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ChildandAdolescentSocialWorkJournal
/s10560-021-00785-6
Transgenderand GenderDiverseYouth’sExperiences
of Gender‑RelatedAdversity
Maggi A. Price1,2,8 ·Nathan L. Hollinsaid1,2 ·Emma J. Bokhour1,3 ·Colleen Johnston1 ·Hilary E. Skov4 ·
Gabrielle W. Kaufman5 ·McKenzie Sheridan6 ·Christy Olezeski7
Accepted:27July2021
©TheAuthor(s),underexclusivelicencetoSpringerScience+BusinessMedia,LLC,partofSpringerNature2021
Abstract
Transgenderandgenderdiverseyouth(TGDyouth;.,childrenandadolescentswhodonotidentifywiththeirbirth-assigned
sex)faceavarietyoftraumasandadversities,includingthoseexplicittotheirgenderidentityand/orexpression(hereafter
“gender”;.,gender-relatedvictimization,caregiverrejection).However,fewstudiesorclinicalassessmentmeasures
-andnon-gender-
relatedadversitiesfacedbyTGDyouthiscriticaltounderstandtheirhighriskformentalhealthproblemsandtoinformbest
-andnon-gender-related
adversitiesusingclinicalinterviewdatafromasampleofTGDyouth(N=49;ages11–20;76%White)seekingservicesat
-
opment,
ofgender-relatedadversitiesamongTGDyouth,thethemesofwhichincludedverbalabuse,threatsoractsofphysicaland
sexualassault,discrimination,nonaffirmation,
avenuesinmeasuredevelopmentarediscussed.
KeywordsTransgender ·Children ·Adolescents ·Trauma ·Adversechildhoodexperiences ·Genderminoritystress
Researchconsistentlyindicatesthattransgenderandgenderorindirectlyrelatedtotheirgender(Valentine&Shipherd,
diverse(TGD)people(whosegenderdiffersfromtheirbirth-2018;Wirtzet al.,2018).TGDpeoplealsoreportsubstan-
assignedsex;Vanceet al.,2014)faceadisproportionatelytialexposuretotraumasthatmaybeunrelatedtogender
highriskforavarietyoftraumaticexperiencesexplicitly(.,physicalneglect;Schnarrset al.,2019).Yet,fewifany
studiesaskparticipantstodifferentiatebetweentraumatic
experiencesthatare,orarenot,relatedtotheirgender(for
*,seeBocktinget al.,2013;Vealeet al.,2017).
******@
RetrospectivestudieswithTGDadultsdocumentratesof
1Schoolof SocialWork,BostonCollege,Chestnut Hill,USAchildhoodviolence(.,abuse,bullying)rangingfrom26
2Departmentof Psychology,HarvardUniversity,Cambridge,to79%(Hwahng&Nuttbrock,2014;Nemotoet al.,2011;
USAReisneret al.,2014,2016),muchofwhichisperpetratedby
3CambridgeHealthAlliance,Cambridge,USAfamilymembers(Grossmanet al.,2008;Penget al.,2019).
4Likewise,TGDyouthreportexperiencingviolentvictimi-
Departmentof Psychology,TulaneUniversity,New Orleans,
USAzation(.,physicalandsexualassault)inschools,their
5communities,andintimatepartnerrelationships(Golden-
MorgridgeCollegeof Education,Universityof Denver,
Denver,USAberget al.,2018;Johnset al.,2019;Murchisonet al.,2019;
6Rosenberg,2019).Ratesofpolyvictimizationareespecially
ClinicalPsychologyDepartment,WilliamJamesCollege,
Newton,USAhighamongTGDyouth;forinstance,inalargenational
7conveniencesampleofTGDadolescents,atleasthalfexpe-
YaleSchoolof Medicine,New Haven,USA
riencedfiveormoreformsofvictimization(.,physical
8McGuinnHall126,BostonCollege,275BeaconStreet,
assault,intimatepartnerviolence)overthecourseofayear
Chestnut Hill,MA 02467,USA
Vol.:(0123456789)13:.
M. A. Priceetal.
(Sterzinget al.,2017).Notably,thesetraumaticexperiencestoourknowledge,nostudieshaveexaminedexpandedACE
significantlycontributetoTGDadolescents’
formentalhealthproblems(.,depression,suicidality;improvedmeasuresmightnotadequatelycapturethecom-
Price-Feeneyet al.,2020;Vealeet al.,2017;Wilsonet al.,plexityofadversitiesexperiencedbythispopulation,as
2016).mountingevidencerevealsthatTGDpeopleexperience
adversitiesspecifictogender(Bocktinget al.,2013;Parr&
Howe,2019;Vealeet al.,2017),whicharenotassessedin
AdverseChildhoodExperience(ACE)extantmeasuresoftraumaandadversity.
