Attachment and Shame in Gender-Nonconforming Children and Their Families: Toward a Theoretical Framework for Evaluating Clinical Interventions

Conversion therapy, suicidality, and running away: An analysis of transgender youth in the U.S

This study analyzes the relationship between conversion therapy and mental health and wellbeing of transgender youth in the U.S. We create a retrospective panel of transgender youth using the 2015 U.S. Transgender Survey to test how exposure to conversion therapy affects the likelihood of attempting suicide and running away from home. The empirical approach employs a difference-in-differences design. Results indicate that exposure to conversion therapy substantially increases the likelihood a transgender adolescent will attempt suicide and run away. The average treatment effect on treated (ATT) of conversion therapy on having attempted suicide is an increase of 17 percentage points, which amounts to a 55% increase in the risk of attempting suicide, and the ATT on the risk of running away is an increase of 7.8 percentage points, more than doubling the risk of running away. These effects are largest when exposure to conversion therapy occurs at a young age (11-14).

Youth should decide: the principle of subsidiarity in paediatric transgender healthcare

Drawing on the principle of subsidiarity, this article develops a framework for allocating medical decision-making authority in the absence of capacity to consent and argues that decisional authority in paediatric transgender healthcare should generally lie in the patient. Regardless of patients' capacity, there is usually nobody better positioned to make medical decisions that go to the heart of a patient's identity than the patients themselves. Under the principle of subsidiarity, decisional authority should only be held by a higher level decision-maker, such as parents or judges, if lower level decision-makers are incapable of satisfactorily addressing the issue even with support and the higher level decision-maker is better positioned to satisfactorily address the issue than all lower level decision-makers. Because gender uniquely pertains to personal identity and self-realisation, parents and judges are rarely better positioned to make complex medical decisions. Instead of taking away trans youth's authority over their healthcare decisions, we should focus on supporting their ability to take the best possible decision for themselves.

Conditions for shared decision making in the care of transgender youth in Canada

Information is lacking on the role shared decision making plays in the care of transgender (trans) youth. This qualitative, descriptive study explored how trans youth, parents and health care providers engaged or did not engage in shared decision-making practices around hormone therapy initiation and what conditions supported shared decision-making approaches in clinical practice. Semi-structured interviews were conducted with 47 participants in British Columbia, Canada, and analyzed using a constructivist grounded theory approach. While formal shared decision-making models were not used in practice, many participants described elements of such approaches when asked about their health care decision-making processes. Others described health care interactions that were not conducive to a shared decision-making approach. The key finding that emerged through this analysis was a set of five conditions for supporting shared decision making when making decisions surrounding initiation of hormone therapy with trans youth. Both supportive relationships and open communication were necessary among participants to support shared decision making. All parties needed to agree regarding what decisions were to be made and what role each person would play in the process. Finally, adequate time was needed for decision-making processes to unfold. When stakeholders meet these five conditions, a gender-affirming and culturally safer shared decision-making approach may be used to support decision making about gender-affirming care. Implications for clinical practice and future research are discussed.

Deconstructing cissexism: The journey of becoming an affirmative family therapist for transgender and nonbinary clients

This article proposes a model for family therapists to become more competent, inclusive, and affirmative in their clinical work with transgender and nonbinary clients. In particular, this article details: (1) barriers to transgender and nonbinary affirmative therapy, (2) impacts of these barriers on transgender and nonbinary people's mental health, (3) a three-step model for becoming an affirmative therapist for transgender and nonbinary clients, and (4) strategies for deconstructing cissexism in therapy. This goal of this article is to invite family therapists to join in on a lifelong journey of "becoming" an affirmative therapist for transgender and nonbinary clients, a journey on which none of us will ever "arrive". We can, however, take continual action to minimize the negative impacts of cissexism on therapists and clients; this article offers ideas for a place to start.

Refusing abjection: transphobia and trans youth survivance

This article argues that Julia Kristeva’s Powers of Horror: an Essay on Abjection lays out a theory that is not universal in its application, but rather details the violent emergence and defence of Eurocentric, colonial and orientalist subjectivities and related hierarchical social orders. The Eurocentrism found in Kristeva’s political and theoretical stances are referenced, with detailed attention paid to explicating how her theory of abjection describes a brutal, colonising, psychological and social mechanism. This framework is applied to transphobia and its manifestations. It is centrally argued that gender diversity, trans rights and trans inclusivity may be the targets of multiple and compounding abjection processes. The essay concludes with looking at how young trans people are starting to refuse transphobic abjection to survive, to thrive and to revitalise gender diversity.

