilities are less safe in schools. Teachers are not responding to violence seen or heard about due to stigmatizing beliefs and cultural norms surrounding disability and violence, with students with disabilities blamed for the violence and the response being their burden. Students with disabilities felt protected by special education teachers; however, disability-based stigma did not end with the student. By association, special education teachers were experiencing stigma from other teachers and were discouraged to respond. This stigma undermined the support special education teachers could provide to decrease school violence. Findings provide direction so teachers can respond to school violence in prosocial ways that create an environment where students with disabilities feel safe.

The Association between Appetitive Aggression and Social Media Addiction Mediated by Cyberbullying: The Moderating Role of Inclusive Norms

Appetitive aggression, i.e., the motivation to obtain rewards through aggressive behaviors, has been suggested as a key driver of cyberbullying. Due to the contextual properties of cyberspace (e.g., anonymity), it is assumed that the negative effects of cyberbullying are masked, leading to a preponderance of its positive outcomes (e.g., thrill). Since cyberbullying occurs predominantly in social media, reward-learning effects may lead to problematic social media use, such as addiction. Anti-cyberbullying inclusive norms might act as a buffering factor to break this chain. However, while inclusive norms are known to reduce cyberbullying in general, their influence on the indirect effect of appetitive aggression via cyberbullying on social media addiction is yet unknown. The present study examined this indirect effect, while taking the moderating role of inclusive norms into account. A total of 1064 adolescents (42.05% male, Mage = 14.07, SD = 2.15) completed questionnaires. Results revealed the indirect effect of appetitive aggression on social media addiction through cyberbullying as expected. Surprisingly, this indirect effect was amplified with increasing anti-cyberbullying inclusive norms. Our findings indicate that appetitive aggression, which manifests in cyberbullying, contributes to the development of social media addiction. The unexpected results and the implications of our findings were discussed.

Discrimination, Substance Use, and Mental Health among Sexual and Gender Minority Adults Accessing Day Shelter Services

BACKGROUND

Sexual and gender minority (SGM) adults are overrepresented in the population of individuals experiencing homelessness, and high rates of substance use are common in this group. Plausibly, poor mental health and discrimination may contribute to substance use among SGM adults experiencing homelessness. This study described participant characteristics, and the interrelations among sociodemographic variables, substance use, mental health, and discrimination experiences among 87 SGM adults seeking services at a day shelter in Oklahoma City, OK. Discrimination experiences were characterized by race (White vs. non-White), sex (female vs. male), sexual identity (heterosexual vs. sexual minority), and gender identity (gender conforming vs. gender minority).

METHODS

Participants reported their past 30-day tobacco (cigarette/cigarillos, alternative tobacco products [ATP]), alcohol, and marijuana use, as well as everyday and lifetime major discrimination experiences, substance use problems, depression, anxiety, and post-traumatic stress disorder (PTSD). Independent samples t-tests examined differences in discrimination based on substance use and mental health.

RESULTS

Participants had high rates of tobacco and marijuana use, substance use problems, depression, anxiety, and PTSD. Over 80% reported experiencing everyday or lifetime major discrimination. Depression and PTSD were associated with ATP use, and anxiety was associated with alcohol use. All mental health variables were associated with substance use problems and everyday discrimination. Depression was associated with lifetime major discrimination.

CONCLUSIONS

SGM adults accessing shelter services frequently experienced discrimination and poor mental health, and substance use was common. Future research should examine the causal impact of discrimination on mental health and substance use among SGM adults experiencing homelessness.

School Climate and Bullying Bystander Responses in Middle and High School

Bullying bystanders' reactions are important for either stopping or perpetuating bullying behaviors. Given school-based bullying programs' focus on bystanders, understanding the associations between school-level factors and individual bystander responses can improve intervention efficacy. Data from 64,670 adolescents were used to examine bullying bystander responses as a function of 13 school-climate dimensions within 3 main factors (Engagement, Environment, Safety) and individual-level factors (e.g., race/ethnicity, perceptions of student-teacher connectedness). Multi-level models showed schools with better Engagement and Safety had higher odds of defender behaviors, a better Environment was associated with lower odds of passive and assisting behaviors. Differences also varied by individual-level factors. For example, an aggressive climate was associated with passive behaviors more strongly in boys and high schoolers. Further, higher perceived parent-teacher and student-teacher connectedness were associated with positive bystander behaviors, and this was stronger for Black and Latinx youth, highlighting the importance of improving relationships as a crucial starting point.

