A teenager identifying as a transgender person
SUPPORTING ME
Introduction
3
How is the sex of a person defined?
4
What is gender?
5
What is transgender?
6
Gender identity and sexual orientation/preference
8
Mental health and transgender young people
11
Supporting a transgender young person
13
What specialist support is available for transgender young people?
15
Common terminology
18
Support services
21
Selected resources
23
References
24
CONTENTS
SUPPORTING ME A teenager identifying as a transgender person Introduction Identifying as a transgender person can be an emotional experience, particularly so for teenagers as they navigate changes to their physical, psychological and social selves. While it can be stressful for the person and those around them, it can be incredibly rewarding too—it is important to provide the necessary guidance and support mechanisms to enable them to feel comfortable and to embrace their true selves. This ebook provides information for parents, carers and peers on how to support a teenager identifying as a transgender person. It discusses terminology, how to recognise a transgender young person, how to provide appropriate assistance and where to access relevant support services. It also explains how occupational therapists can play a part in providing appropriate support.
How is the Sex of a Person Defined?
FACT: Some people are born with other combinations of chromosomal makeup—such as XXY, XYY or uncertain sexual characteristics. Intersexuality refers to people who may not display obvious masculine or feminine sexual characteristics.
Our sex and physical characteristics (e.g. having male and female reproductive organs or the physical characteristics of generally broader shoulders in men and wider hips in women) are differentiated by our genetic makeup. Males are genetically presented with XY chromosomes and females with XX chromosomes. The gender (covered in the next section) newborn babies are assigned at their time of birth is based on their presenting sex and physical characteristics.
FACT: Different cultures may have different views of what is masculine or feminine, as well as what is acceptable or not acceptable to most people within that culture. In Scotland, some men wear kilts (seen as a skirt by many other cultures) which is a part of the Scottish culture.
What is Gender?
Gender is the social, cultural and psychological interpretation of what is feminine and what is masculine. This can be expressed in the roles we play in society or the way we present ourselves. Some people do not recognise themselves as falling neatly into either the male or the female gender. This is considered to be a non-binary view of gender norms. Examples of traditional gender roles: According to popular culture, boys or males assigned at birth, play with trucks and wear blue coloured clothes. Girls or females assigned at birth, play with dolls, grow their hair long and wear pink coloured clothes.
FACT: The term cisgender refers to when a person’s gender identity corresponds with the biological sex or their gender assigned at birth. This means that a girl may say that they feel like ‘a girl in a girl’s body’.
What is Transgender?
Children usually express their gender identity around two to three years of age. It is normal for a child to experiment with gender roles in various ways as they grow into adulthood and most will feel comfortable with their gender identity. Transgender persons have a gender identity that is different from their assigned gender at birth. This means that a person assigned as a boy at birth may say that they feel like ‘a girl in a boy’s body’. They may also wish to express their gender in a way that matches their own gender identity. Some transgender people, who have permanently changed or are looking to change their bodies through medical interventions (such as surgeries and/or the use of hormones) to match their preferred gender, refer to themselves as transsexual. However, it is important to note that this does not apply to all transgender people. Additionally, there are restrictions and laws which dictate the age at which a young person can commence treatment for their transition from one gender to another. These can be different, depending on the states and territories in which the young person resides.
FACT: It is estimated that approximately 1.2% of Australian school students identify as transgender.
"Transgender people have the same range of sexual orientations as everyone else in society and may identify as gay, lesbian, straight or bisexual. "
Often misunderstood, gender identity and sexual orientation/preference are actually very different things. Sexual orientation is used to define whether a person identifies themselves as same-sex attracted (homosexual), attracted to both sexes (bisexual) or the opposite sex (heterosexual). Transgender people have the same range of sexual orientations as everyone else in society and may identify as gay, lesbian, straight or bisexual. For example, a person assigned as a male at birth who identifies her own gender as female, would see herself as a lesbian if she is sexually attracted to other women. In recent times, many more ways to define an individual’s sexuality have been recognised. These include pansexuality, which is romantic attraction to others not based on their gender identity or sex. There are also people who do not feel they have a specific gender, and are therefore ‘agender’.
