Working with gender diverse youth
Here, I present four studies related to gender diverse youth. In the first, published in “6 Things Psychologists Are Talking About” (November 2022), we have the following:
Research in Psychology, Public Policy, and Law reveals that fewer youth attempt suicide in states with hate crime laws that protect LGBTQ individuals. Researchers analyzed health-related responses of more than 83,000 students in the United States surveyed between 2015 and 2018. They found that suicide attempt rates were significantly higher for students who identified as gay or lesbian (25.7%), bisexual (27.1%), or questioning (18.5%) than among their heterosexual counterparts (6.3%). Suicide attempts during the study period decreased by 1.2% for all students in states with hate crime laws protecting sexual and gender minorities, translating into an overall decrease of 16% in annual suicide attempts in those states. There was no decrease in student suicide attempts in states that enacted hate crime laws that excluded sexual minorities as a protected class.
I found these data important, especially in light of the recent suicide attempt by Ted Cruz’s bisexual 14-year-old daughter.
The second study, by Hubachek, Clark, Pachankis, & Dougherty (2022) “Explicit and implicit bias among parents of sexual and gender minority youth” is published in Journal of Family Psychology. Here’s an edited version of the abstract:
Sexual and gender minority (SGM) youth are at disproportionate risk for poor mental health outcomes, in part due to experiences and expectations of anti-SGM bias including from their own parents. Heterosexual/cisgender parents (N = 205, Mage = 46.9 years, SD = 8.5) of SGM youth (≤ 29 years old, Mage = 19.4, SD = 4.7) completed an online study including measures of explicit anti-SGM and implicit anti-SM bias, parental acceptance and psychological control, parent–child unfinished business (unresolved negative feelings related to their child’s identity), parental depression and anxiety, and youth anxiety, depression, substance use, and exposure to bullying. {E}xplicit bias was uniquely associated with lower parental acceptance and greater parental psychological control, parent–child unfinished business, parental anxiety and depression, and youth substance use and exposure to bullying, whereas implicit bias was uniquely associated with greater parent–child unfinished business and parental depression. Further, the combination of high levels of both explicit and implicit bias was associated with the highest levels of parent-child unfinished business, parental depression, and youth anxiety, depression, and exposure to bullying. Results suggest that both types of bias jointly contribute to parenting and parent and youth psychosocial functioning and can help identify families at greatest risk for maladjustment.
This is important and sets the stage for the third article. Buckloh, Poquiz, Alioto, Moyer & Axelrad (2022) published “Best Practices in Working with Parents and Caregivers of Transgender and Gender Diverse Youth” in Clinical Practice in Pediatric Psychology. Here’s the edited abstract:
Transgender and gender diverse youth (TGD) are seeking psychological and medical care at an increased rate. Psychologists and other mental health providers, both on multidisciplinary teams and in the community, are being called upon to support these youth and their families. Evidence-based comprehensive care is imperative, which includes involving parents and caregivers. Moreover, parental and caregiver acceptance and support are one of the most important protective factors against anxiety, depression, and suicidality. By supporting parents and caregivers along their own journey, mental health providers can improve outcomes for the whole family. Best practices for working with parents and caregivers include (a) using a comprehensive, individualized, dynamic process for assessment, psychoeducation, and intervention; (b) assisting families in taking an informed and shared decision-making approach to care; (c) addressing parent and caregiver concerns from a risk/benefit perspective; and (d) understanding the parent and caregiver journey, including complex emotions and experiences of loss and grief. Working with parents and caregivers of TGD youth is an integral part of competent gender affirming care. While there is no one path that will be best for all families, using these best practices will assist mental health providers in supporting parents and caregivers as they adapt and support their TGD children and teens.
The effects on transgender and gender diverse (TGD) young people of not having support from family as they establish their gender identities are well known, including increased rates of anxiety, depression, and suicidality. While the journey will always be complex, this work may be helpful to practitioners as they work with youth and their families. Finally, Clay (2022) published “Updated guidelines for sexual minority people focus on resilience” in APA Monitor. This is a lengthier piece that I have edited:
Psychologists should understand that people have diverse sexual orientations, and those orientations are normal variations and not mental illnesses needing treatment. Psychologists should also understand the multiple systems of oppression sexual minority individuals face, including the environmental, economic, and sociopolitical forces affecting their mental health.
The guidelines aim to clear up common misconceptions, such as conflating sexual orientation and gender identity. A person’s sexual orientation is whom that person is attracted to. That is distinct, the guidelines explain, from a person’s gender identity, or that person’s sense of their own gender.