Association Between Recalled Exposure to Gender Identity Conversion Efforts and Psychological Distress and Suicide Attempts Among Transgender Adults

IMPORTANCE

Gender identity conversion efforts (GICE) have been widely debated as potentially damaging treatment approaches for transgender persons. The association of GICE with mental health outcomes, however, remains largely unknown.

OBJECTIVE

To evaluate associations between recalled exposure to GICE (by a secular or religious professional) and adult mental health outcomes.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, a survey was distributed through community-based outreach to transgender adults residing in the United States, with representation from all 50 states, the District of Columbia, American Samoa, Guam, Puerto Rico, and US military bases overseas. Data collection occurred during 34 days between August 19 and September 21, 2015. Data analysis was performed from June 8, 2018, to January 2, 2019.

EXPOSURE

Recalled exposure to GICE.

MAIN OUTCOMES AND MEASURES

Severe psychological distress during the previous month, measured by the Kessler Psychological Distress Scale (defined as a score ≥13). Measures of suicidality during the previous year and lifetime, including ideation, attempts, and attempts requiring inpatient hospitalization.

RESULTS

Of 27 715 transgender survey respondents (mean [SD] age, 31.2 [13.5] years), 11 857 (42.8%) were assigned male sex at birth. Among the 19 741 (71.3%) who had ever spoken to a professional about their gender identity, 3869 (19.6%; 95% CI, 18.7%-20.5%) reported exposure to GICE in their lifetime. Recalled lifetime exposure was associated with severe psychological distress during the previous month (adjusted odds ratio [aOR], 1.56; 95% CI, 1.09-2.24; P < .001) compared with non-GICE therapy. Associations were found between recalled lifetime exposure and higher odds of lifetime suicide attempts (aOR, 2.27; 95% CI, 1.60-3.24; P < .001) and recalled exposure before the age of 10 years and increased odds of lifetime suicide attempts (aOR, 4.15; 95% CI, 2.44-7.69; P < .001). No significant differences were found when comparing exposure to GICE by secular professionals vs religious advisors.

CONCLUSIONS AND RELEVANCE

The findings suggest that lifetime and childhood exposure to GICE are associated with adverse mental health outcomes in adulthood. These results support policy statements from several professional organizations that have discouraged this practice.

Does Gender Nonconforming Behavior in Early Childhood Predict Adolescents' Depressive Symptoms?

Gender nonconforming behavior (GNB) is a risk factor for poorer psychological adjustment, but little is known about whether preschool-age children displaying GNB are at risk for depressive symptoms during adolescence. We examined maternal report of GNB at age 4-5 years-old as a predictor of adolescents' depressive symptoms at age 16-17 years-old in a longitudinal study of U.S. children from a predominantly low SES (61% received Aid to Families with Dependent Children) and African American (90%) sample. Youth with GNB in early childhood (n = 10) reported more depressive symptoms during adolescence than did their peers without GNB (n = 115), and this relationship remained after controlling for covariates (environmental risk, prenatal exposure, and neonatal medical problems). Our findings suggest that early GNB may be a risk factor for the development of depressive symptoms in adolescence. Further research is needed to replicate the current findings with a larger sample and to identify the underlying mechanisms by which GNB may increase risk for depressive symptoms. If replicated, the findings further highlight the need for both professionals and parents to become aware of the potential challenges that children with GNB face and to become knowledgeable about ways to facilitate healthy adjustment among gender nonconforming youth.

The Gender Feeling Amplitude: an instrument to assist clinicians with the assessment of gender diverse adolescents

Background The Gender Feeling Amplitude (GFA) is a 68-item list of words and phrases with which to identify the feelings and severity of a young person's distress regarding their gender identity and gender diversity, and takes ~1min to administer.

METHOD

For this pilot study, 67 adolescents and youth who sought support, confirmation or intervention (either via themselves or their parents) regarding gender diversity or gender transition were given the GFA in a face-to-face meeting before the beginning of an assessment procedure for gender diversity. Forty-three assigned females and 24 assigned males aged between 10 and 20 years were analysed by frequency of item, age and assigned gender.

