Grad Student in Community Practice Social Work

An Ecological Perspective of Transgender and Nonbinary Adolescents

An Ecological Perspective of Transgender and Nonbinary Adolescents

Note: The following was written for the Human Development I – Child Development course during my first semester as an MSW student (Spring 2020). The task of the assignment was to explore an aspect of adolescent development and minority status that was of interest to me. I chose to focus on trans (including nonbinary) adolescents and their development, risk factors, and protective factors. At the time I was less knowledgeable of the language and used TNB/trans and non-binary, though I have come to understand nonbinariness as one of many kinds of transness.

Excerpt from the prospectus (project proposal)

…I believe the greatest challenge to developing my knowledge base for this assignment is also one of the motivations to explore this subject: how underserved transgender and nonbinary youth are and the lack of certain reliable data specific to this population – namely, how many youth are nonbinary or trans. Frequently, TNB youth (and adults) are grouped in with the rest of the LGBQ population, though they have their own unique risks, vulnerabilities, and concerns that should be given attention. It is my hope this assignment will not only contribute to my knowledge and understanding of this adolescent group but also aid enhancing service and care for TNB youth…

Introduction

Transgender and nonbinary (TNB) adolescents – those whose assigned gender at birth does not completely match their current gender identity – are a population that researchers struggle to quantify. Some researchers estimate 0.3-1.2% of children and youth in America have a transgender identity while a 2017 report by the Williams Institute at the University of California, Los Angeles, School of Law claims 0.7% of youth aged 13-17 identify as transgender/gender non-conforming (Alegria, 2016, p. 522; Herman, 2017, p. 2). According to the United States Census Bureau – which defines adolescence as being between ages 10 and 19 – there are 42 million adolescents in America. Assuming the percentages given by Alegria and the Williams Institute, we can estimate the adolescent TNB population is between 126,000 and 504,000 in America.

Though they are a small population, TNB adolescents are disproportionately more vulnerable to certain risks to their development even when compared to their cisgender (people with a gender identity that corresponds to their gender assigned at birth) LGBQ peers. Transgender and nonbinary adolescents are misunderstood and underserved in many areas of society including schools, healthcare settings, and homes due to implicit and explicit transphobia – negative attitudes and actions that include fear, mistrust, hostility, or violence toward people based on transgender identity – in society. As professionals who abide by a Code of Ethics that calls us to “pursue social change, particularly with and on behalf of vulnerable and oppressed individuals and groups of people” and “treat each person in a caring and respectful fashion, mindful of individual differences and cultural and ethnic diversity”, social workers must build our individual and collective capacity in serving and advocating for transgender clients and communities (National Association of Social Workers, 2017). Understanding how trans identity interacts with adolescent development is a crucial part of building that capacity and facilitating positive outcomes for these youths.

Development for Transgender and Gender Non-Conforming Adolescents

Self-Identity Development

Young people start to explore questions like “Who am I?” and “Who/what will I be in the future?” and “How am I different?” more deeply during adolescence. They “try on” identities via future orientation, role experimentation, exploration, and self-evaluation. For transgender and nonbinary adolescents, these behaviors can help them find their way toward knowing and actively living their identities – including their TNB identities. In their study on transgender identity developmental pathways, Katz et al. discovered TNB youth (ages 7-18) described their gender identity development as “[including] realization of transgender identity, both gradual and immediate, and transition processes (Katz et al., 2017, p. 253). Just as they may try on identities such as cheerleader, gamer, skater, science geek, future doctor, and more to reveal to themselves and the world what their interests are and who/what they might want to be, they can try on gender identities to see which fits.

