Clinician competencies: Strengths and limitations for work with transgender and gender non-conforming (TGNC) clients

Individuals who identify as transgender or gender nonconforming (TGNC) face a number of health disparities compared to individuals who identify as cisgender (those who self-identify with the sex they were assigned at birth). For example, TGNC individuals experience heightened rates of clinical depression, anxiety, general psychological distress, suicidal ideation, and suicide attempts. Despite these troubling disparities, many TGNC individuals report hesitance to seek mental health services due to concerns regarding culturally insensitive or even overtly discriminatory services from providers. In addition to decreasing service utilization among TGNC populations, discriminatory services impair intervention effectiveness even when TGNC individuals persist in seeking mental health services. The American Psychological Association (APA) and the World Professional Association for Transgender Health (WPATH) provide guidelines for culturally competent work with TGNC clients; however, research indicates a profound lack of TGNC-specific training and resources among mental health care providers. To address this gap, the present investigation utilized a mixed-method design to assess training experiences, understanding of terminology, and TGNC competence among mental health care providers at various training levels. Participants were current mental health clinicians across the United States. Implications for improving reported and demonstrated weaknesses are discussed.     

How well do various types of support buffer psychological distress among transgender and gender nonconforming students?

Background: Transgender and gender nonconforming (TGNC) individuals experience an increased prevalence of many psychological disorders, leading many to reach out for support from family, friends, mental health professionals, and religious or community networks. Nonetheless, experiences seeking support are often negative, and many psychotherapists report feeling underprepared to work with TGNC clients. To better understand the experiences of TGNC individuals and better equip psychotherapists in their work with TGNC clients, we investigate which sources of support most successfully buffer psychological distress among TGNC individuals.

Aims: This study aims to identify differences in levels of various types of support (social, family, religious, and living-situation) between cisgender and TGNC individuals and examine how these types of support may or may not buffer psychological distress among TGNC individuals.

Method: We used a United States national sample of 3,090 students (1,030 cisgender men; 1,030 cisgender women; 349 transgender; 681 endorsing another gender identity) from the Center for Collegiate Mental Health 2012–2015 database which provided basic demographic information through the Standardized Data Set. Psychological distress was measured through the Counseling Center Assessment of Psychological Symptoms 34-item questionnaire.

Results: TGNC individuals reported more distress, less family support, more social support, and less frequent religious affiliation than cisgender men and women. Family and social support emerged as the strongest predictors of distress for both TGNC and cisgender individuals. Though religious affiliation and living on-campus buffered distress among cisgender students, they did not buffer distress among TGNC students.

Conclusion: Our study highlights disparities in distress and support between TGNC and cisgender individuals. We found that although religious affiliation and on-campus living are beneficial for cisgender students, neither systematically buffers distress for TGNC students. These findings illustrate the impact minority stress and systemic discrimination may have on TGNC individuals and provide suggestions for therapeutic intervention in work with TGNC individuals.     

Law enforcement and criminal justice personnel interactions with transgender people in the United States: A literature review

This literature review examines research exploring the interactions between transgender people and law enforcement and criminal justice (LECJ) personnel in the U.S. to better understand the experiences of transgender people who come into contact with the criminal justice system. A search of existing academic literature, public health reports, and advocacy group publications revealed 33 studies that contained information about transgender people's interactions with LECJ personnel. Results highlight how large percentages of transgender people experience arrest and incarceration, unjustified stops and arrest, disrespect and poor case handling, and abuse and violence from LECJ personnel while in their communities. Large percentages of transgender people in institutional settings also reported abuse committed by criminal justice personnel, including harassment, assault, and a lack of protection from other inmates. This review also highlights evidence of discriminatory and abusive treatment when transgender victims seek assistance from the legal system. Taken together, this study suggests a need for further work to de-stigmatize the legal and criminal justice systems.     