RESULTS

Of the 68 items, those circled by close to 50% or more of the participants were 'self-conscious', 'awkward' and 'don't fit in'. One-third or more circled the words 'shy', 'supported', 'hopeful', 'discomfort', 'as if I'm not being seen properly', 'forced to be something I'm not', 'depressed' and 'stressed'.

CONCLUSION

Comparisons showed some variations in responses by both assigned gender and age, and the discussion includes ways the GFA may be able to assist a health practitioner with explorations of gender diversity and interventions for counselling.

Research Review: Gender identity in youth: treatment paradigms and controversies

BACKGROUND

Pediatric gender identity has gained increased attention over the past several years in the popular media, political arena, and medical literature. This article reviews terminology in this evolving field, traditional models of gender identity development and their limitations, epidemiology and natural history of cross-gender identification among children and adolescents, co-occurring conditions and behaviors, research into the biological and psychosocial determinants of cross-gender identification, and research into the options regarding and benefits of clinical approaches to gender incongruent youth.

METHODS

Based on a critical review of the extant literature, both theoretical and empirical, that addresses the issue of pediatric gender identity, the authors synthesized what is presently known and what is in need of further research in order to elucidate the developmental trajectory and clinical needs of gender diverse youth.

RESULTS

The field of pediatric gender identity has evolved substantially over the past several years. New research suggests that cross-gender identification is prevalent (approximately 1% of youth). These youth suffer disproportionately high rates of anxiety, depression, and suicidality. Although research into the etiology of cross-gender identification is limited, emerging data have shown that affirmative treatment protocols may improve the high rates of mental health difficulties seen among these patients.

CONCLUSIONS

The field of pediatric gender identity has evolved dramatically. Emerging data suggest that these patients' high rates of anxiety, depression, and suicidality appear to be improved with affirmative protocols, although future longitudinal data are needed.

Understanding the emotion of shame in transgender individuals - some insight from Kafka

Both clinical literature and biographical accounts suggest that many transgender individuals experience shame or have experienced shame at some point in their life for reasons related to their gender identity. In clinical psychology, at least until the 1960s, shame has not received much attention; focus was on guilt and shame was regarded mainly as a 'by-product' of guilt. From the 1960s shame has been identified as an emotion not necessarily related to guilt and with unique features, and has been studied in connection with a number of situations, such as domestic abuse, trauma, illness, and sexual orientation. However shame has been studied less in connection with gender variance. Shame has however intrigued philosophers, writers and artists for a very long time. Yet, the importance of the contribution of various disciplines to the understanding of the experience of shame in vulnerable individuals has been overlooked. This paper attempts to explore the meaning of shame for transgender individuals, by making reference not only to clinical studies, but also to artworks and literary novels. Franz Kafka, named "the poet of shame" is particularly salient to the analysis of shame, and some of his works will enable us to shed light on the complexities of the experience of shame in transgender individuals which may defy clinical observation.

Beyond the Binary: Trans-Negotiations in Couple and Family Therapy

Dualistic notions about gender and sexuality have permeated the field of couple and family therapy. These binary constructions have been limiting for everyone, especially those who fall outside the male/female dichotomy. This article examines the impact of these binary notions, especially on transgender and gender-creative individuals, couples, and families. Current theory and research in the field as they relate to gender identity, sexuality, and gender minority stress in couples and families are presented. Case examples are used to illustrate affirmative approaches to treatment issues such as coming out, safety, grief and loss, redefining relationships, and social/medical transitions that may arise for transgender or gender nonconforming (TGNC) individuals, couples, and families.

Gender independent kids: A paradigm shift in approaches to gender non-conforming children

Recent years have seen a substantial change in how children who challenge gender norms (referred to in this article as “Gender Independent”) are regarded by professionals, by their families and by the public at large. Pathologized and treated for decades as a mental illness, childhood gender non-conformity would seem to be imbued with new meaning, as evidenced by a growing number of public voices claiming gender variance as part of human diversity. Call it a paradigm shift: from disorder to diversity, from treatment to affirmation, from pathology to pride, from cure to community. This commentary article reflects on recent shifts in language, shifts in identity options, and shifts in the focus of intervention with gender non-conforming children. Drawing on existing research and public discourse, I consider what the field of human sexuality can learn from “Gender Independence.”