Keywords
Gender affirming care; Transgender and gender diverse youth; Mental health; Minority stress model; Social transition; Psychosocial support
Abstract
In the current climate, it is more important than ever for healthcare providers to act as advocates for Transgender and Gender Diverse (TGD) youth.
INTRODUCTION
In the current climate, it is more important than ever for healthcare providers to act as advocates for Transgender and Gender Diverse (TGD) youth. Particularly as the landscape of legislation surrounding gender affirming medical care across the United States continues to rapidly evolve, it is vital to be aware of additional ways to support this vulnerable patient population. As of 2023, 21 out of 50 states in the USA, home to 35.1% of TGD youth, have passed bans on gender affirming medical care [1]. In contrast to recent restrictions for TGD youth, research has shown that comprehensive gender affirming care reduces many of the mental health disparities that this population faces, including elevated rates of depression and suicidal ideation [2]. As this patient population is disproportionately affected by worse mental health outcomes, likely related to increased levels of societal stigma and discrimination, it is crucial to be aware of ways to best support for TGD youth [3]. In light of recent legislation that limits gender affirming care for TGD youth across state lines in the United States, this paper will outline tangible recommendations for physicians to provide comprehensive gender affirming care in several domains, including social, legal, mental health impacts, classroom-based care, family support, and health equity and access.
Minority stress model
To provide background and context surrounding why gender affirming care is so crucial for gender diverse youth, it is important to briefly outline the concept of the minority stress model. The minority stress model is a theory that suggests that minority group members experience stress and discrimination rooted in prejudice and stigma, which translates into higher risks of negative physical and mental health [4]. The minority stress model can be applied to gender and sexual minorities, including TGD youth, to help explain why these populations suffer worse mental health outcomes than non-minority peers. Stressors range from incredibly acute and powerful (victims to targeted violence, unfair termination in work or school), to broader institutional stressors (discriminatory laws and policies in the workplace), to more insidious experiences with discrimination and microaggressions [5]. It is not uncommon for TGD youth to find themselves victim to instances of misgendering, microaggressions, and stigma from the healthcare system, their peers, and by society at large [6]. Research has shown that a culmination of these acute on chronic triggers lead to worse mental health outcomes in TGD youth, including significantly higher instances of depression, anxiety, and suicidal ideation compared to cis-gender peers [7-9].
General overview of gender affirming care
Throughout this paper, we will focus on non-medical interventions to support TGD youth in the current climate. Gender affirming care encompasses a broad range of interventions to support TGD youth, including psychosocial, medical, structural, and family-systems based interventions to help affirm an individual’s gender identity when it may not align with the gender that they were assigned at birth. Providing gender affirming care encompasses a multidisciplinary approach to care, often involving healthcare, mental health, parental involvement, as outlined in depth in WPATH Standards of Care for the health of TGD youth [10]. For many TGD youth, gender affirming care can be life-saving. Notably, gender affirming care plays a significant role in relieving gender dysphoria in TGD youth, which is a severe psychological state of distress related to one’s gender identity not aligning with their gender assigned at birth. Studies have demonstrated gender-affirming care to be associated with lower odds of depression and suicidality, which can be particularly relevant in gender diverse youth struggling with self-harm and suicidal ideation [3,11-15]. While interventions described in WPATH outline the gold standard for gender affirming care, this paper recognizes that access to parts of gender affirming care, specifically gender affirming medical care, is not available in many regions of the United States. As such, this paper will dive into non-medical interventions to provide comprehensive gender affirming care.
MATERIALS AND METHODS
Research and data from this paper were compiled from a literature review, referencing data from several landmark research studies and drawing upon guidelines from WPATH SOC-8, the gold standard reference for gender affirming care.
RESULTS
TGD youth commonly experience distress related to their anatomy, particularly surrounding their chest and genital regions. Being wellversed on gender-affirming social transitions can help providers alleviate this distress and improve gender dysphoria [16]. Social transitioning encompasses a wide range of typically reversible, non-medical practices to best support TGD youth. Examples of reversible, nonmedical interventions include changing one’s name, gender, pronouns, appearance, and gender expression through tucking, padding or binding. Studies have shown that the act of social transitioning has improved mental health disparities in TGD youth so that measured levels of depression and suicidality are comparable to their cis-gender peers [17].
