5/3/2017
Supporting Sexual and Gender
Minority Children and
Adolescents
Sonia Fines, R. Psych, Psychological Services
Amanda Richardson, MCP, RSW – Metta Clinic, AHS
2 Main Objectives:
 Gender
Identity and Sexual Orientation101
 School,
Health, and Community supports
for Gender and Sexual Minority Children
and Adolescents
Gender Identity and
Sexual Orientation
101
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National Centre for Trans Equality Now Video
It’s a baby!
It’s a Girl!
• Female physical anatomy
• Female hormones
• Female chromosomes
It’s a Boy!
• Male physical anatomy
• Male hormones
• Male chromosomes
Babies are assigned a sex at birth – boy or girl
depending on the above
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However, in approximately 1:1,500 babies, there are
variations in…
- physical anatomy
- hormones
- chromosomes
These are “Differences of Sex Development”
Disorders of Sex Development
(examples)
Congenital Adrenal Hyperplasia (CAH)
Androgen Insensitivity Syndrome (AIS)
5-α Reductase Deficiency (5α-RD)
Klinefelter’s Syndrome
Differences of Sex Development In Context
99.9993% of population –
male or female
- 13,902 CBE employees
0.0007% of population Intersex
- 10 CBE employees
- 115,923 CBE students
- 77 CBE students
- 4,796,640 Albertans
- 3,360 Albertans
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What is Gender Identity?
• Gender identity is a personal, deeply felt sense of being
male, female, both or neither. Everyone has a gender
identity. Gender identity is about how you view yourself
and how you feel. This starts at a young age.
• Around age 2 children become aware of the physical
differences between boys and girls.
• By age 3 most children label themselves as a “boy” or a “girl”.
• By age 4 most children have a strong sense of their gender identity and at
the same time children learn gender role behavior – the “things boys” do and
the “things girls do” (e.g., how they dress, what toys they play with, what
activities they do, etc.)
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Gender Expectations, Roles, etc.
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Gender Diversity
• Not all peoples’ gender identity matches their biological sex
• Some people who were assigned the sex of “boy” at birth actually feel like a
girl or vice versa and so their gender identity is that of a girl/boy.
• Some people recognize that their gender identity isn’t a match with their
biological sex at a really young age and some know much later.
• Most people in the world feel like a male or a female. However, some people
feel like both a boy and a girl and some feel like neither a boy nor a girl.
• Gender identity can fluctuate over time. For some people it is dynamic rather
than static and can change from day to day or year to year.
ALL of these different gender identities are valid and are not
considered mental disorders.
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Gender Diversity
• There are lots of terms to describe people whose gender identity doesn’t
match their sex assigned at birth:
•
•
•
•
•
•
•
•
•
•
Transgender (not trangendered)
Gender non-conforming
Gender queer
Gender fluid
Gender diverse
Masculine of centre/Feminine of centre
Male/female
Gender Creative
Non-binary
etc
• Some people relate to the terms above and some don’t want to be called
“transgender” – instead they simply want to be called a boy/girl because that
is what their gender identity is (even if their sex assigned at birth is female or
male).
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How does Gender Identity differ from…
• Sexual orientation
• Gender expression
• Biological sex
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Gender Identity
• How you view your
gender and how you
feel about it.
Sexual
Orientation
Gender
Expression
Biological Sex:
• Physical Anatomy
• Hormones
• Chromosomes
• Clothing
• Hair style
• Mannerisms
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Prevalence Rates
• Approximately 0.3% of the population is transgender or gender non-conforming.
• In Canada its approximately 107,500 people
• In Alberta its approximately 12,000 people.
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Children 0-12yrs
Children who experiment with cross gender play,
roles, expression, wish (say) they are the opposite
gender, etc.
As adults, 80-85% identify
as the sex assigned at
birth (although their sexual
orientation may not be
heterosexual)
As adults, 15-20% have a gender
identity different than the sex they
were assigned at birth
Children who are insistent, persistent and consistent are more likely to
identify as transgender as adults.
There is also a difference between behaving like the opposite sex and
wanting to be the opposite sex.
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Adolescents 12-17yrs
Adolescents who experiment with cross gender play, roles,
expression, say they are the opposite gender etc.