Gender Identity and Sexual Orientation/ Preference Gender identity and sexual orientation/preference
"being transgender or gender diverse is not a mental health problem in itself"
Is being transgender a mental illness? The American Psychiatric Association released the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) in 2013, which superseded Gender Identity Disorder with Gender Dysphoria and amended the associated diagnostic criteria. Gender Dysphoria is a) the clinically significant distress felt by people whose gender identity is different from the gender they are assigned at birth, or b) the impairment experienced in social, occupation, or other important areas of functioning as a result of the distress. If a transgender person is not distressed by their experience, a diagnosis of gender dysphoria is not necessarily applicable. Additionally, in June 2018, the World Health Organisation (WHO) and its proposed 11th International Classification of Diseases (ICD) moved gender incongruence (the term used in the ICD for people whose gender identity is different from the gender they were assigned at birth) out of the mental disorders chapter into the sexual health chapter (World Health Organization, 2018). Historically, transgender identity was classified as a pathological condition in the ICD (Winter, De Cuypere, Green, Kane & Knudson, 2016). Therefore, the recent changes in both the DSM-V and the upcoming ICD-11 (scheduled to be presented at the Seventy-second World Health Assembly for endorsement by member states in May 2019), recognise that being transgender or gender diverse is not a mental health problem in itself. However, many transgender young people do experience gender dysphoria and mental health concerns such as depression, anxiety, self harm and suicidality. In younger children, this can also be present in the form of emotional and behavioural difficulties.
Mental Health and Transgender Young People
The following diagram demonstrates the results of an Australian research survey (Smith, et al, 2014), which examined self-harm and suicide attempts by young people who had experienced abuse, harassment or discrimination.
Transgender young people are more likely than the general population to experience mental health conditions (Lenning & Buist, 2013). This concern is compounded by the fact that transgender people are reluctant to seek health assistance (McNeil, 2012). In a study conducted by La Trobe University and the University of New England (Smith, Jones, Ward, Dixon, Mitchell & Hillier, 2014), almost half of the young people surveyed had been diagnosed with depression by a health professional. While more than one-third had experienced suicidal ideation, only one in four had reported the ideation to a health professional. Apart from an increased risk of developing mental health problems (such as depression, anxiety and eating disorders), some transgender young people also experience symptoms of trauma and post-traumatic stress disorder (PTSD) due to the stigma and discrimination they commonly face.
discrimination and bullying Occurrences of misunderstanding, discrimination and bullying are often experienced by transgender young people. The term ‘transphobia’ refers to a dislike of, or prejudice against, transsexual or transgender people. In Australia, discrimination based on sex, gender identity or expression is against the law (The Sex Discrimination Act), no matter whether this occurs at school, in the workplace, online or in public space. Any forms of discrimination and bullying because of a young person’s gender identity and expression must NOT be tolerated. It is important that these unwanted behaviours are reported to the appropriate people such as teachers, parents, other trusted adults or the police. It is important that young people seek appropriate support from friends, families or professional services if they are subjected to discrimination and bullying—the Support Services section in this e-book provides several recommendations to facilitate this process.
Supporting a Transgender Young Person There are simple steps we can all take in supporting young people who identify as transgender: Listen to their needs without judgement. Allow them to talk about their experiences. Encourage them to engage in social activities. Assist them to find suitable and accurate information about transgender, mental health, available support services and treatment options. Encourage them to seek appropriate professional help, such as from a doctor or other health professionals, including a mental health clinician. Provide them with support and encouragement to engage in selfcare activities and hobbies. Encourage them to take adequate rest and develop a healthy sleep routine. Encourage them to exercise and to consume a balanced, healthy diet. Maintain contact with them and check in with them from time to time. If they are not ready to talk right now, let them know that they can talk when they are ready, and check up on them again soon. Provide them with appropriate information on a variety of mental health problems and mental illnesses. Help them to locate and engage with relevant support groups and organisations. If appropriate, educate their family and close friends about transgender, and encourage them to adopt an inclusive approach in support of young people. Educate them about their rights to be treated fairly and equally, and where to seek advocacy support if required. Check for any declines in mental state and functioning, which can be acute or longer-term. Encourage them to seek support from relevant doctors and medical specialists in relation to transitioning (e.g. taking hormones). Discourage the use of substances or self-medication to deal with mental health problems. Find out and use the person’s preferred pronouns (e.g., “he” or “she”, or more gender neutral pronouns such as “ve” or “e”). For example, ask “What pronouns would you like me to use?”