Austin (2016) notes researchers Bokting and Coleman, in two separate studies, presented a five-stage model for trans gender identity development with each stage marked by the following feelings and behaviors:

  1. a notable feeling of difference
  2. articulation of this difference to self and to others.
  3. exploration of new gender roles and expressions of gender, as well as community resources and connections which can support a new sense of self.
  4. aim to develop intimacy and first relationships in one’s preferred gender role
  5. resolution of several key identity related issues (e.g., grief over lost time and missed opportunities) and a deeper level of acceptance of [TNB] identity (p. 217)

The researchers recognize this model is not linear or standard – gender identity development will look different in everyone. At the same time, oppressive contexts may delay aspects of identity development for TNB adolescents. Unsupportive family, bullying peers, and social services and healthcare workers who lack the humility and capacity or will to adequately serve or advocate for these youth can do harm to adolescents working through the process of discovering and claiming their identities. Morgin, a trans Latina, went into foster care at the age of 16, and she described how she denied her identity development until then:

Ever since I was five years old, I was totally– just I knew I was going to be a woman, like I just knew it. But I was in denial within myself because I have a very religious family. And my mom is a minister, my aunt’s a minister. The people that was always around, they didn’t stand for it. I mean, yeah, I just gradually– once I got in foster care, I became who I am today (French, 2016).

Some TNB youth do not find their foster care experience to be the protective space that allowed Morgin to grow more into herself. “Trans youth are more likely than their peers to be placed in group foster homes because they are often rejected by their own families and less likely to be adopted by or temporarily placed with private families (Olson, p. 26) Still other TNB youth find themselves on the street. A 2013 interview study of homeless youth (ages 14-21) found “6.8 percent identifying as transgender, which is three times the percentage of transgender youth found in a recent national study”(Family and Youth Services Bureau, 2014, p. 2) Being unhoused may or may not give TNB youth the space to embrace their gender identity (and other parts of their identities), but it can present risks to other areas of their development and their lives as they are forced into terrible choices due to acknowledging or presenting (knowingly or not) across or beyond the gender binary,

Social-Emotional Development

Adolescence is a period of development in which the individual’s social sphere typically grows broader. For transgender and nonbinary youth, their minority status can present challenges to their social and emotional development as they may experience internal and external pressures including confusion, isolation, harassment, and abuse from multiple areas of their social environment due to their identity. Parents and family can unfortunately be an early and enduring source of this psychosocial stress as they withhold acceptance due to lack of understanding or inability to reconcile their child’s identity with their own culture and belief systems or visions for their child. Katherine, a trans teen of Bengali heritage put this stress into her own words:

It’s just… emotionally and mentally confusing for me. I came out to my parents about being a woman, but they simply can’t understand it. I mean, I get where they’re coming from – they’re coming from a culture where, being transgender… there’s not even a word for it in Bengali. So, it’s a completely foreign idea for them. So… I don’t blame them for not understanding, but I just wish it was easier and they were more accepting. (French, 2016)

Parent behaviors toward TNB youth may be more antagonistic than withholding acceptance. Grossman and D’Augelli (2007) found a 50% rate of verbal abuse and 25% rate of physical abuse for TNB adolescents they studied, and Alegria (2016) asserts “the research suggests that the likelihood of abuse is increased as the degree of gender nonconformity increases” (p. 523). Abuse and rejection from family put these youth at risk for homelessness and further victimization as they seek support and autonomy in other areas of their social environment.

Family may not be the only source of social-emotional challenges for TNB youth. As they move beyond family and pursue more association with peers, rejection and aggression from these peers can have devastating effects. “The pervasiveness of peer victimization among transgender youth and their mental health concerns are alarming, as 1 in 3 transgender youth experienced victimization and almost half of them presented with depressive symptoms and suicidal ideation in the past year” (Hatchel et al., 2019, p. 2473) In fact, several studies show high rates of substance abuse, “depression, suicidality and self-harm, and eating disorders” in TNB adolescents compared to their cisgender peers (Price-McFeeny et al., 2020, p. 2; Newcomb et al., 2020; Grossman & D’Augelli, 2007). TNB teens may also experience more difficulty finding romantic partners as illustrated in the findings of Bungener et al. (2017) that transgender adolescents in the Netherlands had less experience with falling in love and romantic relationships than did their cisgender peers.