Gender-Oriented Mental Health Prevention: A Reappraisal

Many studies have investigated the impact of gender on mental health, but only a few have addressed gender differences in mental health risk and prevention. We conducted a narrative review to assess the current state of knowledge on gender-specific mental health preventive interventions, along with an analysis of gender-based risk factors and available screening strategies. Out of 1598 articles screened using a comprehensive electronic search of the PubMed, Web-of-Science, Scopus, and Cochrane databases, 53 were included for review. Among risk factors for mental health problems, there are individual, familiar, social, and healthcare factors. Individual factors include childhood adversities, which show gender differences in distribution rates. However, current childhood abuse prevention programs are not gender-specific. Familiar factors for mental health problems include maternity issues and intimate partner violence, and for both, some gender-specific preventive interventions are available. Social risk factors for mental health problems are related to education, employment, discrimination, and relationships. They all display gender differences, but these differences are rarely taken into account in mental health prevention programs. Lastly, despite gender differences in mental health service use being widely known, mental health services appear to be slow in developing strategies that guarantee equal access to care for all individuals.

Timing of Social Transition for Transgender and Gender Diverse Youth, K-12 Harassment, and Adult Mental Health Outcomes

PURPOSE

Many transgender and gender diverse (TGD) youth undergo a social transition in which they change their gender expression to align with their gender identity. Our objective was to examine associations between timing of social transition (during the prepubertal childhood period, adolescence, or adulthood) and adult mental health outcomes.

METHODS

We conducted a secondary analysis of the 2015 U.S. Transgender Survey, a cross-sectional nonprobability survey of 27,715 TGD adults in the United States. Based on self-reports, participants were categorized as having undergone social transition during childhood (ages 3-9 years), adolescence (ages 10-17 years), or adulthood (ages ≥18 years). Using multivariable logistic regression, we examined associations between timing of social transition and adult mental health outcomes.

RESULTS

After adjusting for demographic and potential confounding variables, childhood social transition was associated with lower odds of lifetime marijuana use (adjusted odds ratio .7, 95% confidence interval = .5-.8, p < .0001) when compared with adult social transition. Before adjusting for K-12 harassment based on gender identity, adolescent social transition was associated with adverse mental health outcomes, including greater odds of lifetime suicide attempts when compared with adult social transition (adjusted odds ratio 1.3, 95% confidence interval = 1.1-1.7, p = .004). These associations were no longer significant after further adjusting for K-12 harassment.

CONCLUSIONS

Although past research has shown TGD youth who undergo social transition have favorable mental health outcomes in the short term, they may have worse mental health in adulthood if not protected from K-12 harassment based on gender identity. It is the responsibility of clinicians to emphasize the importance of adolescents having safe and affirming social environments.

Transgender women of color in the U.S. South: A qualitative study of social determinants of health and healthcare perspectives

Background: Research has shown that transgender and nonbinary people experience health disparities. However, few studies have explored, in-depth, the health-related experiences, perceptions, needs, and priorities of transgender women of color living in the U.S. South, a region that poses unique challenges to achieving health for transgender people. Aims: This study explored the social determinants of health, healthcare experiences, and health-related priorities of transgender women of color living in the U.S. South. Methods: Using a community-based participatory research approach, we conducted iterative in-depth interviews with 15 African American/Black and Latinx transgender women in North Carolina in May-July 2019 for a total of 30 interviews. We analyzed interview data using constant comparison, an approach to grounded theory. Results: Participants' mean age was 34 (range 19-56) years. Twenty themes emerged that were categorized into three domains: (1) social determinants of health (family rejection; bullying, discrimination, and violence; isolation; policy barriers; mistrust in systems; employment obstacles; sex work; high cost of care; transportation barriers; church antagonism; and substance misuse), (2) healthcare experiences (emotional burden of healthcare interactions; name and gender misidentification; staff discomfort and insensitivity; sexual risk assumptions; and use of nonmedical or predatory providers), and (3) health-related priorities (understanding healthcare; respect at all levels of healthcare; inclusive gender-affirming care; and comprehensive resources). Discussion: Transgender women of color living in the U.S. South face profound health barriers compounded throughout the life course and have unmet healthcare needs. Participants faced multilayered minority stressors: racial discrimination from society at large and within the LGTBQ community; gender identity discrimination within their regional context and racial/ethnic communities; and exclusion from existing health equity movements for transgender women of color, which often are found in and focus on larger urban communities. Health interventions mindful of this intersection are needed, including antidiscrimination policies and increasing gender-affirming healthcare access.