When treating TGD youth and families, it is important to emphasize that socially transitioning is a reversible intervention that can be an incredibly powerful first step in treating TGD youth. It is also important to note that while socially transitioning helps to affirm gender identity in TGD youth, socially transitioning will neither cause nor perpetuate youth to “become” transgender. While parental concerns regarding the impacts of social transitions on a child’s gender identity formation, research has not supported claims that social transition can convert a youth’s innate sense of gender identity [18].
Discussing gender affirming options for social transition can be simple and extremely helpful interventions to reduce a patient’s gender dysphoria [19].
As a clinician, it is important to take the child’s lead with gender affirming treatment and not go quicker than a child feels comfortable. It is also important to consider the timing and appropriateness of socially transitioning. For instance, many children may find making these changes easier during natural breaks in the school year, such as summer or winter breaks, or when changing to a new school grade or district. It is also imperative to assess social implications and the safety of transition, particularly in specific spaces where transitioning may not be safe and may need extensive discussion and consideration. Providers should be well-versed and open to discussing specific gender affirming social transition techniques, including tucking, wearing gaffs, and binding. Tucking is a social transition technique used to reduce the outward bulge and appearance of male genitalia. It involves pulling the penis down between legs and simultaneously pushing testicles up through the inguinal canal. It is important to note that these techniques should not extend for long periods of time, as risk factors include decreasing blood supply, increased irritation from friction, and increasing temperature inside the testicles, which can affect overall sperm count and quality [20].
Patients can also consider wearing a gaff, which is an undergarment that safely compresses the tissues and contours external genitalia to a more flattened appearance. Gaffs are typically safe to be worn throughout the day and can be excellent options for trans folks interested in exercising or swimming. Chest binding, or compressing the breast tissue to contour the chest to a more flattened appearance, is a common technique to make the chest appear less feminized. Popular and safe methods of binding include using sports bras, commercial binders, or elastic materials to give the chest a more flattened appearance. Studies have found that binding can help reduce misgendering, which has been linked to negative impacts on mental health in TGD youth [21].
However, binding is not without risk and patients should consult their physicians prior to binding to learn about proper materials to use and the potential risks. It is important to note that chest binding for extended periods of time can affect the skin and muscles surrounding the chest, and lead to skin changes and infections, pain in the chest, and even respiratory problems including shortness of breath [22].
If chest masculinization (“top”) surgery is being considered, it is also important to limit binding prior to surgery, as frequent binding can affect the skin’s elasticity and impact surgical success rates. For transfeminine patients, counseling patients to consider simple cosmetic procedures including electrolysis, laser-hair removal and makeup can be simple ways to help patients’ bodies align with their gender identities. Recent studies have found that gender affirming hair removal has been associated with less psychological distress and suicidal ideation related to gender dysphoria [23].
In addition to the above techniques for social transition, physicians should also be well-versed in providing referrals for gender affirming care that require additional expertise, including voice therapy and vocal coaching. Vocal coaching sessions can occur in a matter of weeks and have been shown to relieve gender dysphoria related to self-perception of gender identity based on one’s voice [24].
Mental health
Numerous studies have demonstrated that TGD youth have higher rates of mental illness, including depression, anxiety, and suicidality, compared to cisgender peers [25-27]. Notably, studies suggest alarming rates of suicidal ideation amongst TGD youth. Recent research suggests that more than half of TGD individuals have reported suicidal ideations and almost a third of TGD individuals have attempted suicide [28]. Higher rates of mental illness in this vulnerable population is likely attributable to a combination of the minority stress model, societal stigma, and heightened levels of discrimination and violence against individuals who identify as transgender [29].
Fortunately, research has shown that TGD youth that receive comprehensive gender affirming care have notable improvements in their mental health, including lower incidence of depression and suicidality with rates similar to their cisgender peers [30,31]. Engagement in consistent therapy can be beneficial for TGD youth, as they begin to explore their gender identity. As such, it is important for mental health professionals to be well-versed on how to best support TGD youth. Additionally, as TGD youth may also have other salient identities, providers should also be mindful of the impacts of various intersecting identities, which may impact the degree to which gender exploration is accepted. WPATH outlines several ways for mental health providers to develop clinical competence in working with TGD youth, including ways to engage in continued education to assist TGD youth and their families. Notably, the therapist’s role can extend beyond the traditional office setting, as there are many opportunities for mental health providers to act as liaisons and advocates with families, schools, and communities, to help support the TGD youth’s transition.