As adults, very few
identify with the sex
assigned at birth
As adults, nearly 100% have a
gender identity different than the sex
they were assigned at birth
If an adolescent tells you they are transgender it is VERY likely to be
true for life.
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Very Vulnerable Population
Recent evidence suggests that Trans* youth are:
 8X more likely to have had suicide attempts
 More likely to engage in self harm (37%)
 More likely to face school victimization (40%)
 3X more likely to use illegal drugs
 3X more likely to be high-risk for HIV and STIs
 Overrepresented in the homeless population (25-40%)
(TransPulse Study, 2012)
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GD Assessment
World Professional Association for Transgender Health
(WPATH) Standards of Care Pathway
1. Assess
Gender
Dysphoria
2. Gender
Identity and
Expression
3. Assess,
Diagnose, &
Treat
Comorbities
+/Psychotherapy
4. Eligibility
and Referral
for Hormone
Therapy
5. Eligibility
and Referral
for Surgery
+/Psychotherapy
Coleman, E., et al. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender‐Nonconforming People, Version 7. International Journal of Transgenderism 13, 165–232.
DSM-5: Gender Dysphoria Diagnosis - Children
A marked incongruence between one’s experienced/expressed
gender and assigned gender, of at least 6 months’ duration, as
manifested by at least six of the following (one of which must be
Criterion A1):
Criterion A:
1. Strong desire to be an alternative gender
2. Strong preference for cross-dressing
3. Strong preference for cross-gender roles in make-believe play
4. Strong preference stereotypical activities of other gender
5. Strong preference for playmates of other gender
6. Strong rejection of stereotypical activities of natal gender
7. Strong dislike of natal sex anatomy
8. Strong desire for sex characteristics of other gender
Criterion B:
The condition is associated with clinically significant distress or
impairment in social, school, or other important areas of functioning.
*(+ Insistent, persistent, consistent)
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DSM-5: Gender Dysphoria Diagnosis –
Adolescents/Adults
A marked incongruence between one’s experienced/expressed
gender and assigned gender, of at least 6 months’ duration, as
manifested by at least two of the following:
A marked incongruence between one’s experienced/expressed gender and assigned, of at
least 6 months’ duration, as manifested by at least two of the following:
Criterion A:
1. A marked incongruence between preferred gender and
natal sex characteristics
2. A strong desire to prevent or remove natal sex
characteristics (because of the incongruence)
3. A strong desire for sex characteristics of alternative gender
4. A strong desire to be of the other or alternative gender
5. A strong desire to be treated as an alternative gender
6. A strong conviction that one has the typical feelings and
reaction of the other/alternative gender
Criterion B:
The condition is associated with clinically significant distress or
impairment in social, school, or other important areas of functioning.
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IMPORTANT FACT!
Being transgender or gender diverse is NOT a mental disorder. A diagnosis
of gender dysphoria is made when a person experiences psychological
distress due to the mis-match between their gender identity and assigned
gender… “the distress is not limited to a desire to simply be of the other
gender, but may include a desire to be of an alternative gender, provided
that it differs from the individual’s assigned gender” (DSM 5)
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Differential Diagnosis and Comorbidities
Differential
Diagnosis
Comorbidities
• Transvestic
Disorder, with
Autogynephilia
• Body Dysmorphic
Disorder
• Dissociative
Disorders
• Psychosis
• Mood & Anxiety
Disorders
• Personality
Disorders
• Substance Use
Disorders
• Autism Spectrum
Disorder
Heylens, G. et al. Psychiatric characteristics in transsexual individuals: multicentre study in four European countries. Br J Psychiatry (2013).
Transitioning
2 main types:
• Social Transitioning
• Medical Transitioning
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Social Transitioning
Social Transitioning - living as the gender you identify with
(as a boy/girl, both or neither)
Examples:
•
Using a new name and pronouns (e.g., he/him
instead of she/her or they/them)
•
Getting a different hair cut
•
Dressing differently
•
Introducing oneself to others as a male/female
•
Changing ones mannerisms
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What about “official” documents in Alberta?