Beyond family and peers/potential romantic partners, teachers, healthcare workers, social service professionals, and other community members may contribute to TNB adolescents’ social and emotional development being at risk. This happens if these figures fail to provide safe and affirming spaces for the adolescents to process the emotions associated with development, protect the adolescents from threats to their mental or physical health, or advocate for the adolescents. Along with previously mentioned strategies of self-injury and substance abuse, TNB youth may use a variety of negative coping strategies to cope during this period of development including:

  • conforming to gender expectations
  • avoidance of communication
  • avoidance of emotion
  • avoidance of gender presentation
  • avoidance of introspection
  • isolation

On a hopeful note, for TNB youth, this period may also present protective factors, positive coping strategies, and positive opportunities for growth in the social-emotional domain if TNB youth are provided support from their social sphere and/or are able to locate and connect with resources and social entities that affirm their individuation. These relationships and protective factors will be discussed further in the section on relationships and community.

Physical and Sexual Development

The onset of puberty presents biological changes for young people as their bodies mature toward adulthood. For TNB youth, this period can be a particularly vulnerable or dreaded time due to changes in their hormones and physical appearance that have the potential to exacerbate a primary problem of their minority status – the association of their body with assigned gender rather than their gender identity. Some transgender and nonbinary youths can embrace their TNB gender identity, though potentially still with struggles, while allowing their bodies to develop without hormonal or surgical intervention. Austin notes “growing numbers of TGNC [transgender and gender nonconforming] youth and adults are not interested in medically transitioning, instead feeling comfortable with a gender-neutral, non-binary presentation of gender which does not necessitate the use of hormones or other medical interventions” (2016, p. 216)

Still, for other TNB adolescents “the opportunity to medically transition is a critical component of health and well-being” and “recognition of this need is often preceded by a long, confusing, and painful process of self-discovery” (Austin, 2016, p. 216). Some may experience gender dysphoria – a condition in which individuals experience distress due to their gender assigned at birth not being congruent with their gender identity – even before puberty. They may desire and pursue puberty suppression – if they can afford it – “to relieve suffering caused by the development of secondary sex characteristics, to provide time to make a balanced decision regarding the actual gender affirming treatment (by means of cross-sex hormones and surgery), and to make passing in the new gender role easier (Vrouenraets et al., 2016 p. 1698). Weighing the use of puberty suppression, cross-sex hormones, and surgery also means youth and their families must consider the ramifications for their future fertility and reproductive options. Adolescent medicine specialists Mehringer and Dowshen advise “Counseling on fertility and reproductive options is recommended prior to initiation of puberty blockers or gender-affirming hormones for transgender youth” (2019, p. 4) These decisions can cause distress for TNB youth – including those not afforded the choices due to social pressure or financial cost.

Because of lack of access to appropriate care, many young transgender women in particular engage in ‘’survival sex’’ (trading sex for drugs, money, or a place to stay) and use street procedures (e.g., silicone injections, also known as ‘‘pumping’’), hormones, and other gender-affirming medications not under the supervision of a healthcare provider. Young transgender women also face extremely high rates of HIV infection” (Dowshen et al., 2016, p. 76)

However, these choices can also be welcome (if daunting) opportunities for youth to affirm their identities and take charge of their futures if given the right access and support.

Transgender and nonbinary youth may also, like their cisgender peers, lack adequate nutrition, exercise, and sleep because, “few adolescents maintain a healthy balance during their time in adolescent flux. (Hutchison, 2019, p. 197). Adding to the typical concern about adolescents’ physical well-being, we have already discussed the TNB are more at risk for homelessness, substance abuse, self-harm, and eating disorders among other issues. In fact, a study by Watson et al. “found that nearly half of 14–18-year-old transgender youth… engaged in binge eating or fasting, using pills, laxatives, or vomiting to lose weight” (2017, p. 519). Therefore, as I will discuss in more detail later, it is crucial to decrease risk factors and increase protective factors for these young people

Cognitive Development

According to Piaget, around adolescence youth enter the fourth stage of cognitive development: formal operational thought. This period is marked by improved reasoning skills (including hypothetical thinking, abstract thinking, thinking about thought, and the ability to retain larger amounts of information than they could earlier in childhood. Little research has been done on TNB adolescent cognitive development, but Olson et al. conducted a study in 2018 comparing the cognition of prepubescent (ages 5-12) cisgender children and TNB children. Despite the common assumptions that TNB youth are confused, being oppositional, going through a phase, pretending, or in need of psychological correction regarding their gender, the researchers found:

Instead, transgender children show responses that look largely indistinguishable from those of cisgender children, who match transgender children’s gender expression on both more- and less-controllable measures. Further, and addressing the broader concern about transgender individuals’ mere existence raised at the outset of this article, the data reported here should serve as evidence that transgender children do indeed exist and that their identity is a deeply held one (p. 7).