The guidelines also call on psychologists to eradicate their monosexist bias and affirm bi+ identities. Bi+ women in the United States are a bigger population than lesbians, gay men, and bi+ men combined, the guidelines point out, yet bi+ individuals are often overlooked or subjected to harmful, inaccurate stereotypes that cast them as hypersexual people, cheaters, and spreaders of HIV and other sexually transmitted infections.
“We know that bi-erasure and bi-negativity are incredibly common and have really negative mental health effects,” said task force member Jennifer Vencill, PhD, an assistant professor of psychiatry and psychology at the Mayo Clinic in Rochester, Minnesota. Bi+ individuals, especially women, have the highest suicide rate of any sexual orientation group, for example. Bi+ young people are at higher risk of depression.
At the societal level, institutional discrimination such as same-sex marriage bans and religious exclusion is associated with poorer mental, behavioral, and physical health outcomes. Psychologists themselves can perpetuate this kind of discrimination through seemingly innocuous acts like defaulting to the terms “mother” and “father” on intake forms instead of using the term “parent” or “guardian,” which does not imply assumptions about family composition.
Sexual minorities experience interpersonal discrimination, too, ranging from microaggressions to physical abuse. A psychologist could commit a microaggression by seeming to endorse heteronormativity, for example. At the other extreme, sexual minorities of all ages face higher rates of victimization than their heterosexual peers.
These stressors can lead sexual minorities to internalize heterosexism and other forms of stigma. That might mean feeling anxious or trying to conceal one’s identity. These stressors can result in reduced psychological well-being, increased risk-taking, and worse physical outcomes.
But psychologists should not just focus on the negative. “Because oppression toward this community is so prevalent, we are often unable to see beyond disparities. We wanted to recognize that this population is not just coping with adversity, but many are thriving.”
The guidelines urge psychologists to respect diverse relationships and recognize the complexity of sexual health for sexual minorities.
Polyamorous relationships are one example. While research suggests that heterosexual and sexual minority people engage in consensually non-monogamous relationships at similar rates, mental health practitioners often stigmatize such behavior among sexual minorities. In addition to lacking knowledge about this relationship structure, they may claim non-monogamy is inferior to monogamy or even push patients to renounce these relationships.
“Both socially and clinically, there are many different types of relationship structures that are healthy, normative, and appropriate. These relationship structures should not be pathologized.” Intake forms might just have one line for spouse or partner when a patient may have multiple partners, for example.
Psychologists may hold similarly stigmatizing views about sexual health. “There is a long history of pathologizing sex in this community, connecting it with HIV and other sexually transmitted infections, high-risk behaviors, and bad relationships,” said Dispenza. While rates of new HIV infections are highest among sexual minority men, that narrow focus has meant a lack of attention to other aspects of sexual health. Sexual minority women, for instance, experience much higher rates of sexual assault than heterosexual women.
Other guidelines urge psychologists to understand sexual minority people’s families—both their families of origin and families of choice. Coming out to families of origin can result in conflict, internalized stigma, and adverse psychological outcomes, with acceptance and rejection influenced by the family’s racial and ethnic background and religious beliefs. Psychologists should respect a patient’s decision not to disclose their identity to their families. Psychologists should recognize that sexual minority patients may have other forms of close relationships and inquire about significant relationships beyond biological family. While research shows there are no disadvantages for children raised by sexual minority parents and there are associated strengths, sexual minority parents face stigma, adverse policies, and other challenges that psychologists should strive to understand.
Psychologists also need to understand the educational issues sexual minorities face. At the high school level, for example, sexual minority students report higher levels of in-person and online bullying, violence, and sexual violence than their heterosexual peers. The victimization does not stop once students head to college. Sexual minority college students, especially those who have other forms of oppressed identities, report more isolation, drug use, depression, and suicidal ideation.
In addition, psychologists need to understand the unique issues sexual minorities face on the job. Discrimination and other factors lead to higher overall rates of poverty for this population.
The final guideline urges researchers to take an affirming stance toward sexual minorities in all aspects of their work as a way of reducing health disparities and promoting well-being.
“At minimum, that means asking people about their sexual identities. That is still not routine in the psychological research that we do, and that is a huge demographic variable that is being overlooked.”
Researchers should also broaden their research population beyond upper-middle-class White urbanites and be careful not to lump all sexual minorities together, added Vencill, pointing to the unique experiences and needs of bi+ people in particular. The guidelines also identify several gaps in the research, such as research on asexuality and interracial relationships—a type of relationship more prevalent among sexual minority populations.
Taken together, these articles provide important information for practitioners.