NCFY Reports: Serving Transgender Youth

A gender nonconforming young person.

Young people who identify as transgender experience high rates of family and community rejection. That, compounded with growing up in a world that typically sees people as male or female, means that transgender youth arrive at youth-serving agencies with substantial trauma histories. In addition to providing a welcoming and safe environment, it’s important that programs and systems understand the experiences of transgender youth and their unique service needs.

In this edition of NCFY Reports, we explore different areas that transgender youth may have to navigate - shelters and transitional living programs, sexual health clinics, and foster care. For each space, there are steps that adults can take to help transgender youth feel welcome and successfully make their way into adulthood.

Catering to Transgender Youths’ Needs Supports Their Mental Health and Well-Being

As transgender youth move out of the Castro Youth Housing Initiative (CYHI), a transitional living program for homeless lesbian, gay, bisexual, and transgender youth in San Francisco, Calif., Kate Calimquim does all she can to help them get through rough times.

“I’ve had quite a few youth say, ‘If it wasn’t for this program, I don’t think I would be alive,’” said Calimquim, the Larkin Street initiative’s program manager.

Young people who identify as transgender experience high rates of family and community rejection. That, compounded with growing up in a world that often sees people as male or female, means that transgender youth arrive at her agency with substantial trauma histories.

Calimquim sees firsthand how CYHI’s culturally-competent services save lives and boost transgender young people’s mental health and overall well-being.   As transgender youth navigate their gender identity and their transition process, CYHI’s gender-affirming environment provides a safe space for young people to figure things out, she says.

Johanna Olson-Kennedy, MD, the medical director of the Center for Transyouth Health and Development at Children’s Hospital Los Angeles, says the transgender youth she works with arrive with many of the same diagnoses that children who have experienced chronic trauma receive, such as oppositional defiant disorder, anxiety, impulse control problems, and suicidality.

Gender is such an integral part of who we are, Olson-Kennedy adds, and transgender youth can’t escape the body they were born in, or the onslaught of subtle and overt aggressions from people who judge and discriminate against them.

"Choose, choose, choose. The world around you is always saying, ‘Choose,’ as if it's a choice, first of all, and as if it's that important when it really is not,” Olson-Kennedy said of society’s insistence that everyone identify as male or female.  “And so you can imagine what that must feel like.”

Calimquim and Olson-Kennedy agree that organizations can support the mental health of transgender homeless youth by providing gender-affirming services that honor each young person’s gender identity, and a welcoming, safe space that is transgender-inclusive.

Create an Inclusive Environment

Asking youth for their chosen name and gender pronoun during intake is a way to bolster transgender young people’s self-esteem and personal growth, Colimquim says. It’s important for staff to acknowledge there are alternative pronouns beyond ‘he’ and ‘she,’ like ‘they’ and ‘ze,’ an alternative, gender-free pronoun some people use when referring to another person.

Olson-Kennedy recommends that youth workers try not to use the phrase, “preferred pronoun,” because it implies that transgender youth have a choice in their gender and pronoun, and it also gives others permission to disregard it since it is “preferred.” Olson-Kennedy suggests staff ask, “Which pronoun most accurately reflects your gender?”

The physical environment of an agency also has the potential to communicate welcoming messages to youth. Olson-Kennedy recommends staff hang posters and other visuals in waiting areas and offices that say things like, “We welcome all genders here,” or “Tell us about your gender.” Transgender youth feel more comfortable when they see posters that affirm the fluidity of gender and the spectrum of gender identities, Calimquim says.

Olson-Kennedy and Calimquim offer several other ways to put transgender youth at ease, including providing gender-neutral bathrooms and hiring transgender adults to work at your agency.

Provide Transgender-Specific Services

In addition to providing a welcoming and safe environment, it’s important that staff understand the experiences of transgender youth and their unique service needs.

Transgender youth experience something called “gender dysphoria,” Olson-Kennedy explains, which is an ongoing state of distress caused by the awareness that one’s gender identity doesn’t match the sex  assigned at birth. Medical care such as hormone blockers for younger children, and cross-sex hormone therapy for adolescents and young adults, helps resolve young people’s gender dysphoria and improves their mental health.