Specialist support for transgender young people—particularly those experiencing gender dysphoria—largely depend on their individual needs and the needs of the family unit. The emphasis should be on promoting physical, social and psychological wellbeing, as well as developing mental resilience, knowledge and awareness of services and how to access them. This includes working with the school and other key environments for young people. Medical support may be necessary for young people who are distressed by the physical changes of puberty. This includes the use of puberty blockers (also known as Stage 1 treatment) which is reversible. For those over 16 years of age, Stage 2 treatment is available which involves the use of hormones to render the body more consistent with the identified gender of the young person. Stage 2 treatment requires court approval in Australia for young people under the age of 18. Surgical treatments such as sex reassignment surgery are not permitted at all for young people under the age of 18 (Gender Centre, 2016).
What specialist support is available for Transgender Young People?
how can an occupational therapist help?
Occupational therapists are health professionals who provide, treatment and specialised support to maximise the function, participation and independence of individuals with an illness, disability or social and environmental limitations. This includes providing care to people with physical or psychosocial issues across the lifespan. Occupational therapy is a client-centred health profession that enables people to live their life in a purposeful manner, whether it be in work, leisure or activities of daily living. Occupational therapists can work with transgender young people in various settings and cater for their different needs, such as in the school system or mental health services. There are many occupational therapists working with transgender young people in the public service domain, such as in Child and Youth Mental Health Services (CYMHS) or relevant paediatric services. They can be a part of a multidisciplinary team working alongside other health professionals or as part of a specialised occupational therapy service. Occupational therapists also work in private practices, delivering care through a variety of approaches. For example, there are occupational therapists with recognised mental health experience and training providing Focussed Psychological Strategies (FPS) services to clients through the Better Access initiative of Medicare. The unique healthcare frame of reference employed by occupational therapists makes them particularly useful in promoting the occupational identity of transgender young people, with an emphasis on how social and physical environments influence their occupational performance, health and life satisfaction (Avrech Bar, Jarus, Wada, Rechtman and Noy, 2016). Occupational therapists are well equipped to support young people going through social transition into their affirmed gender by preventing the loss of engagement in meaningful occupations for the individual, whilst helping them to adjust to changing social roles (Murphy, Tinsley, Schaefer and Washington, 2017).
Common Terminology (Green, 2017)
AFAB – Person assigned female at birth, also referred to as FAAB (female assigned at birth) or DFAB (designated female at birth). AMAB – Person assigned male at birth, also referred to as MAAB (male assigned at birth) or DMAB (designated male at birth). Asexual – Someone who does not experience sexual attraction. Assigned at birth – the gender that was given to a person when they were born. Binary – A system where there are only two options; used in the trans community to refer to the binary gender system, where people are either male or female (also known as the gender binary). Cisgender – Can be abbreviated to cis; refers to someone whose gender identity matches the gender that was assigned at birth. Dysphoria – a profound sense of unease. FTM, F2M – Female-to-male, a person who was given the gender of female when he was born but identifies as a male. Gender – the state of being male or female; generally refers to social and cultural differences (as opposed to sex, which refers to biological differences). Gender dysphoria – the profound sense of unease related specifically to a person’s assigned gender at birth not matching their gender identity. Gender expression – how a person expresses their gender identity to others (such as name, pronouns, clothing, voice or body characteristics). Gender identity – an individual’s internal sense of gender; gender identity is not always necessarily visible to others. Gender nonconforming – Refers to an individual whose gender expression is different from societal expectations related to gender. Genderqueer – refers to individuals who identify anywhere on the gender spectrum (but not necessarily as either male or female). Heterosexual – someone who is sexually attracted to a person of the opposite gender. Homosexual – someone who is sexually attracted to a person of the same gender. Intersex – refers to people who are born with a variation in sex characteristics (i.e. external genitalia, chromosomes or internal reproductive systems that are not traditionally associated with the typical male or female configurations). Misgender – the use of the wrong pronouns for a person, in contrast to their identified gender. MTF, M2F – Male-to-female, a person who was given the gender of male when she was born but identifies as a female. Non-binary – an umbrella term for people who don’t identify as entirely male or entirely female. Pansexual – someone who is sexually attracted to a person irrespective of their gender. Sexual orientation – sexual orientation refers to the orientation of the person in relating to who they are sexually attracted to. Transgender people may be straight, lesbian, gay, pansexual or bisexual. Trans – used as shorthand to mean transgender or transsexual. Trans is an adjective, so it is a trans woman (not transwoman) in the same way that it would be a short woman (not a shortwoman). Transgender – an umbrella term for people whose gender identity, expression or behaviour is different from their assigned sex at birth, including but not limited to cross-dressers, androgynous people, genderqueer people, non-binary people, transsexuals and gender nonconforming people. Some intersex people also identify as transgender. Transition – transition includes some or all of the following steps: telling family, friends and co-workers; choosing and using a new name and new pronouns; dressing differently; changing name and/or sex on legal documents; hormone therapy; and surgery of some type. Transphobia – discrimination against, or hatred towards, a person because they are or are perceived to be trans. Transsexual – a term used for people whose gender identity is different from their assigned sex at birth. Often, transsexual people alter or wish to alter their bodies through hormones and/or surgery to match their bodies to their gender identity. Transvestite – an outdated term for a cross-dresser that is considered derogatory.