Research seems to indicate that TNB youth develop cognitively in the same or similar manner to cisgender youth, but that their cognitive process might be affected by psychological adjustments they have to make in response to oppression. In their study exploring nine transgender adults’ responses to transphobic microaggressions, Nadal et al. found “participants reported rationalization of others’ discriminatory behavior, the difficult situation of struggling with double-bind situations, engaging in cognitions around vigilance and self-preservation [perhaps to an extent beyond other minorities’ responses to microaggressions], and thoughts about resiliency and empowerment” and the results “demonstrate that although transgender people do indeed engage in some avoidant coping strategies, they also report an array of facilitative cognitions”(2014, p. 77-79).

Moral and Spiritual Development

Adolescence is a time of “spiritual awakening” and adolescent spirituality includes “elements of service, inner spiritual growth, and a relationship with a higher power” (Hutchison, 2019, p. 215). As they are exploring and trying on identities, adolescents are also seeking meaning and connection. Trans and nonbinary youth are no exception to this, and depending on their environment, they may or may not face extra obstacles (compared to cisgender peers) walking their paths of spiritual growth. For TNB adolescents, religion and spirituality may serve as sources of support and affirmation, or they can be sites of rejection and violence. “Just as there is no homogeneous experience, identity, or expression across TGNC people, there is no homogeneous understanding of or approach to the myriad religions, faiths, and spiritualities of TGNC people” (Hopwood and Witten, 2017, p. 214). TNB adolescents may have the common experience (but for their unique reason) of being let down by a religion/spirituality close to them or their family/culture as Morgin did with her birth family. However, they may also seek to reclaim that belief from trans-antagonistic entities or find solace in other belief systems.

Relationships and Community

Impact of developmental challenges on relationship development

The developmental challenges presented across these domains can deeply impact transgender and nonbinary youth’s relationships and lives. As discussed earlier, foundational experiences of transphobia from family and those in their microsphere/mesosphere as well as structural barriers can lead to family schisms, a lack of peers, and an array of mental health issues and internalized and externalized violence. Some TNB youth may engage in negative coping strategies or face tough choices like whether to leave an unsupportive home. These experiences have the potential to be detrimental to their ability to form and sustain relationships.

Wider environment’s impact on adolescent development for Transgender/GNC Youth

The overarching implication of this research is it is crucial to provide TNB adolescents with affirming environments for healthy development in all domains and to mitigate and dismantle transphobia in society. While the data and anecdotal evidence can be alarming, as social workers, we have the potential to help alleviate risk factors and establish protective factors associated with their minority status. Some recommendations to achieve that are:

  1. Refer to TNB adolescents using their pronouns and chosen names. In their study of TNG youth in inpatient psychiatric care, Acosta et al. reported “Using accurate identifiers was highlighted by patients as an important contributor to a positive inpatient experience” (p. 607)
  2. Explore gender differences and assess for transphobic stigma and bullying. “Instead of waiting for TGD youth to disclose experiences of victimization, bullying or marginalization, these should be standardized components of a TGD affirmative assessment” (Austin, 2017, pp. 77-78)
  3. Encourage skills, talents, and competencies. “Personal mastery (i.e., feeling able to impact important life outcomes) was associated with a lower risk of depression and fewer symptoms of mental trauma” in TNB youth (Johns et al., 2018, p, 278)
  4. Foster and protect diversity and visibility in their environments. “School diversity, on-campus activism, and a visible transgender community showed some support for being protective. Transgender youth reported that the presence of visible LGBTQQ… communities and allies in school improved school climate and contributed to their development of self-advocacy skills and resilience” (Johns et al., p. 293)
  5. Serve as a mentor connecting youth with ways to get involved socially – particularly with causes close to them. Transgender teen Johanna said, “Whenever Deb [high school principal] took me to anything that was, like, community-based, like, I enjoy that. It’s very nice to see so many people that are peers and are going through what I’m going through.” (Skurnik, 2016)
  6. Work to establish gender-inclusive care for patients in healthcare and social services. “The office should have institutional, practice-wide policies and expectations related to acknowledging and respecting a patient’s gender expression and identity” (Dowshen et al., 2016, p. 80)
  7. Advocate for/with TNB youth. “Counselors can capitalize on numerous opportunities to collaborate with stakeholders and community partners, such as families, community centers, and churches. Counselors can act as consultants to provide additional training and education” (Chan, 2017, p. 158)