It is also important to note that much of the research on TGD youth focuses on a specific subset of the population that also struggle with mental health comorbidities. While TGD youth struggle with mental illness at higher rates than the general population, one should be aware that many TGD youth with gender dysphoria do not have comorbid mental illness. Therapists should also be aware that TGD youth struggle with the same mental health stressors that the general population struggles with, separate from their gender identity. As such, it is important for the adept mental health clinician to be mindful when treating aspects of mental health both related to and independent from their gender identity. As adolescence is a critical period for youth to explore various aspects of their identity, it is important for mental health professionals to encourage open exploration of gender in TGD youth during this period of development. WPATH recommends practitioners to facilitate open exploration of gender for TGD youth, without favoring a particular identity [32].
When discussing mental health for TGD youth, it is also important to warn of the harmful impacts of conversion/reparative therapy on TGD youth’s mental health. Conversion therapy encompasses efforts to change a person’s gender identity to align with their sex assigned at birth. Many major medical and mental health organizations, including the American Psychological Association, American Academy of Child and Adolescent Psychiatry, and WPATH, strongly recommend against efforts to change gender identity through conversion/reparative therapy for TGD youth. In fact, studies have found these approaches did not result in changes to TGD youths’ gender identity [33] and often led to unethical and harmful psychological consequences in transgender individuals, including increased suicidality [33,34].
Mental health providers also serve a crucial role in providing comprehensive psychological evaluations and capacity evaluations for TGD youth who seek medical and surgical gender interventions. Though medical and surgical gender affirming interventions are only briefly highlighted in this context of this paper, WPATH guidelines can be referenced to provide more comprehensive details.
Medical care
Gender affirming medical care involves a range of interventions, including puberty suppression using puberty blockers as well as gender affirming hormones. Several studies have outlined how gender-affirming hormones are associated with improvements in depressive symptoms related to gender dysphoria [35-38]. Medical interventions range from reversible interventions such as puberty blockers and contraception for menstrual cessation, to irreversible interventions, which include gender affirming hormones and surgery.
While medical interventions can be done in tandem with a patient’s social transition, some patients may elect to not have any gender affirming medical care as part of their gender journey. It is important to mention that in the current political climate in the United States, almost half of all states have placed bans on gender affirming medical care for youth, with some states even making gender affirming medical care for TGD youth a felony. State bans raise important ethical concerns as they risk increasing health disparities by limiting access to trained clinicians and resources involved in gender affirming care based on where TGD youth live. TGD youth from families with more resources may be able to travel to states where gender affirming medical care is legal, while those with fewer resources likely cannot. Standards of care for gender diverse youth highlights gender affirming medical interventions as important options for TGD youth despite these bans. Guidelines for many of these interventions can be found throughout WPATH resources.
Despite restrictions on certain gender affirming medical interventions, it is still important for clinicians to be competent in working with TGD youth. Data suggest that transgender youth report poorer health and access healthcare at lower rates than their cisgender peers. Lower utilization of resources in this population is driven by previous negative outcomes with the healthcare system [39]. Posting affirming symbols, utilizing preferred name and pronouns with patients and on registration forms, as well as training staff on working with TGD youth are inclusive practices that medical offices can implement [40].
Legal changes
An important aspect of gender affirming care includes navigating legal changes involved in gender affirmation. People who identify as transgender and gender diverse have been observed to report a high burden of discrimination related to employment, housing, and access to health care [41]. By reducing discrimination and positively impacting social determinants of health, studies have shown that these legal changes for TGD youth can improve access to care and even improve socioeconomic opportunities [42]. Physicians can serve as liaisons by providing resources to help gender diverse patients with this process, which can include changing name and gender on legal documents such as birth certificates, driver’s licenses, passports, and social security cards.