• Legal name changes
• Changes to birth certificates
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Medical Transitioning
Medical Transitioning – making changes to ones body to
match ones gender identity:
Examples:
• Hormone suppressants (blocking puberty from happening –
putting it on hold)
• Cross-sex hormone therapy (usually at or around age 15yrs)
• Having gender confirming surgeries
Many people don’t medically transition, or they do some of the
options, or they wait. Its all very personal and private.
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Criteria for Hormone Therapy
 Longstanding pattern of gender non-conformity or
dysphoria (+/- RLE, +/- Psychotherapy)
 No confounding psychological, medical, or social
problems that would affect treatment
 Informed consent (risks and benefits)
 Age of majority in given country *
For adolescents
 Gender dysphoria emerged or worsened with puberty
(WPATH SOC 7)
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Masculinizing Effects of Hormones
Coleman, E. et al. Standards of Care for the Health of Transsexual, Transgender, and Gender‐Nonconforming People, Version 7. International Journal of Transgenderism 13, 165–232 (2012).
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Feminizing Effects of Hormones
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Coleman, E. et al. Standards of Care for the Health of Transsexual, Transgender, and Gender‐Nonconforming People, Version 7. International Journal of Transgenderism 13, 165–232 (2012).
Requirements for GRS Funding (AB)
 GID/GD diagnosis from a psychiatrist
 1 year “RLE” – Real Life Experience
 12 months cross-gender hormones
 Support from 2nd psychiatrist confirming diagnosis and
suitability for GRS
 Support from endocrinologist/physician managing hormones
 Support from physician that patient is physically fit for
surgery
 No symptomatic mental health disorder
 No significant/symptomatic personality disorders
PERMISSION VS ATTENTION?
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Best Practices to Support Children and Youth
Use a Gender Affirming Approach:
• Listen in a non-judgemental way
• Believe them and tell them that
• Let them experiment with different ways of expressing their
gender (attire, names, pronouns, mannerisms, etc.)
• Share information about gender identity
• Don’t box them in to any particular gender identity
• Follow their lead
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Best Practices Continued
Know the language -
Gender Terminology
Body Image - has an impact not only on relationships but also on many aspects of
the self
Respect your client’s self-identification – use preferred names and pronouns
“Coming out” is different for transgender people than for LGB people
Trans clients do not always require “specialized” mental health services (listen
and ask questions about what they may need to support them)
School Supports
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CBE Sexual Orientation and
Gender Identity Team (SOGI):
 Multidisciplinary
 System
Level Team
 Forwarding
the work related to gender
and sexual minority students, staff and
families
Top 10 Questions Students ask…
1.
Should I expect my school to support me?
2.
What will my teacher tell my parents/guardians?
3.
Can I change my name, pronouns and gender at school?
4.
What bathroom can I use?
5.
What change room can I use?
6.
What sports team can I play on?
7.
How do I tell my school I’m trans?
8.
Is there help to socially transition at school?
9.
What can schools do to help transgender students?
10. How can I get a GSA started at my school?
Alberta: Bill 10 and Bill 7
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History of Bill 10 and Bill 7
 June 2015, Bill 10 was proclaimed resulting in several amendments to
the School Act
 November, 2015, Alberta Education released Guidelines for Best
Practices (re: sexual and gender minority students, staff and families)
and asked school boards to use them to develop their own policies
and procedures
 December, 2015, the Alberta Human Rights Act was amended to
include explicit protection from discrimination based on gender identity
and gender expression.
 January, 2016, Education Minister asked Boards to submit policies,
procedures and regulations related to Bill 10 by March 31, 2016
 March, 2016, Calgary Board of Education submitted Creating the
Conditions to Thrive Guidelines to the Education Minister.
 August, 2016, Public Interest Alberta reviewed SOGI guidelines from
12 Alberta schools. A call was made for all schools to meet the
minimum standard of A+. CBE met this standard.
