Presented by:

Lisa Richards and Rachel Watkins

Bullying and depression among

transgender youth

Agenda

• Questions to think about

• Introduction

• Definitions

• Bullying and Depression

• Effects of Bullying

• Clinical Applications

• References

Questions to think about:

• How might you treat a transgender youth presenting with depressive symptoms differently than a cisgender youth suffering from the same?

• How might anti-transgender bullying and harassment affect a trans youth differently than other types of bullying against cis youth?

• What are at least two things that you would want to be mindful of when working with a transgender child or adolescent? Why would this be important? Would you change anything about your approach if you were working with a child versus an adolescent?

Introduction

According to Lombardi, Wilchins, Priesing, and Malouf

(2001), over half of their sample reported experiencing

violence or harassment in their lifetime. Russell, Ryan,

Toomey, Diaz, and Sanchez (2011) found that school

bullying among the LGBT community as a whole is a

public health problem. Bullying is a relevant issue for

this population and we must find ways to advocate for

them in order to increase their safety. This presentation

will discuss the negative impacts of bullying as well as

clinical applications for this population.

Definitions

• Transgender: umbrella term that means to cross gender lines. (Gibson & Catlin, 2010)

• Cisgender: not transgender, that is, having a gender identity or gender role that society considers appropriate for the sex one was assigned at birth. (urban dictionary)

• Bullying: a form of aggressive behavior in which someone intentionally and repeatedly causes another person injury or discomfort. Bullying can take the form of physical contact, words or more subtle actions. The bullied individual typically has trouble defending him or herself and does nothing to “cause” the bullying. (APA)

Transgender Youth

• Important phase of development

• Previously suppressed (by self or parents), gender expression emerges

• Some adolescents acknowledge that they are transgender, some need help understanding their feelings

• Gender-related stress often results in depression, self-neglect, and self-destructive behavior

• Puberty• Urgency to decide whether or not to stop pubescent process with

puberty blockers (possibly followed later by hormone therapy)

• Adolescents may be at risk of self-mutilation in rejection of the genitals with which they were born (Swann & Herbert, 1999)

Bullying and Violence

Statistics of BullyingAccording to the Center for Transgender Equality:

More than 4 out of 5 transgender youth (82%) reported that they felt unsafe at school because of who they were.

Nearly 9 out of 10 reported experiencing transphobic or homophobic harassment from peers, and most reported that it happened “often” or “frequently.”

A majority of transgender students said they had been shoved, pushed, or otherwise physically harassed at school in the last year.

Nearly half (44%) of transgender students said they’ve been punched, kicked, or injured with a weapon on at least one occasion in the last year.

76% reported that they had experienced unwanted sexual remarks or touching from peers.

Large majorities reported both cyberbullying (62%) and the theft or destruction of their property (67%) by peers.

http://www.transequality.org/PDFs/US%20Civ%20Rts%20Commn%20NCTE%20statement%205%206%2011.pdf

Source: National Center for Transgender Equality, 2011

Transgender experiences with

violence and discrimination

Lombardi, Wilchins, Priesing, and Malouf (2001)

Results:

Over half of the sample had experienced verbal

harassment for being transgender at one point in

their lives

59.5% reported experiencing either violence or

harassment (26.6% experienced violence, 37.1%

experienced harassment)

14% reported being raped or someone attempted to

rape them at some point in their lives

47% were assaulted in some way in their lives

LGBT Adolescent School

VictimizationAlthough this study includes LGB folks, I feel it contributes to this presentation.

Russell et al., (2011)

Females reported less victimization when compared with males and transgender youth

Participants who identify as queer reported more victimization when compared with LGB participants

LGBT youth who reported high victimization were 2.6 times more likely to report depressive symptoms and 5.6 times more likely to report having attempted suicide at least once, and having a suicide that required medical attention

Participants who reported high levels of victimization were more than twice as likely to report having an STD diagnosis and to have been at risk for HIV

Parental ReactionsGrossman, D’Augelli, and Frank (2010)

Participants: 31 MTF and 24 FTM youth between the ages of 15 and 21

54.5% classified their mothers’ first reaction as negative or very negative, 62.9% classified their fathers’ first reaction similarly

At the time of study, approximately 3 years had passed since the initial disclosure. 50% of youth continued to describe their mothers’ reactions as negative or very negative, 44.4% classified their father’s reactions similarly

Effects of Bullying(from parents and the school)

Stress in Female-Identified

Transgender YouthIgnatavicius (2013)

• Parental Support (or lack there of)

- Parents react to a child’s gender nonconforming behavior most commonly with anxiety, grief, confusion, or anger.