Name changes
While not all TGD youth elect to change their name, for many, this can be a powerful step in their transition and can provide much welcomed relief to gender dysphoria associated with given names. In fact, studies have found that people who updated their identification to match their gender identity had lower levels of psychosocial distress and suicidal ideation compared to peers who had not [43].
Changing given names to chosen names in social settings often occur early on in transition, while legally changing names can take time. From a legal perspective, it’s important to recognize that laws vary state by state for changing legal documents. The name change procedure can be daunting for patients, who historically have been required to appear in court to legally change their names. The name change process itself can also take several weeks to months to be completed and legally.
recognized. There can be several hundred dollars worth of fees involved in the process, including obtaining notarized copies and court fees. Some states even require name changes to be published in a newspaper announcement before the name change process is considered complete. These publications often have an additional fee associated with them. States may have stringent guidelines about the types of newspaper these announcements are posted in, so it is best to seek legal counsel to best help with the process. Some states have specifically dedicated legal representative groups dedicates towards working with patients to break down the barriers involved in changing legal documents. Additional information about these groups are highlighted in our resource section.
Gender Markers
Similarly, many TGD youth may also decide to change their gender markers on legal documents to match their gender identity rather than their gender assigned at birth. A recent study found that legal gender marker changes have been associated with improved mental health and fewer negative emotional responses to gender-based mistreatment amongst the TGD youth population [44]. The process often involves several forms of documentation, including a birth certificate, social security card, driver’s license, physician’s letter, documentation of residence, and an assigned court order and hearing led by a judge. As laws to change gender markers also vary state by state, it is prudent to be aware of laws within the state where you are practicing medicine, to best guide your patients. While many states are not stringent about prerequisites prior to changing gender markers, some states require proof that patients have undergone gender affirming surgery prior to changing one’s gender on their birth certificate. Once gender marker changes are approved, patients should also prepare to dedicate time updating related documents, including passports, driver’s licenses, social security, bank accounts.
Individuals who do not identify as a binary gender may also consider changing their gender marker to “X”, to signify a non-binary/agender or undisclosed gender. When counseling patients interested in making this change, patients should be aware that some countries do not recognize the “X” gender marker and it may make traveling challenging outside of the United States.
Family supports
For many TGD youth, the degree of family support plays a crucial impact on the development of health and well-being. While some parents may believe that restricting gender identity exploration in TGD youth may help them fit in with cisgender peers, TGD youth may in fact view this restriction as a rejection of their entire identity. Research has shown just how impactful family behavior and attitudes can be for TGD youth in multiple domains, including self-worth, mental health, self-esteem, and risk-taking behaviors. In a study conducted by the Family Acceptance Project (FAP), researchers found that TGD youth from families who are not affirming of their identity are at higher risk of negative mental health sequelae, including depression, substance use, risk taking behaviors, and health risks such as contracting sexually transmitted infections [48]. Perhaps of most concern is that TGD youth without family acceptance are at significantly higher risk of attempting suicide, compared to TGD youth with highly accepting families [48].
On the contrary, families that supported TGD youth identity exploration were found to be protective against developing depressive disorders, substance use, and risk taking behaviors [49].
Engaging in family therapy can also play an important role in improving family cohesion and acceptance of TGD youth. There are several resources listed in the resource section at the end of this paper that can provide support and guidance for families of TGD youth. Specific resources from FAP help guide families to be supportive of their TGD youth and avoid stigmatizing language. The FAP approach attempts to cut across belief systems and stigma to focus on shared values, such as love, family connections, and desire for offspring to live a healthy, happy life. Additionally, family support groups can be helpful for family members to process their experiences and connect with a larger community of individuals who can relate. PFLAG is an organization that offers support groups specific to families of TGD youth as they may have needs that are distinct from sexual minority youth [50].