It’s important for staff to receive training so they know how to discuss sensitive topics like transgender health care and the gender transition process with youth, Calimquim says. Building rapport with young people is important so they feel safe discussing it, so it’s best to wait until they bring it up themselves, or until you know them better. When youth approach you seeking transition-related health care, culturally-affirming mental health care, or help changing legal documents, be ready with a list of referrals, she says.

Experiencing homelessness, gender dysphoria, discrimination, and family rejection is very painful, Olson-Kennedy says, and it’s essential that staff understand where transgender youth are coming from and why they may use drugs and alcohol to self-soothe. Recently one of her patients demonstrated this point when they said, “When I’m high, I don’t actually have to think about my body.”

One of the most powerful ways agencies can support the overall well-being of transgender youth is to address family rejection. If staff can help family members move from a place of rejection to a place of understanding and acceptance, transgender youth have the possibility of reuniting with their families.

“When you increase people’s awareness and capacity for celebration of their trans child, you change the world,” Olson-Kennedy said. “If you just keep taking trans kids and confining them into the system, without trying to change families, we don't move the world as fast.” 

Sexual Health and Transgender Youth

Transgender and gender nonconforming youth have some of the highest sex education needs, but lack the resources and programs to meet them. For example, research shows that transgender females of color experience the highest rates of HIV infection of any other group.

The few studies of transgender youth’s sexual health risk factors and behaviors investigate outcomes among transgender homeless youth, finding that many of them participate in sex work, and have a low rate of condom use (PDF, 435KB).

There are some developing evidence-based programs that target this population, but overall, research, policies and programs are sorely behind.

Improving Sexual Health Outcomes for Transgender and Gender Nonconforming Youth

When it comes to making sex education inclusive for transgender youth, there are several things to consider, according to Dr. Nancy McLaren, Director of the Transgender Health Clinic at the University of Virginia.

“You can’t make any assumptions on sexual practices based on who they are with—gender is one thing, and sexual orientation another,” McLaren explains.

To improve sexual health among transgender and gender nonconforming youth it’s important to deliver sex education programs specific to their experiences and needs.

Brian Mustanski, director of the Northwestern University Institute for Sexual and Gender Minority Health and Wellbeing, created and tested Queer Sex Ed, an online sex education program for both sexual- and gender-minority youth. The program incorporates gender-neutral language throughout and consists of a selection of online videos on topics including condom use, coming out, and being part of a community. The modules also direct participants to resources to find a local HIV testing site and birth control.

It’s important to make transgender youth aware that they still need contraception to prevent pregnancy, not just sexually transmitted infections, McLaren says. For example, transgender males may think taking testosterone hormones prevents pregnancy, but while it decreases fertility it doesn’t eliminate it.

Moreover, it’s important to speak candidly with youth about the fact that they are at higher risk for violence and unwanted sex, and encourage forms of long-acting reversible contraception (LARCs) in the event that they are victimized, McLaren recommends.

Advocates for Youth has a fact sheet on LARCs for young women, such as intrauterine devices (IUDs) that last for five years and implants in the arm that last for three years, and these also apply to transgender males. However, McLaren emphasizes that transgender youth must acquire the hormonal IUD and implant that contain only progesterone, not estrogen, which may conflict with cross-hormones they may be taking during their transition.

When working to improve the sexual health of transgender youth, it’s also important to create a safe environment for these young people to learn and access services.

[Take our Online Training: Creating a Safe Space for LGBTQ Teens]

Kris Gowen, a researcher at Oregon Health & Science University, recommends that educators and service providers interested in becoming more inclusive take a look at the Teaching Transgender Toolkit, a curriculum for use with a range of audiences including college students, community groups, faith communities, and parent and family groups. The toolkit is designed to foster awareness and acceptance through gay-straight alliances and policies for safe zones.

In addition, Gowen found in her study, “Lesbian, Gay, Bisexual, Transgender, Queer, and Questioning Youths’ Perspectives of Inclusive School-Based Sexuality Education,” that youth want more conversations about sexual orientation, gender identity, and healthy relationships regardless of LGBTQ status.

Mustanski recommends that educators and parents access the Gender Identity & Expression Map, a comprehensive youth-friendly resource describing the difference between sex and gender, gender identity and expression, and how to use gender pronouns and terms appropriately.