- A lack of parent support has been shown to have profound effects on transgender youth- Feelings of failure or disappointment, negative self-image, risk-

taking behaviors, anxiety, PTSD, hypervigilance and depression

- 3x higher suicidal rates for transgender youth without parental support compared to those with parental support

• Depression and Suicide

- Study found that 20% of transgender youth meet the criteria for major depressive disorder

- Youth of color tend to experience a greater level of depression

- Transgender youth with depression, low self-esteem, and under the age of 25 who were subjected to discrimination, verbal abuse, and physical abuse are more likely to attempt suicide

- 45% of participants in study attempted suicide at least once

Family Rejection, Social Isolation, and

Loneliness as Predictors of Negative Health

Yadegarfard (2014)

260 respondents; 129 self identified as transgender and 131 were self identified as cisgender

The transgender participants reported significantly higher rates of family rejection, lower social support, higher loneliness, higher depression, lower protective factors and higher negative risk factors related to suicidal behavior, and were less certain in avoiding sexual risk behaviors

For both transgender and cisgender participants, their experience of loneliness was the most common predictor of their levels of depression, suicidal thinking, and certainty in avoiding sexual risk behaviors

Clinical Applications

“Clinicians should be agents of change

when it comes to helping families rear

differently gendered children and

assisting schools to integrate such

children and prevent peer aggression.”

(Lev, 2004, p. 334)

Clinical Areas of Focus

Affirmation & validation

Family rejection/acceptance

Social isolation & loneliness

Advocacy & support

Areas of competency for working

with transgender youth

Comprehensive knowledge of treatment guidelines, protocols, and procedures as they relate to the effective treatment of transgender youth

Knowledge about community resources available

Willingness to advocate for client and family

Continued education on contemporary research, literature, and social issues around transgender issues

Strong sense of awareness of feelings, beliefs, and values about gender diversity

(Bernal & Coolhart, 2012)

Affirmation & Support

Lev’s (2004) Supportive Psychotherapy Model for working w/ trans youth & their families:

Psychoeducation: provide information and education on gender diversity and transgender issues to trans youth and their family members

Resources: provide community resources and referrals to reduce individual and family isolation

Advocacy: act as an advocate for the youth and their families in school and legal settings

Boundaries: appropriate boundaries and limits should be developed and encouraged

“The focus is not on changing the child, but helping him or her adapt to the constraints of a gendered culture, while simultaneously working to change the social system that encourages the abuse.” (Lev, 2004, p.

346)

Supporting gender expression

Clinician can balance negative messages by providing positive, affirmative messages around gender diversity

Asking and using a client’s preferred pronouns and chosen name Modeling this for parents/family members and

explain the importance

Can invite the youth to use the therapy room as a space to fully express gender (i.e. allowing affirmative clothing, behaviors, etc.)

(Coolhart, 2012)

Enhancing Resilience

Resilience: the capacity to cope with adversity, stress, and other negative events as well as the capacity to avoid psychological problems while experiencing difficult circumstances (p. 105)

May serve as a protective factor for transgender youth

Predictive components: Sense of personal mastery Self-esteem Social support Coping skills

Interventions targeting these variables may enhance resiliency

(Grossman, D’Augelli, & Frank, 2010)

Treating Depression Must be sensitive to the role of social stigmatization,

discrimination, and victimization in client’s presenting symptomatology

CBT interventions (Buendia Productions, 2005): Cognitive triad through a social influence lens: Explore what

growing up and living in a heterosexist and homophobic environment has taught the client about themself, others, and the world

Negative automatic thoughts (i.e. internalized transphobia): Identify, evaluate, and reframe negative messages about oneself as positive & affirming

Core beliefs: Challenge a client’s negative core beliefs (i.e. “there’s something wrong with me”) by pointing out exceptions, and suggesting that rather than seeing them as exceptions, maybe the core beliefs need to be reconsidered

Involving the Family Research suggests that trans youth w/ more accepting and

supportive parents/family may have better mental and physical health outcomes (Ryan, Huebner, Diaz, & Sanchez, 2009)

Framing the struggle:

“Families of gender non-conforming children need to negotiate the interactions between two gender systems: a rigid gender binary imported from familial, social, and cultural experiences and a fluid gender spectrum articulated by their child.” (Malpas, 2011, p. 453)

Key tasks in family therapy (Coolhart, 2012):

supporting and affirming gender non-conformity

educating parents/family members and supporting their process

exploring transition options

advocacy in schools

connecting the family with outside resources

being a trans-affirmative clinician

Multi-Dimensional Family Approach

(MDFA)

Components (Malpas, 2011): (1) Parental engagement and education

During initial session w/ parents, important to inquire about their responses to the atypical journey of their child

Clinicians should clarify their position on gender non-conformity as a normal human expression

Helpful to review the difference between sex, gender, and sexual orientation

Emphasize the importance of parents’ roles in their ability to find collaborative ways to nurture their children and to affirm their choices