Impact of policy/law on mental health
In recent years, the creation of state legislation banning transgender care has sparked debate and concern throughout the country. Many of these bills directly impact TGD youth by restricting access to gender affirming healthcare and limiting LGBTQ+ material, content, and education from schools. The impacts of discriminatory social policies and laws can yield harmful consequences on TGD youths’ mental health. Data from studies on the impact of same-sex marriage bans has been shown to directly relate to adverse mental health outcomes in LGBTQ+ youth [45]. A recent survey of TGD youth and young adults across the United States found that upwards of 86% of TGD youth felt that anti-transgender policies and bills negatively impacted their mental health [46]. Specifically, TGD youth reported higher rates of anti-trans discrimination, cyberbullying, and strained family relationships as a result of anti-LGBTQ bills [46]. While the direct impacts of bills restricting gender affirming care for TGD youth vary significantly across state lines, the impacts of anti-trans legislation leads to broader impacts of discr.
While some states have enacted bills to restrict access and care for TGD youth, it is important to note that other states have enacted legislation to specifically protect the rights and care for TGD youth. For instance, recent legislation in certain states, geared towards protecting TGD youth, included requirements to incorporate LGBTQ+ awareness into school curricula. Another bill instituted in some states requires the board of education of every school district to establish policies and procedures related to the treatment of transgender and gender non-confirming youth in schools [46].
Other important legislation, known as “shield” or “refuge” laws, have been enacted in certain states across the country to safeguard TGD youth and families when accessing gender affirming care, as well as providing protection for their medical providers. For example, “shield” laws can be protective if a transgender patient travels from a state where transgender healthcare is banned, by protecting the patient and healthcare provider against legal actions from the state where healthcare is banned. As new legislation impacting gender affirming care is frequently enacted, it is important for healthcare professionals to remain up to date on the most recent laws. Several organizations actively update newly enacted bills in the United States, organized by state. The resource section of this paper lists several resources for healthcare professionals to access, to remain up to date on the latest legislation.
Community supports
Community resources can be vital supports for TGD youth. Communities can provide safe spaces, access to resources, and opportunities to commune with other transgender youth and allies. The resources available in individual communities vary widely, and are often influenced by community demographics such as region, size,political climate, degree and type of religious affiliations, and visibility of LGBT individuals and families among others. Various organizations have collated national, state, and local resources available to transgender youth and their families [62-64].
When resources are lacking, or the general environment is discriminatory, transgender youth often suffer. Research from The Trevor Project emphasizes the importance of affirming spaces for TGD youth by outlining the impacts that such spaces can have on their mental health. Strikingly, research has found that queer and TGD youth consistently report lower rates of suicide attempts when they have access to LGBTQaffirming spaces [66]. The importance of preserving access to genderaffirming spaces and care for TGD youth across the country can therefore be a matter of life and death for many youth in this vulnerable population. Data suggests that campaigns supporting discriminatory laws against sexual and gender minority individuals may lead to increased rates of harassment for these minorities in addition to the psychological burden of being in an openly marginalized group [67].
Affirming spaces in the community can support many needs for transgender youth. Community centers dedicated to LGBTQ+ individuals often provide an array of resources, such as: lists of medical providers, shelter, transitional living programs, employment support, and therapy services. These centers provide a safe social space for transgender youth to connect with one another. Formal programing such as conferences, workshops, or even school advocacy may also be available in these centers [68].
Community events such as Pride festivals with targeted programming for youth can provide a space for queer youth to commune, increase visibility, support one another, focus on positive aspects of their shared identities, and foster resiliency [69].
Other communal spaces include LGBTQ+ or even transgender-specific summer camps. Such programs have been shown to increase resiliency in these youth and promote a positive outlook about the future [70]. Affirming and inclusive symbols such as pride flags, transgender flags, or safe space posters can help transgender youth feel safer and more supported in their communities. These symbols often direct transgender youth to supportive individuals or resources such as teachers, doctor’s offices, or community businesses [71].
When resources are limited in a particular community, transgender youth often turn to online spaces for a sense of community and support. Transgender youth spend more time online than cisgender peers and report being more “out” online than in person [72]. These youth often seek sexual health and behavior information online, or use online spaces to learn about LGBTQ+ and their own identities [73]. In the absence of local resources, these online spaces can provide much needed support for TGD youth.