Uneven Progress in Inclusive Sex Education Policy and Research

“We live in interesting times,” Mustanski says, “and so much depends on where you live.”

Alabama, South Carolina, Texas, and Utah have laws known as “no promo homo” laws that prohibit educators in public schools from discussing lesbian, gay, bisexual, transgender, and questioning (LGBTQ) people, issues or history, or only allow discussion in a negative light.

At the same time, McLaren notes, states like Virginia and Pennsylvania have robust transgender health services embedded in their state or local health departments. Additionally, nine states, including Oregon and California, have mandates that require inclusive discussion of sexual orientation and identity in sex education programs. The full list of states and their inclusivity can be found in the March 2016 Guttmacher Institute brief (PDF, 143KB). However, even in these states, the mandate is not perfect.

“That all sounds good on paper, but the bottom line is that it’s a law without a penalty if you don’t follow it . . . there’s no oversight committee and there are no evidence-based practices or curricula,” Gowen says.

While more can be done to provide effective sex education programs for LGBTQ youth, especially for transgender and gender-nonconforming youth, Gowen thinks the links between inclusive school environments and better well-being across the board are clear.

“Creating a safe environment for young people to thrive in, no matter who they are, is going to help with sexual health outcomes,” she says. “Acknowledging various sexual orientation and identities during lessons helps create environments in schools where LGBTQ young people thrive, feel better about themselves, and make better decisions.”

More data about the connection between safe spaces and sexual health is on the way. The annual Oregon Healthy Teen Survey, which measures sexual health outcomes and other indicators of well-being, is adding a question about gender identity. In addition, the Centers for Disease Control and Prevention’s Youth Risk Behavior Survey is following suit, which means researchers will eventually be able to analyze changes over time in the sexual health and well-being of gender-minority youth at the national level.

5 Things Transgender Youth Need

A medical professional works to put a young person at ease.
Medical Care: Youth whose gender identity is established at an early age need access to counseling and hormone blockers, and if puberty has already begun, teens require cross-hormone therapy. Contact the World Professional Association for Transgender Health, the association of medical providers who specialize in treating transgender people, for referrals.

Much of the literature about how to best serve lesbian, gay, bisexual, and transgender youth lumps them all together. Although these youth face similar struggles and challenges, transgender (or gender non-conforming) youth require special services to ensure they feel safe and included. Learn more about best practices to specifically serve transgender youth.

More on Serving Transgender Youth

Ask NCFY: Meeting the Needs of Transgender and Gender Non-Conforming Youth

New York City's New Guide to Working With Transgender and Gender Non-Conforming Children and Youth

Research Roundup: Helping Transgender Youth Access Community Services

From FosterClub: Tristan’s story

FosterClub connects, educates and supports youth in and from foster care with an online network, resources and training events. Tristan, an 18-year-old transgender male from Nevada, is a FosterClub spokesperson and recently participated in its #FosterEquality campaign. Here he shares his story of the 9 months he spent in the child welfare system and the changes he’s working to make so other LGBTQ youth don’t have a similar experience.

Advocating for myself was the most difficult part of being in the foster care system, but it’s also a vital skill to learn. Before entering the system, I had suffered plenty of abuse for being a trans man who dared to come out of the closet. My teachers rejected me, my peers kept their distance, and my home life was dreadful enough to land me in a center for suicide prevention. When grasping at the last reasons for my life to continue, I was visited by Child Protective Services (CPS) and assigned to a home within the week. After one meeting with my future foster parent, I was expected to be a perfect fit for her home because she had a family member who was transgender.

The “perfect fit” foster home quickly became a bad fit after several incidents of discrimination. I was locked in the foster parent’s room and berated for being transgender. I was once again on the precipice of ending everything after she used her biological children’s confusion with gender to stigmatize my existence. Her exact words were, “You changing your gender is like me changing my skin color from black to white; it’s never going to happen.” Bullied and with violated dignity, I pleaded for help from my caseworker, my attorney, and my therapist, but no one was willing to stand up for me. It wasn’t until I met André Wade at The Center that I was finally moved out of that foster home. He was the only adult who validated my existence, and he was abhorred at how I was left to fend for myself.