REFERENCES

Acosta, W., Qayyum, Z., Turban, J. L., & van Schalkwyk, G. I. (2019). Identify, Engage, understand: Supporting Transgender Youth in an Inpatient Psychiatric Hospital. Psychiatric Quarterly, 90(3), 601–612. https://doi.org/10.1007/s11126-019-09653-0

Agana, M., Apple, R., Alavi, Z., Gibb, T., Soares, N., & Augustyn, M. (2019). Caring for the Transgender Adolescent: It Takes a Village. Journal of Developmental and Behavioral Pediatrics, 40(5), 397–399. https://doi.org/10.1097/DBP.0000000000000680

Austin, A. (2016). “There I Am”: A Grounded Theory Study of Young Adults Navigating a Transgender or Gender Nonconforming Identity Within a Context of Oppression and Invisibility. Sex Roles, 75(5-6), 215-230. doi:http://dx.doi.org/10.1007/s11199-016-0600-7

Austin, A. (2018). Transgender and gender diverse children: Considerations for affirmative social work practice. Child and Adolescent Social Work Journal, 35(1), 73-84. doi: 10.1007/s10560-017-0507-3

Budge, S., Belcourt, S., Conniff, J., Parks, R., W. Pantalone, D., & Katz-Wise, S. (2018). A Grounded Theory Study of the Development of Trans Youths’ Awareness of Coping with Gender Identity. Journal of Child & Family Studies, 27(9), 3048–3061. https://doi.org/10.1007/s10826-018-1136-y

Chan, C. (2017). A Critical Analysis of Systemic Influences on Spiritual Development for LGBTQ+ Youth. Journal of Child and Adolescent Counseling, 3(3), 146–163. https://doi.org/10.1080/23727810.2017.1341795

Connolly, M. D., Zervos, M. J., Barone, C. J., II, Johnson, C. C., & Joseph, C. L. M. (2016). The Mental Health of Transgender Youth: Advances in Understanding. Journal of Adolescent Health, 59(5), 489–495. https://doi.org/10.1016/j.jadohealth.2016.06.012

Dowshen, N., Meadows, R., Byrnes, M., Hawkins, L., Eder, J., & Noonan, K. (2016). Policy Perspective: Ensuring Comprehensive Care and Support for Gender Nonconforming Children and Adolescents. Transgender Health, 1(1), 75-85. doi:http://dx.doi.org/10.1089/trgh.2016.0002

Family and Youth Services Bureau. (2014). Street Outreach Program: Data collection project executive summary. Washington, DC: U.S. Department of Health and Human Services. Retrieved from https://www.acf.hhs.gov/sites/default/files/fysb/fysb_sop_summary_final.pdf

French, P. (Director). (2016). Becoming More Visible [Video file]. Video Project. Retrieved April 7, 2020, from Kanopy.

Hatchel, T., Valido, A., De Pedro, K. T., Huang, Y., & Espelage, D. L. (2019). Minority Stress Among Transgender Adolescents: The Role of Peer Victimization, School Belonging, and Ethnicity. Journal of Child and Family Studies, 28(9), 2467–2476. https://doi.org/10.1007/s10826-018-1168-3

Hopwood, R. A., & Witten, T. M. (2017). Spirituality, faith, and religion: The TGNC experience. In A. Singh & lore m. dickey (Eds.), Affirmative counseling and psychological practice with transgender and gender nonconforming clients. (pp. 213–230). American Psychological Association. https://doi.org/10.1037/14957-011

Hutchison, E. (2019). Dimensions of Human Behavior: The Changing Life Course, 6th edition. Thousand Oaks, CA: Sage.