DISCUSSION AND CONCLUSION
In the present day, gender affirming care for TGD youth remains both vital and exceedingly relevant. Though a tremendous amount of social progress has been made to support LGBTQ communities over the past several decades, evolving legislation across the United States has become increasingly restrictive of gender-affirming medical care. In addition, the youth mental health crisis sweeping the United States has brought attention to sharp rises in depression and suicidality in youth throughout the nation. As youth mental health resources are often limited, even in well-resourced areas, it remains exceedingly important for healthcare professionals to be aware of ways to best provide comprehensive care for TGD youth.
While many of the principles discussed in this paper reference specific interventions to support TGD youth, several of these psychosocial supports can also be universally applied to all youth struggling with normative aspects of identity development and personal growth. Notably, it is paramount to highlight that evidence has shown that gender affirming care for TGD youth improves mental health, physical health, and most importantly, saves lives. As such, healthcare professionals should pay special consideration to optimizing family support, school support, and youth mental health. With an expanding body of evidence supporting the standards of care for TGD youth, staying up to date on best practices and standards of care to support TGD youth remains a crucial part of providing quality care for TGD patients. Although increasingly restrictive laws limiting gender affirming medical care forTGD youth are being enacted across the United States, clinicians should not find themselves discouraged, and feel empowered by the many ways for providers to support TGD youth. [table]
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Summary: Supporting TGD Youth |
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Social Transition |
Methods outlined to support social transitions in TGD youth include name change, chest binding, tucking, wearing gaffs, laser hair removal, voice coaching. |
Providers should be aware of ways to support legal changes for gender diverse patients, which can include resources for name changes, changing gender markers, and updating legal documents. |
Clinicians are recommended to follow WPATH guidelines for gender affirming interventions when available. |
Efforts to change gender identity (conversion therapy) have been found to be ineffective and potentially harmful. |
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Mental Health |
Mental health practitioners provide comprehensive assessments and capacity evaluations for patients seeking gender affirming care. |
Gold standard and concurrent treatment of mental health disorders - including a combination of therapy and medication. |
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Medical Care |
Clinicians are recommended to follow WPATH guidelines for gender affirming interventions in locations where they are available. |
Multidisciplinary and collaborative care is recommended to best support the dynamic and multifaceted needs of this population as outlined in WPATH. |
|
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Family |
Supportive families reduce negative mental health outcomes in TGD youth. |
Resources can help families understand their child better and be more effective in their support. Family Acceptance Project, PFLAG, family therapy, etc. (see resources section). |
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Schools |
Gender Sexuality Alliances, inclusive curricula, and comprehensive sexual education improve health and educational outcomes for TGD youth. |
Gender affirming policies: use of affirming names/pronouns, access to affirming bathrooms, and non-discrimination policies in extra-curricular activities. |
Anti-bullying and anti- harassment policies that enumerate protections for LGBTQ+ youth are more effective than broader policies. |
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Communities |
Community centers can provide community support, temporary shelter, housing, employment support, and therapy services. |
Community events/supports: Pride festivals, summer camps, visible signs of TGD support. |
Online spaces often provide support for TGD youth in less affirming communities. |
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Glossary
• Coming out: A phrase used to refer to the process of LGBTQ self-disclosure of gender identity, sexual orientation, and/or romantic attraction
• Gender: The social, psychological, cultural and behavioral construct of being a man, woman, or other gender identity
• Sex: Biological descriptor based on reproductive, hormonal, anatomical, and genetic characteristics
• Sexual orientation: An inherent enduring emotional, romantic or sexual attraction to other people
• Gender identity: A person’s internal and innate sense of their own gender
• Gender dysphoria: A severe psychological state of distress related to one’s gender identity not aligning with their gender assigned at birth
• Gender binary: The concept that gender is categorized into only two distinct, opposite categories of male or female
• Gender expansive identities: The concept gender identities exist between or outside of gender binary, including, but not limited to, identities such as genderfluid, genderqueer, gender non-conforming, non-binary, agender
• Queer: An umbrella term to categorize folks who do not identify as cisgender/heterosexual. This term was initially used pejoratively towards LGBTQ populations but in recent years has been reclaimed as a neutral/positive selfidentification
• LGBTQIA+: An evolving acronym which stands for lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and other identities that individual use to describe their sexual orientations and gender identities
• Assigned Female at Birth (AFAB)/Assigned Male at Birth (AMAB): Refers to the biological sex that is assigned to an infant, most often based on the infant anatomy
• Transgender and Gender Diverse (TGD) youth: An umbrella term for children and adolescents whose gender identity does not align with sex assigned at birth. These youth may identify with a gender or genders outside of the gender binary
Schools
School environments have a major impact on the overall wellbeing of youth. This is especially true for transgender students whose experiences at school can either be supportive or actively stigmatizing depending on the climate of the school. School connectedness is described as meaningful engagement in school activities and formation of caring relationships at school [51]. When levels of school connectedness are higher, LGBTQ students perform better academically and report lower levels of suicidal ideation [52,53]. School policies and characteristics that promote inclusion and protection of transgender youth are discussed here.