Transitioning Between Systems of Care: Missed Opportunities for Engaging Adults with Serious Mental Illness and Criminal Justice Involvement

Individuals with serious mental illness are overrepresented in the criminal justice system and face difficulties accessing mental health services both during incarceration and upon re‐entry into the community. This study examines how such individuals describe their experiences receiving care both during and after their time in custody and explores the perspectives of mental health service providers who treat this population upon re‐entry. Semi‐structured interviews were conducted with 43 individuals identified as having a history of serious mental illness and criminal justice involvement, as well as with 25 providers who have worked with this population. Clients noted the stress of transitioning to criminal justice settings, the uneven availability of services within jail and prison, and the significant challenges faced upon re‐entry. Providers reported barriers to working with this population, including minimal coordination with the criminal justice system and challenging behaviors and attitudes on the part of both clients and providers. Findings identify potential target areas for improved care coordination as well as for additional provider education regarding the unique needs of this population. Copyright © 2013 John Wiley & Sons, Ltd.     

The Counseling Experiences of Transgender and Gender Nonconforming Clients

The counseling experiences of 13 transgender and gender nonconforming (TGNC) individuals were examined via semistructured, in‐depth interviews. Using multiple standards of trustworthiness (e.g., member checking, negative case analysis), the authors analyzed each interview from an interpretative phenomenological analytic framework. Four main themes were identified: mental health professional selection process, transaffirmative approach, transnegative approach, and support systems beyond counseling. Implications for implementing culturally responsive TGNC affirmative counseling, TGNC sensitive counselor training, and social justice–oriented research are discussed.     

Changes in Jail Inmates’ community connectedness across the period of incarceration

ABSTRACT

Jails bring inmates into proximity with one another and separate them from the community. Because inmates’ connectedness to one another and to the community influences post-release functioning, understanding risk factors for maladaptive shifts in connectedness may inform interventions. The current study examined changes in jail inmates’ (N = 203) connectedness to the community at large and to the criminal community, and predictors of individual differences in changes over time. Connectedness to both communities did not change on average during incarceration, but younger and less guilt-prone inmates increased more in connectedness to the criminal community than older and more guilt-prone inmates, suggesting connectedness interventions should target individuals exhibiting this constellation of attributes.     

First impressions online: The inclusion of transgender and gender nonconforming identities and services in mental healthcare providers' online materials in the USA

Background: When accessing mental healthcare services, transgender and gender nonconforming (TGNC) individuals face systemic barriers to gender-affirmative care. Initial points of contact, like intake forms, may show limited consideration for the heterogeneity of TGNC identities and can lead to negative consequences prior to face-to-face interaction with providers. Aims: The first aim was to mimic a likely pathway a TGNC individual may follow to seek mental healthcare services in the USA and to describe the extent to which they may encounter enacted stigma or affirmative messages that may impede or facilitate access to care. The second aim was to determine if a positive State legal climate for TGNC people was associated with more affirmative provider materials. Methods: Content analysis was used to examine a national sample of websites and intake forms of mental healthcare providers who advertise online as working with TGNC clients. Intake forms were coded for usage of affirmative language in gender/sex questions and including questions for a client's pronouns and preferred name. Websites were coded for mentioning a variety of services or resources for TGNC clients. Results: While provider websites were found through Google searches for a “gender therapist,” only 56.6% of websites stated a provider specialty to work with TGNC clients and 32.1% of websites had no mention of services or resources for TGNC people. Additionally, a significantly larger proportion of intake forms from States with legal protections for TGNC people used affirmative language in gender/sex questions and asked for a client's pronouns than intake forms from States without legal protections. Discussion: Barriers to affirmative healthcare for TGNC people within patient and provider interactions have been identified in previous research and these data show TGNC individuals may face enacted stigma even in their search for a provider, particularly those TGNC people living in States without legal protections.     

Addressing the Challenge of Community Reentry Among Released Inmates with Serious Mental Illness

The purpose of the paper is to discuss the formidable challenges to community reentry and reintegration faced by U.S. prison inmates with serious mental illness and to describe various strategies for improving transitional services for these individuals. We review epidemiologic data supporting the high prevalence of severe mental illness in U.S. prisons as well as the historical factors underlying the criminalization of the mentally ill. The importance and challenges of providing adequate psychiatric care for mentally ill prisoners during their incarceration are discussed. We also review the numerous psychosocial and economic challenges confronting these individuals upon their release from prison, such as unemployment and vulnerability to homelessness, as well as specific barriers they may encounter in attempting to access community-based mental health services. We follow with a discussion of some of the more promising strategies for improving the transition of the mentally ill from prison to the community. In the final sections, we review the evidence for a relationship between serious mental illness and recidivism and briefly discuss emerging alternatives to incarceration of the mentally ill.     