(2) Individual assessment and child therapy Aim to create a space where children and their subjectivity can

be seen more fully; important to hear the account directly from the child

Should include conversations about comfort in school and potential instances of bullying and teasing

MDFA (cont) (3) Parental coaching

Empower parents to be a resource for their child

Help parents identify ways in which gender non-conformity resonates in their lives (meaning-making)

Facilitate resolution of marital and parental discord around the issue of gender non-conformity

Support parents in making difficult decisions (i.e. social transition)

(4) Systemic family therapy Support a positive and functional family climate where parents can

attune to the gender identity of their child and where children can respect the limits set by their parents

Repair the relational bond between parents and child when it has been eroded by the conflict surrounding the gender non-conformity

Mobilize family resilience and collaborative problem solving skills to negotiate gender expression at home and in the social world

(5) Parent support group Provides a sense of community and access to peers going through a

similar journey

Provides processing space where information and reflections on their own experiences can be shared

Affirming Youth and Parents

One of the major goals in working w/ families of

trans youth is to move from “either/or” to

“both/and” (p. 457)

Youth can both affirm their identity and understand

the demands of a world mostly organized the rigid

gender binary

Parents can both nurture their child’s singularity and

operate as mediator between the child’s wish and

the social reality

(Malpas, 2011)

Parents

May need to be met with separately at first

Initial focus on supporting their process

Provide validation and normalization for varied emotions

Examine their reactions and beliefs and where they

come from

Explain how society reinforces rigid rules around gender,

making gender non-conformity difficult to tolerate

Explore other cultural factors that may be barriers to

acceptance (i.e. religion, ethnicity)

Identify related beliefs or values that may support

acceptance (i.e. importance of family or unconditional love)

(Coolhart, 2012)

Parents

Can serve as a buffer for discrimination and

bullying in other contexts, like school (Espelage et al.,

2008)

Parental support was found to be significantly

associated w/ higher life satisfaction, lower

perceived burden of being transgender, and fewer

depressive symptoms (Simons, et al., 2013)

Interventions that promote parental support may

significantly affect the mental health of trans youth

Parents

Help parents develop scripts for talking to others about their child Extended family, school, neighbors, parents of peers, etc.

Vow of Parental Acceptance (Brill & Pepper, 2008)

1. Speak positively about my child to them and to others about them.

2. Take an active stance against discrimination. 3. Make positive comments about gender diversity. 4. Work with schools and other institutions to make these places

safer for gender variant, transgender, and all children. 5. Find gender variant friends and create our own community. 6. Express admiration for my child’s identity and expression,

whatever direction that may take. 7. Volunteer for gender organizations to learn more and to further

the understanding of others. 8. Believe my child can have a happy future.

Exploring Transition Options Psychotherapy alone has it’s limits for many transgendered

teens, and transition options may need to be explored Nonmedical transition: clothing, hairstyle, preferred name &

pronouns, body language & behaviors, etc.

Hormone blockers to delay puberty – may reduce psychological distress

Initiation of hormones

Benefits of early transition (Lev, 2004): Avoiding the development of secondary sex characteristics that

would require medical procedures during adulthood

Avoiding the development of a false gender identity and expression that feels inauthentic

Prevention of many of the struggles of coping with gender dysphoria that can contribute to various mental health issues like depression, suicidality, and and substance abuse

Important to provide psychoeducation to youth and families about their options and associated benefits and risks

Advocacy in Schools “Transgender youth are often functioning within

systems (such as school) that do not fully support or

understand their transgender identity; therapists can

help advocate and educate within these systems so

their clients may be treated with increased care and

consideration.” (Bernal & Coolhart, 2012, p. 293)

Can help guide and support parents in advocating on

their child’s behalf within the school system

Clinicians can facilitate a meeting with school principals

and other key school personnel

“Attending school was reported to be the most

traumatic aspect of growing up.” (Grossman & D’Augelli, 2006,

p. 122)

“It is not enough to provide competent

psychotherapeutic services, but is

incumbent on the clinicians to serve as

an advocate in addressing systemic and

macrolevel policies that interfere with

the child’s safety.”

(Lev, 2004, p. 345)

Advocacy in Schools (cont)

Can include: The use of preferred name & pronouns Updating policies and forms Providing training and education for students, staff, & parents Adopting zero-tolerance policy for discrimination and bullying

that includes gender Allowing youth to use bathrooms, locker rooms, dress codes,

and gym activities that are congruent w/ affirmed gender

Clinicians can write a letter of support for their client (examples found in Brill & Pepper, 2008)

May increase feelings of support from parents, enhancing therapeutic alliance

(Coolhart, 2012)

“A child’s experience at school can significantly enhance or undermine their sense of self. Furthermore, children need to feel emotionally safe in order to learn effectively. A welcoming and supportive school where bullying and teasing is not permitted and children are actively taught to respect and celebrate difference is the ideal environment for all children. This is especially true for gender-variant and transgender children, who frequently are the targets of teasing and bullying. A child cannot feel emotionally safe, and will most likely experience problems in learning, if they regularly experience discrimination at school.”