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Bill 10:
Creating welcoming, caring,
respectful and safe learning
environments
6 Key Components of Bill 10:
1. New system-wide student
code of conduct
2. Address bullying behaviour
3. Sharing responsibility with
parents/guardians and
students
4. Student-run organizations
5. Guidelines for gender and
sexual minorities
6. Protections for LGBTQ staff
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3. Sharing responsibilities with parents
and students
 Bill 10 states that students, parents/guardians and schools
are accountable for working collaboratively to support
positive school environments
 Students and parents/guardians all contribute to
welcoming, caring, respectful and safe school communities
 Parents/guardians are responsible for supporting their
children in complying with the new system wide Student
Code of Conduct
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4. Student-run organizations
Schools must support student
initiated requests for
activities/clubs that foster a sense
of belonging and respect for
diversity
 Gay-Straight Alliances (GSAs)
are one example.
 GSAs are generally student
initiated and teacher sponsored
(may be staff initiated)
 Direction for school principals
regarding student initiated clubs
will be articulated in the School
Information Handbook for 16/17
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5. CBE Guidelines: Creating conditions to
thrive
The CBE guidelines:
 Formalize our practices to
accommodate gender and
sexual minority youth
 Align with the provincial
guidelines
 Provide support for
students, families and staff
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Three Levels of Support (system, school, individual)
 What can schools do to help transgender students?
Preferred Name
Gay stuff,
trans stuff,
queer stuff,
blah blah
blah
Metta Clinic – Alberta Health
Services:
 Metta
Clinic was established as a
“demonstration of concept” project in
2014
 Multi-disciplinary
 Assessment,
follow-up.
team
diagnosis, consultation,
Community Supports








Calgary Sexual Health http://www.calgarysexualhealth.ca/
Outlink – http://www.calgaryoutlink.ca
WPATH http://www.wpath.org/site_home.cfm
Family Project - http://familyproject.sfsu.edu/
Camp FyerFly - http://www.campfyrefly.ca/
CAMH GID clinic – http://camh.net (adult only)
Metta Clinic – Alberta Children’s Hospital
The Alex Youth Health Center http://www.thealex.ca/
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Questions?
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REFERENCES
Abramovich, I.A., No Safe Place to Go, LGBTQ Youth Homelessness in Canada: Reviewing the Literature.(2012). Canadian Journal of Family
and Youth, 4(1)., 29-51.
de Vries ALC., McGuire JK., Steensma TD., et al. Young adult psychological outcome after puberty suppression and gender reassignment.
Pediatrics 2014;134:696-704. Doi: 10.1542/peds.2013-2958
de Vries, A., McGuire, J.K., Steensma, T.D., Wagenaar, E.C.F., Doreleijers, T. A.H., Cohen-Kettenis , P.T. (2014). Young Adult
Psychological Outcome After Puberty Suppression and Gender Reassignment ; Pediatrics ,134, 696–704.
de Vries, A., Cohen-Kettenis, P.T., Delemarre-Van de Waal, H., (2006). Clinical Management of Gender Dysphoria in Adolescents, A1-A11.
Ryan, C. (2009). Supportive Families, Healthy Children. Helping Families with Lesbian, Gay, Bisexual & Transgender Children .
San Francisco State University.
Malpas,. J. (2015, Feb ruary 25). Fifty Shades of Gender . [Webinar] . Retrieved from
https://www.dropbox.com/s/a0uneewsmbpqe8c/GFP.FPWebinar.2.25.15.V1.Handout.%20FINAL%20LG.pdf?dl=0
White Holman, C., & Goldberg , J. (2006). Caring for Transgender Adolescents in BC: Suggested Guidelines , Ethical, Legal, and
Psychosocial Issues in Care of Transgender Adolescents. B1-B16.
Lebowitz, S., & Telingator, C. (2012). Assessing Identity Concerns In Children and Adolescents: Evaluations, Treatments, and Outcomes.
Current Psychiatry Rep, DOI 10.1007/s11920-012-0259-x
Travers, R., Bauer, G., Pyne, J., Bradley, K., Gale, L., & Papadimitriou, M. (2012). Impacts of Strong Parental Support for Trans Youth.
TransPULSE Project.
World Professional Association of Transgender Health (WPATH). Standards of Care Version 7
Community Education Service
For more information or to register for an upcoming education
session, visit:
http://community.hmhc.ca/
CES email:
[email protected]
Telephone: 403-955-7420
Fax: 403-955-8184
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