Actuarial risk assessment at sentencing: Potential consequences for mass incarceration and legitimacy

The growing utilization of actuarial risk assessment instruments (RAIs) in the American criminal justice system may potentially lead to more restrained, better-targeted uses of incarceration. However, critics have raised a variety of concerns regarding RAIs and suggested, among other things, that their incorporation into court procedures may tend to dehumanize defendants and exacerbate, rather than alleviate, mass incarceration. In response to such concerns, this article offers recommendations for policy and practice that may help an increasingly risk-focused criminal justice system to achieve decarceration goals – and to do so without undermining its own legitimacy in the eyes of defendants or the public at large. These recommendations are aimed particularly at judges, in their roles as sentencers and makers of courtroom and courthouse policy.     

Trauma Recovery in the Transgender and Gender Diverse Community: Extensions of the Minority Stress Model for Treatment Planning

Transgender and gender diverse (TGD) populations, including those that do not identify with gender binary constructs (man or woman) are increasingly presenting for treatment of posttrauma sequelae. Providers who offer services for trauma survivors including posttraumatic stress disorder (PTSD) treatment should be knowledgeable about evidence-based care and have some cultural familiarity with TGD experiences. Indeed, the Minority Stress Model suggests that the combination of distal and proximal minority stressors can combine to produce increased mental health symptoms as compared with cisgender peers, though this model has yet to be fully tested. Clients often present with a complicated picture of experiences, which include a variety of minority stressors, microaggressions, discrimination, and traumatic events that can all be related to their identity. However, conceptualizations of trauma treatment in the context of extensive minority stress are lacking. This paper summarizes the existing literature and offers guidance to mental health providers who are well positioned to address stigma, discrimination, violence, and related symptoms that arise from micro-, mezzo- and macro-level spheres of TGD individuals’ experience.     

The Experiences of Bystanders of Workplace Ethnic Harassment

The present research examined the experiences of individuals who witnessed or knew about ethnic harassment of their coworkers. Through 3 studies, we found that knowledge of other people's harassment was differentiated from personal experiences as a target and was associated with deleterious occupational, health-related, and psychological consequences beyond those accounted for by direct harassment and affective disposition. Ethnicity and gender did not moderate these relationships. Knowledge of others' ethnic harassment can therefore be construed as bystander harassment. Results also indicated that bystander and direct harassment were relatively common occurrences. Both harassment types contributed to how ethnic conflict is experienced. The consequences of ethnic harassment are not restricted to ethnic minority employees. Rather, everyone is at risk from such behaviors.     

Internalized transphobia: Exploring perceptions of social messages in transgender and gender-nonconforming adults

Background: Transgender and gender nonconforming (TGNC) individuals encounter a variety of minority stressors that have yet to be fully articulated or explored within the research literature. The purpose of this study is to better understand internalized stigma—the experience of accepting and internalizing negative social messages and experiences about one's identity—an underexplored minority stressor for TGNC people.

Method: We conducted in-depth interviews with 30 diverse TGNC participants using consensual qualitative research (CQR) methodology.

Results: Following data saturation and analysis, six distinct themes emerged across participants: (1) TGNC identities are regarded negatively by society; (2) social messages are perceived as originating from the media and religious ideology; (3) TGNC individuals report emotional distress; (4) negative self-perceptions in response to social messages; (5) TGNC individuals report resilience processes in response to negative social messages; and (6) social messages are perceived generally to differentially impact TGNC people of color.

Conclusion: Findings highlight the common experience of encountering social marginalization for TGNC individuals. Structural interventions that target pervasive sociocultural messages regarding TGNC identities are warranted.     