In my new foster home, discrimination endured and things didn’t end on good terms. After a family member learned I was transgender, the foster parents withheld food from me. After five months, the foster parents wanted an emergency extraction so that they didn’t have to deal with me anymore. After an argument erupted on the basis of my gender identity, the foster parents called my caseworker in the middle of the night while I packed my belongings in trash bags waiting for someone to help me. Their last words to me repeat in my mind constantly, “You’re a freak. Your only friends are transsexuals at The Center.”

Read the rest of Tristan’s story.

Glossary

Not sure about the difference between genderqueer, gender non-conforming and transgender? Here are some definitions from GLAAD to help in your work with transgender youth.

Cisgender
A term used by some to describe people who are not transgender. "Cis-" is a Latin prefix meaning "on the same side as," and is therefore an antonym of "trans-." A more widely understood way to describe people who are not transgender is simply to say non-transgender people.

Genderqueer
A term used by some people who experience their gender identity and/or gender expression as falling outside the categories of man and woman. They may define their gender as falling somewhere in between man and woman, or they may define it as wholly different from these terms. The term is not a synonym for transgender or transsexual and should only be used if someone self-identifies as genderqueer.

Gender Dysphoria
In 2013, the American Psychiatric Association released the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) which replaced the outdated entry "Gender Identity Disorder" with Gender Dysphoria, and changed the criteria for diagnosis. The necessity of a psychiatric diagnosis remains controversial, as both psychiatric and medical authorities recommend individualized medical treatment through hormones and/or surgeries to treat gender dysphoria. Some transgender advocates believe the inclusion of Gender Dysphoria in the DSM is necessary in order to advocate for health insurance that covers the medically necessary treatment recommended for transgender people.

Gender Expression
External manifestations of gender, expressed through one's name, pronouns, clothing, haircut, behavior, voice, or body characteristics. Society identifies these cues as masculine and feminine, although what is considered masculine and feminine changes over time and varies by culture. Typically, transgender people seek to make their gender expression align with their gender identity, rather than the sex they were assigned at birth.

Gender Identity
One's internal, deeply held sense of one's gender. For transgender people, their own internal gender identity does not match the sex they were assigned at birth. Most people have a gender identity of man or woman (or boy or girl). For some people, their gender identity does not fit neatly into one of those two choices. Unlike gender expression (see below) gender identity is not visible to others.

Gender Non-Conforming
A term used to describe some people whose gender expression is different from conventional expectations of masculinity and femininity. Please note that not all gender non-conforming people identify as transgender; nor are all transgender people gender non-conforming. Many people have gender expressions that are not entirely conventional -- that fact alone does not make them transgender. Many transgender men and women have gender expressions that are conventionally masculine or feminine. Simply being transgender does not make someone gender non-conforming. The term is not a synonym for transgender or transsexual and should only be used if someone self-identifies as gender non-conforming.

Transexual (adj.)
An older term that originated in the medical and psychological communities. Still preferred by some people who have permanently changed - or seek to change - their bodies through medical interventions (including but not limited to hormones and/or surgeries). Unlike transgender,transsexual is not an umbrella term. Many transgender people do not identify as transsexual and prefer the word transgender. It is best to ask which term an individual prefers. If preferred, use as an adjective: transsexual woman or transsexual man.

Transgender (adj.)
An umbrella term for people whose gender identity and/or gender expression differs from what is typically associated with the sex they were assigned at birth. People under the transgender umbrella may describe themselves using one or more of a wide variety of terms – including transgender. Some of those terms are defined below. Use the descriptive term preferred by the individual. Many transgender people are prescribed hormones by their doctors to change their bodies. Some undergo surgery as well. But not all transgender people can or will take those steps, and a transgender identity is not dependent upon medical procedures.

Transgender man
People who were assigned female at birth but identify and live as a man may use this term to describe themselves. They may shorten it to trans man. (Note: trans man, not "transman.") Some may also use FTM, an abbreviation for female-to-male. Some may prefer to simply be called men, without any modifier. It is best to ask which term an individual prefers.

Transgender woman
People who were assigned male at birth but identify and live as a woman may use this term to describe themselves. They may shorten to trans woman. (Note: trans woman, not "transwoman.") Some may also use MTF, an abbreviation for male-to-female. Some may prefer to simply be called women, without any modifier. It is best to ask which term an individual prefers.