on LGBTQ related topics, providing emotional support, and working to create a more affirming school environment. Data consistently shows that GSAs can mitigate some of the risk of a hostile school climate [54], with participation in a GSA associated with higher connectedness to the school community among LGBTQ students [55]. GSAs can have a broader impact on school climate given that rates of victimization of LGBTQ youth were found to be lower in schools with a GSA [56].
Additionally, the benefits of GSAs can extend into young adulthood as data indicates that LGBTQ youth from schools with GSAs were more likely to obtain a college education [57]. Identifying whether or not a school has a GSA and encouraging transgender youth to participate, if present, can positively impact these student’s sense of safety and connectedness in the school. If a GSA is not present in a school, it is possible to promote the creation of such a group. The right to assemble a GSA has been upheld in multiple court cases where GSA assembly was initially denied by various school districts in the United States [58,59].
Inclusion of transgender identities in school curriculum and sexual education that includes information for gender and sexual minority students also leads to a more supportive school environment for transgender youth. Benefits of inclusive curricula include decreased victimization in schools [60], as well as higher grade point averages and increased likelihood to pursue higher education among transgender students [61]. Some organizations have developed inclusive curricula for various ages and developmental levels that can be easily obtained and implemented in schools (see Appendix).
Gender affirming school policies help to create an inclusive environment for transgender students. Such policies include: Use of affirmed names and pronouns, access to gender affirming or gender neutral bathrooms, ability to change name on official school documents, and participation in affirming gendered extra-curricular activities [61].
Evidence shows that anti-bullying and anti-harassment policies that enumerate protections for LGBTQ students are more effective at protecting these youth. Teachers who received training on LGBTQ student issues were more effective at intervening when observing bullying or harassment of these students. Policies such as these have been associated with lower levels of victimization and absenteeism in transgender students [60]. The resource section at the end of this paper has more detailed guidelines from the State Education department for educators and schools.
In addition to understanding gender identity and challenges that TGD youth may face in the classroom, this guide outlines policies for creating safe spaces in the school setting and helpful procedures for updating school records for TGD youth who may change their names and gender identities. Connection to affirming adults and spaces in schools can reduce risk and promote school connectedness for transgender youth. Knowing state laws and the availability of supportive resources in local schools can help parents and clinicians advocate for these resources. Many organizations provide resources to educate school leadership by highlighting negative outcomes associated with school victimization and describe policies that promote safety and inclusivity for all students [62-64]. Clinicians can support families by suggesting these resources as a foundation for advocating in school settings [65].
REFERENCES
37. Achille C, Taggart T, Eaton NR, Osipoff J, Tafuri K, Lane A, et al. Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: Preliminary results. International Journal of Pediatric Endocrinology. 2020; 2020: 1-5.
42. Hill BJ, Crosby R, Bouris A, Brown R, Bak T, Rosentel K, et al. Exploring transgender legal name change as a potential structural intervention for mitigating social determinants of health among transgender women of color. Sex Res Soc Policy. 2018; 15: 25-33.
52. Blum RW. A case for school connectedness. Educational Leadership. 2005; 62: 16–20.
63. Lambda Legal Resource List.
64. National Center for Transgender Equality Resource List.
66. The Trevor Project. 2023 U.S National Survey on the Mental Health of LGBTQ Young People. 2023.
Citation
Johnson B , Frankel J (2024) Gender Affirming Psychosocial In terventions for Transgender and Gender Diverse Youth (In an Era of Gen der Affirming Care Bans). SM J Psychiatry Ment Health 6: 8.