Transgender and gender non-conforming adult preparedness for aging: Concerns for aging,and familiarity with and engagement in planning behaviors

Abstract

Background: Research on transgender and gender-nonconforming (TGNC) aging is limited. To date, most of the literature about TGNC aging has focused on discrimination (particularly in healthcare), violence and abuse, caregiving and family relations, and religiosity.

Aims: The purposes of this study were to: (a) document concerns about aging among TGNC adults, including concerns that are identity-specific; (b) examine preparation for aging and end of life (i.e., familiarity and planning) among TGNC adults; and (c) examine potential differences in familiarity and planning based on gender identity.

Methods: One hundred fifty-four individuals who currently or have ever identified as TGNC completed a national online survey assessing these constructs.

Results: TGNC individuals reported many concerns about aging, both gender identity-specific and not. The most common aging concern was losing the ability to care for themselves followed by having to go into a nursing home or assisted living facility. The age preparatory behaviors individuals were most commonly aware of included: life insurance, wills, organ donation, regular medical checkups, living wills, durable power of attorney for healthcare, and trusts. Gender-nonconforming individuals had significantly more familiarity with age preparatory behaviors than trans feminine individuals, but had lower levels of planning to engage in age preparatory behaviors than both trans masculine and trans feminine individuals.

Conclusion: The current findings highlight the need for providers to address age preparatory behaviors with TGNC individuals or provide referrals to support individuals in this planning.     

Attitudes and perceptions of workers to sexual harassment

The authors investigated how individual factors (age, gender, gender role, past experiences of sexual harassment) and organizational factors (gender ratio, sexual harassment policies, the role of employers) related to workers' attitudes toward and perceptions of sexual harassment. In Study 1, participants were 176 workers from a large, white-collar organization. In Study 2, participants were 75 workers from a smaller, blue-collar organization. Individuals from Study 2 experienced more sexual harassment, were more tolerant of sexual harassment, and perceived less behavior as sexual harassment than did individuals from Study 1. For both samples, organizational and individual factors predicted workers' attitudes toward and experiences of sexual harassment. Individual factors-such as age, gender, gender role, past experiences of sexual harassment, and perceptions of management's tolerance of sexual harassment-predicted attitudes toward sexual harassment. Workers' attitudes, the behavioral context, and the gender of the victim and perpetrator predicted perceptions of sexual harassment. The authors discussed the broader implications of these findings and suggested recommendations for future research.     

Suffering in Silence: Procedural Justice Versus Gender Socialization issues in University Sexual Harassment Grievence Procedures

Although some studies suggest that sexual harassment is a prevalent problem in academia, it is accompanied by consistently low reporting rates. An examination of the relative explanatory power of procedural justice (Lind & Tyler, 1988) and gender socialization (Riger, 1991) to account for this situation was conducted. Demographic, situational, and attitudinal variables representing various obstacles to filing formal grievances were assessed in two groups: reporters and nonreporters of sexual harassment. Results indicate that procedural justice (e.g., skepticism regarding the response efficacy of filing a complaint) was more related to nonreported sexual harassment than was gender socialization (e.g., a caring vs. a justice perspective). Results are discussed in terms of their implications for a broader theoretical framework and for the ways in which formal agencies that are mandated to protect university members from sexual harassment could refine their grievance procedures.     

Cumulative Adversity as a Correlate of Posttraumatic Growth: The Effects of Multiple Traumas,Discrimination, and Sexual Harassment

While trauma is, by definition, a necessary precursor of posttraumatic growth, other aspects of individuals’ life experiences affect their ability to cope with trauma, foster resilience, and grow following adversity. Most research on posttraumatic growth overlooks the accumulation of trauma and sub-trauma stressors as possible predictors of growth. In addition, most research on cumulative adversity omits all but the most extreme examples of discrimination and sexual harassment stressors. This exploratory study of 46 university students with trauma histories used measures of posttraumatic growth, trauma, major (sub-trauma) life events, chronic stressors, sexual harassment, and discrimination to examine the relationship between cumulative adversity and the development of posttraumatic growth. We found that cumulative adversity is positively correlated with posttraumatic growth, and that there are important relationships between gender, race, and cumulative adversity. A hypothesized curvilinear relationship between cumulative adversity and posttraumatic growth was not supported. These findings suggest that successfully coping with some amount of sub-trauma adversity may facilitate the development of posttraumatic growth. Additionally, sexual harassment and discrimination were closely linked to the number of chronic stressors; thus, they need to be included in measures of cumulative adversity to more fully represent the experiences of marginalized groups.     