Irvine, A., & Canfield, A. (2016). The Overrepresentation of Lesbian, Gay, Bisexual, Questioning, Gender Nonconforming and Transgender Youth Within the Child Welfare to Juvenile Justice Crossover Population. The American University Journal of Gender, Social Policy & the Law, 24(2), 243-261. Retrieved from https://search.proquest.com/docview/1788300785?accountid=9920

Johns, M. M., Beltran, O., Armstrong, H. L., Jayne, P. E., & Barrios, L. C. (2018). Protective factors among transgender and gender variant youth: A systematic review by socioecological level. The Journal of Primary Prevention, 39(3), 263-301. Retrieved from https://doi.org/10.1007/s10935-018-0508-9

Katz-Wise, S. L., Budge, S. L., Fugate, E., Flanagan, K., Touloumtzis, C., Rood, B., Perez-Brumer, A., & Leibowitz, S. (2017). Transactional pathways of transgender identity development in transgender and gender-nonconforming youth and caregiver perspectives from the Trans Youth Family Study. International Journal of Transgenderism, 18(3), 243–263. https://doi.org/10.1080/15532739.2017.1304312

Mehringer, J., & Dowshen, N. L. (2019). Sexual and reproductive health considerations among transgender and gender-expansive youth. Current Problems in Pediatric and Adolescent Health Care, 49(9), 100684. https://doi.org/10.1016/j.cppeds.2019.100684

Nadal, K. L., Davidoff, K. C., Davis, L. S., & Wong, Y. (2014). Emotional, behavioral, and cognitive reactions to microaggressions: Transgender perspectives. Psychology of Sexual Orientation and Gender Diversity, 1(1), 72–81. https://doi.org/10.1037/sgd0000011

Navasky, M. [Producer/Director] & O’Connor, K. [Producer/Director] (2015). Frontline: Growing Up Trans. USA: Mead Street Films. Retrieved from https://www.pbs.org/wgbh/frontline/film/growing-up-trans/

Newcomb, M. E., Hill, R., Buehler, K., Ryan, D. T., Whitton, S. W., & Mustanski, B. (2020). High Burden of Mental Health Problems, Substance Use, Violence, and Related Psychosocial Factors in Transgender, Non-Binary, and Gender Diverse Youth and Young Adults. Archives of Sexual Behavior, 49(2), 645-659. doi:http://dx.doi.org/10.1007/s10508-019-01533-9

Olson, K. R., Key, A. C., & Eaton, N. R. (2015). Gender cognition in transgender children. Psychological Science, 26(4), 467-474.

Pleak, R. (2009). Formation of Transgender Identities in Adolescence. Journal of Gay & Lesbian Mental Health, 13(4), 282–291. https://doi.org/10.1080/19359700903165290

Rosenthal, S. M. (2014). Approach to the Patient: Transgender Youth: Endocrine Considerations. The Journal of Clinical Endocrinology and Metabolism, 99(12), 4379–4389. https://doi.org/10.1210/jc.2014-1919

Skurnik, J. (Director). (2016). Becoming Johanna [Video file]. New Day Films. Retrieved April 6, 2020, from Kanopy.

Vrouenraets, L.J.J, Fredriks, A., Hannema, S., Cohen-Kettenis, P., & de Vries, M. (2016). Perceptions of Sex, Gender, and Puberty Suppression: A Qualitative Analysis of Transgender Youth. Archives of Sexual Behavior, 45(7), 1697-1703. doi:http://dx.doi.org/10.1007/s10508-016-0764-9

Whitehead, J., & Whitehead, E. (2014). Transgender Lives: From Bewilderment to God’s Extravagance. Pastoral Psychology, 63(2), 171–184. https://doi.org/10.1007/s11089-013-0543-7


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