(Brill & Pepper, 2008, p. 153-154)

GSAs: Offsetting Risks & Providing

Support

Gay-straight alliances (GSAs) are student led, school-based clubs whose goals involve improving the school climate for LGBT youth and educating the school community about sexual and gender minority issues (GLSEN, 2007)

Can be a place for LGBT youth to spend time w/peers and may increase social support

May contribute to a safer atmosphere for LGBT youth by sending a message that hate speech and victimization will not be tolerated

Schools w/ GSAs may be viewed as a place where LGBT youth feel they belong and are supported

May help LGBT youth identify supportive teachers and staff, which may positively impact academic achievement and experiences

GSAs (cont)

Youth who attended a high school w/ a GSA report significantly more positive outcomes related to school experiences, alcohol use, and psychological distress (Heck, Flentje, & Cochran, 2011)

Youth w/ GSAs had lower scores on depression inventory than youth w/o GSAs

GSAs may provide a space where straight youth can become educated about LGBT issues Can strengthen straight allies

Study found that youth-led interventions in peer networks might be effective in diminishing transphobic bullying (Wernick, Kulick, & Inglehart, 2014)

LGBT Resources in Schools

GSAs, teachers supportive of LGBT youth, and LGBT-inclusive curricula were related to lower levels of victimization based on sexual orientation and gender expression Positive effects of GSAs found to be stronger for

trans students than cis LGB students

Youth in schools with a comprehensive anti-bullying policy were found to be victimized as often as those in schools without such a policy

Less focused on prevention

(Greytak, Kosciw, & Boesen, 2013)

School Psychologists

Recommendations for how to improve the school climate for LGBT students: establishing and publicizing an anti-bullying policy that is

inclusive of sexual orientation, gender, and gender identity

training teachers to recognize and intervene when students engage in homophobic or transphobic behaviors

supporting the establishment of GSAs or similar student organizations

integrate information about sexual orientation and gender identity into educational curricula and discussions of diversity

(Russell, McGuire, Laub, & Manke, 2006)

Safety Precautions

Brill and Pepper (2008) recommend that

transgender teenagers carry a letter from their

doctor or therapist explaining that they are

transgender

A letter can be helpful if an encounter with the police

occurs. There have been situations where police officers

have spread the status of a child’s transgender gender

identity

The letter should include the importance and need for

sensitivity and privacy around their gender identity

Further recommendation: Make a letter into a wallet size

card and laminate it to carry with them

Case Example #1

“I felt very unsafe . . . and me being a double minority, I felt really uncomfortable having to go to school, being called names, being picked on verbally, physically sometimes . . . I left school in my second year, in tenth grade. I left because I literally had to fight my way through school, and I said, you know what? If I have to receive an education this way, I’ll just do it another manner, you know?” Anwar, identifies as a male living a female lifestyle

(Sausa, 2005, p. 19)

Case Example #2

“I was constantly running from people, because everybody wanted to fight me for some reason. I’d get off the school bus and somebody would come after me, and I would run . . . Every single day that I was in school something was thrown at me in the lunchroom . . . I can never remember a time where someone actually stopped someone from doing things, or took them aside and hugged me or nothing. No one ever, ever gave me support or nurturing . . .” Phoenix, assigned male at birth who identifies as a drag

queen

(Sausa, 2005, p. 20)

Case Example #3

“I failed gym because of that (harassment). Every

year, every semester, I failed gym. I didn’t take

gym because of the locker room, because I would

not go in the locker room. I didn’t do any sports in

high school because I would not go in that locker

room.”

Aidan, identifies as a feminine male

(Sausa, 2005, p. 21)

Resources Important to provide resources for youth and parents/family

Can help reduce loneliness for youth, a major predictive factor of depression

Support groups (i.e. PFLAG, group therapy) Can be validating to hear the stories of other families w/ trans youth

Can give youth a space to gain support while offering parents the space to talk openly

Bibliotherapy: The Transgender Child: A Handbook for Professionals and Families

(Brill & Pepper, 2008) Beyond Magenta: Transgender Teens Speak Out (Kuklin, 2014)

Be aware of trans-affirmative referral sources for endocrinologists and psychiatrists

Provide youth-oriented literature containing LGBT-inclusive information about HIV/AIDS and safe sex

Provide phone numbers for youth-support hotlines

References

• Brill, S., & Pepper, R. (2008). The Transgender Child: A handbook for families and professionals. San Francisco:Cleis Press, Inc.

(64-71).

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