Reducing gender identity bias through imagined intergroup contact

Transgender individuals face high levels of stereotyping, prejudice, discrimination, and violence. However, there is a paucity of research (particularly experimental work) investigating the magnitude of gender identity bias (GIB) targeting transgender individuals, as well as interventions designed to ameliorate it. To address this gap, we conducted experimental investigations of reactions to identical, highly qualified men or women job applicants described as either transgender or cisgender (Experiments 1a, 1b), and tested the efficacy of an imagined intergroup contact (IIC) intervention (relative to a control condition) in ameliorating GIB against transgender women (Experiment 2). As expected, all applicants were perceived as equally highly competent, adding to the literature suggesting that clearly demonstrating excellent qualifications can prevent biased judgments of candidate competence. However, revealing GIB, transgender men and women were rated as less likeable and hirable than the identical cisgender applicants, despite the fact that they were viewed as equally competent (Experiments 1a, 1b). Providing additional evidence of GIB, in the absence of IIC, participants rated a transgender female applicant as less likeable and hirable than the identical cisgender applicant, and also reported less self‐other overlap and perspective taking for the transgender applicant (Experiment 2). However, these target gender identity differences were reduced (for likeability) or fully eliminated (for the remaining outcomes) in the IIC condition. Put another way, while reactions to the cisgender applicant were unaffected by intervention condition, IIC elevated perceptions of the transgender applicant, suggesting that it may function as an effective GIB intervention.     

Ideology or experience: A study of sexual harassment

“Ideology or Experience” is a replication and redefinition of a study done at the University of Prince Edward Island (UPEI), Canada, which examined response biases with respect to the reporting of sexual harassment. In the replication, 192 William Paterson College (WPC), New Jersey, students were used to investigate the role of ideology and previous sexual harassment experiences in reporting sexual harassment incidents. Both studies assessed the relationship between one's experiences, perceptions, and attitudes toward sexual harassment. The WPC study, however, overcame acknowledged potential reporting biases by using face to face scale distribution rather than mailed questionnaires. Findings replicate most of the previous study and suggest that neither the experience of being sexually harassed nor a feminist ideology affects the reporting of sexual harassment. A gender by experience interaction was found with regard to tolerance of sexual harassment suggesting potential differences in cultural, and/or gender, attitudes toward sexual harassment. Further analysis, redefining the experience variable, as suggested by Mazer and Percival, also supports the notion that experience does not affect the reporting of sexual harassment.     

Too Many Boxes,or Not Enough? Preferences for How We Ask About Gender in Cisgender,LGB, and Gender-Diverse Samples

As U.S. society has become more aware of gender identity issues, there has been a push for more inclusive demographic categories that go beyond the traditional gender binary of male/female. In three studies, we assessed the attitudes of U.S. cisgender men and women across sexual orientations (Study 1), heterosexual cisgender men and women (Study 2), cisgender LGB men and women (Study 3), and transgender and gender non-binary individuals across sexual orientations (Study 3) regarding different formats of gender questionnaires. Studies 2 and 3 showed a strong overall preference for the non-binary formats. Across all three studies, preferences for the binary format and objections to the non-binary formats were related to gender-binary beliefs, distinctiveness threat, cisgender and mostly heterosexual male participants, conservative political orientation, and religiosity. These findings suggest that general opposition to utilizing non-binary formats may be influenced by institutionalized binary gender norms and heteronormativity. Across both cisgender and gender-diverse samples, most participants preferred a non-binary gender question format, and gender-diverse individuals overwhelmingly preferred the expanded format. We suggest that those who collect gender data use the expanded format in order to be more inclusive and allow gender-diverse individuals to identify themselves if they choose to do so.