ExposureAmongTGDYouth
AmuchsmallerresearchbasedocumentsTGDyouth’sGender‑RelatedAdversities
exposuretoadversechildhoodexperiences(ACEs),histori-
callydefinedasspecifictraumaticevents(.,childhoodGenderminoritystressorsaredefinedasthosethatare
physicalabuse)associatedwithpoormentalandphysicaluniquetoTGDpeople(.,notexperiencedbycisgender
healthoutcomes(Felittiet al.,1998).ACEexposureistradi-people;Meyer,2003;Testaet al.,2015)andinvolveboth
tionallyassessedona10-itemmeasurefocusingondomainsdistal(orexternal)experiences(.,discriminationininter-
ofhouseholddysfunction,abuse,andneglect(.,thepersonalrelationships)andproximal(orinternal)responses
ACEs-Questionnaire;Felittiet al.,1998).Consistentwith(.,internalizedtransphobia).Distalgenderminority
thebroadertraumaliterature,TGDpeoplereportsubstantialstressorsencompassgender-related(1)interpersonalor
,inonestudy,61%institutionaldiscrimination,includingpoliciesrestricting
ofTGDadultsreportedatleast4ACEs(Schnarrset al.,TGDpeoplefromactualizingorexpressingtheirgender
2019).Further,bothTGDadults(Schnarrset al.,2019)and(.,deniedaccesstobathroomsorhealthcare;Clarket al.,
youth(Craiget al.,2020)aremorelikelytoreportACEs2018),(2)rejection,orbeingemotionallyorphysicallydis-
(.,neglect,emotionalabuse)whencomparedtocisgen-tancedfrompeersorfamilymembersbecauseofgender,
derlesbian,gay,andbisexual(LGB)people—apopulation(3)victimization,orbeingverbally,physically,orsexually
thatalsoexperiencesdisproportionatelyhighACEexpo-abusedbasedongender,and(4)nonaffirmation,orways
sure(.,relativetocisgenderheterosexualpeople;Austininwhichothersquestion,failtoacknowledge,oractively
et al.,2016a,2016b).However,thecurrentliteratureonACEdenyTGDyouth’sgender(Chang&Chung,2015;Testa
exposureinTGDsamplesmaybelimitedbythenarrowet al.,2015).Nonaffirmationmayormaynotinvolvemali-
scopeofitsmeasurement(Vance&Rosenthal,2018),asciousintentandcanbeenactedthroughmisgendering(.,
mostresearchhasexclusivelyutilizedtheoriginalACEscalemisclassifyingTGDpeoplebasedondominantunderstand-
(.,Craiget al.,2020;Schnarrset al.,2019).ingsofgendersandbodies;Riggset al.,2015),deadnaming
TheexpansionoftheoriginalACEscale(Felittiet al.,(.,theunwanteduseofone’sbirthname,ratherthantheir
1998)hasbeensupportedinseveralrecentstudiesofnovelaffirmedname;Johnsonet al.,2020),andbroaderstatements
ACEmeasuresencompassingadversitiesoccurringoutsideunderminingone’sgender(.,questioning,minimizing,
thehome(.,discrimination,peerbullying;Cronholmand/ordenying;Johnsonet al.,2020;Parr&Howe,2019;
et al.,2015;Finkelhoret al.,2015;Karatekin&Hill,2019;Pulice-Farrowet al.,2017a,2017b;Pulice-Farrowet al.,
Koitaet al.,2018).Suchmeasuresmaymorefullycapture2017a,2017b).StudiesofTGDyouthhavelinkedthesegen-
,ameas-derminoritystressorstonegativementalhealthoutcomes
ureincludingcommunity-levelACEs(.,communityvio-(.,depression,anxiety,suicidalideation;Hidalgoet al.,
lence,fostercareinvolvement)betteridentifiedinequitiesin2019;Johnsonet al.,2020;Russellet al.,2018;Wilsonet al.,
adversityexposureacrossseveraldemographiccharacteris-2016).Thoughgenderminoritystressorshavenotbeensitu-
tics(.,race,income)thantheoriginalmeasure(CronholmatedwithinanACEframework,thesefindingssuggestthat
et al.,2015).Likewise,amodifiedscalemeasuringACEtheysimilarlyimpactTGDpeople’-
frequencyoutperformedthetraditionaldichotomousscaleingly,comprehensivemeasuresoftraumaandadversityfor
(.,askingwhetherrespondentsexperiencedagivenACE)TGDyouthshouldbedesignedtoencompassthosethatare
inpredictingmentalhealthoutcomesforalargeLGBandexplicitlyrelatedtogender(Kroppmanet al.,2021;Vance&
TGDsample(Bondet al.,2021).Takentogether,thesefind-Rosenthal,2018).Tothisend,qualitativeresearchwithTGD
ingssuggestthatamorenuancedACEframeworkmightbeyouthcanbeusefultobettercharacterizeandthuseffectively
moreappropriateforminoritizedgroups(.,peoplewhomeasuretheseexperiences(Creswell&Zhang,2009;Stut-
areplacedintoa“minority”statusreflectinghistoricalandterheim&Ratcliffe,2021).Addressingthisgaphasgreat
structuralmarginalization,ratherthanstatisticalunderrep-potentialtohelpsocialworkersandotherproviderscom-
resentation;Benitez,2010;Sotto-Santiago,2019).However,prehensivelyassessTGDyouth’smentalhealthrisksand
13:.
Transgenderand GenderDiverseYouth’sExperiencesof Gender-RelatedAdversity
wellbeing—acompetencyarealackinginsocialwork(Aus-Table1Participantdemographicinformation
tin,et al.,2016a,2016b)despiteimportantadvancesintheSampledemographics(N=49)
NASWCodeofEthics(NationalAssociationofSocialWork-
ers,2017)andrecentcallsforincreasedsocialworktrainingAgerange11–20;
M(SD)=
inculturallyresponsiveandaffirmingcarewithTGDpeople()
(.,InternationalFederationofSocialWorkers,2014;see
Breaux&Thyer,2021forareview).Inaddition,thoroughlyRace/ethnicity(n)
examiningTGDyouth’sadversityexposurewillhelpschol- AfricanAmerican1
arsbetterunderstandfactorsthatdrivethesubstantialineq- Asian1
uitiesinmentalhealthproblems(.,suicidality)facedby Latinx8
thispopulation(Becerra-Culquiet al.,2018). Non-HispanicorUnknownWhite37
 Non-HispanicOther2
 Missing0
ThePresentStudySelf-identifiedgenderexpression(n)
 Nonbinaryorgendernonconforming5
ThisstudyaimstoelucidateTGDyouth’sadverseexperi- Transgender44
ences,-identifiedgenderidentity(n)
studiestodatehaveexaminedgender-relatedadversityin Genderfluid1
TGDyouthqualitatively,andnonetoourknowledgehas Genderqueer1
donesousinganACEframeworktosupportfuturemeas- Nonbinary4
 Transfemale9
ofthecomplexinterplaybetweenACEsandgenderminor- Transmale34
itystressors(Craiget al.,2020).Accordingly,weutilizedBirth-assignedsex(n)
boththeExpandedACEsScale(Karatekin&Hill,2019) Birth-assignedmale11
andtheGenderMinorityStressandResilience(GMSR) Birth-assignedfemale38
measure(Hidalgoet al.,2019;Testaet al.,2015)toinformInsurancetype(n)
aqualitativeanalysisofclinicalinterviewdataontrauma Public(.,Medicaid)12
andadversityinasampleofTGDyouthseekinggender- Militaryinsurance2
affirmingcare. Private35
Method
Participantsand Procedurespsychologistwithexpertiseingender--
ingadministration,assessorsattemptedtodocumentpar-
ParticipantswereTGDyouth(N=49;ages11–20)seek-ticipants’verbatimanswers;theirnoteswereelectronically
inggender-affirmingcare(.,servicessupportingTGDtranscribedandprovidedtotheresearchteamforanalysis.
people’ssocialand/ormedicaltransitiontoliveastheirAllstudyproceduresanddocuments(.,assents,
affirmedgender)atapediatricgenderclinic(seeTable 1consents)wereIRB-(forpartici-
forparticipantdemographics).Ataninitialevaluation,par-pantsyoungerthan18 years)andconsent(forparticipants
ticipantscompletedaroutineassessmentbatteryregard-18 yearsandolder)tostudyparticipationwereobtained
,
(.,pubertalsuppression,gender-affirminghormoneminorswhoassentedcouldonlyparticipateiftheircar-
therapy).
forTransgenderHealth’sStandardsofCare,theseassess-bothverballyandinwritingaccordingtobestpracticesfor
mentsincludedacomprehensivesemi-structuredclinicalresearchwithTGDpeople(Adamset al.,2017)afterbeing
interviewaddressingtopicscriticaltoafully-informedgivencopiesoftheformstorea