Support Services
beyondblue 1300 22 4636 beyondblue provides information and support to help everyone in Australia achieve their best possible mental health, whatever their age and wherever they live. The Gender Centre The Gender Centre offers services, information and support to transgender and gender diverse people, their partners, families and friends. Based in New South Wales, they also act as an education, support, training and referral service. headspace The national youth mental health foundation dedicated to improving the wellbeing of young Australians. Kids Helpline Kids Helpline is a 24-hour, seven day a week counselling service for Australian young people aged between 5 and 25 years. Kids Helpline talk to more than 6,000 kids each week, about all sorts of problems. Young people can access Kids Helpline by calling 1800 551 800 or visiting the website. National LGBTI Health Alliance The National LGBTI Health Alliance provides health-related programs, services and research focused on lesbian, gay, bisexual, transgender, and intersex people (LGBTI) and other sexuality, gender, and bodily diverse people and communities. SANE Helpline 1800 18 7263 Information about mental illness symptoms, treatments, where to go for support and help for carers. Transcend Transcend provides parent/carer support, community connection, information, advocacy and fundraising. Transcend was founded in 2012 by Rebekah Robertson. It was the first parent led peer support network for the families of transgender children in Australia. Q Life 1800 184 527 or Online Chat (3pm to midnight across Australia, everyday) QLife is Australia’s first nationally-oriented counselling and referral service for people who are lesbian, gay, bisexual, trans, and/or intersex (LGBTI). QLife provides nation-wide, early intervention, peer supported telephone and web based services to people of all ages across the full breadth of people’s bodies, genders, relationships, sexualities, and lived experiences. YGENDER Ygender is a peer led social support and advocacy group for trans/gender diverse young people. Further support, assessment and referral options can be obtained from a local GP (general practitioner, family doctor), or a specialist gender clinic/service in your area. For mental health specific needs, the local public mental health services, headspace centres , or private psychiatrist and other mental health service provider in the local area can be contacted.
Selected Resources
This is a list of resources that might be helpful. Inclusion does not indicate that the resources are necessarily endorsed by Occupational Therapy Australia. Books Angello, M., & Bowman, A. (2016). Raising the transgender child: A complete guide for parents, families, and caregivers. Berkeley, CA: Seal Press Brill, S., & Kenney, L. (2016). The transgender teen: A handbook for families and professionals. San Francisco, CA: Cleis Press, Inc. Nealy, E. C. (2017). Transgender children and youth: cultivating pride and joy with families in transition, New York: W.W Norton & Company, Inc. Testa, R. J., Coolhart & D., Peta, J. (2015). The gender quest workbook: a guide for teens and young adults exploring gender identity, Oakland: NewHarbinger. Online Resources From Blues to Rainbows Report headspace – Gender identity and mental health Healthy Children.org – Gender identity development in children Healthy Children.org – Gender-diverse & Transgender Children Human Rights Campaign – Supporting and caring for transgender children
references
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC Australian Human Rights Commission, Resilient individuals: sexual orientation, gender identity & intersex rights (2015). At: https://www.humanrights.gov.au/sites/default/files/document/publication/ SOGII%20Rights%20Report%202015_Web_Version.pdf (viewed 01 August 2018). Avrech Bar, M., Jarus, T., Wada, M., rechtman, L. and Noy, E. Male-to-female transitions: implications for occupational performance, health and life satisfaction, Canadian Journal of Occupational Therapy, Vol 83 (2), 2016. Gender Centre (2016), Getting treatment: what to do if you trans and under 18, accessed 18 August 2018, At: https://gendercentre.org.au/images/Services/Youth_Support/Getting_ treatment-_what_to_do_if_you_are_trans_and_under_182.pdf GLAAD (2018), accessed 18 August 2018, https://www.glaad.org/reference/transgender Green, J. (2017), The trans partner handbook – a guide for when your partner transitions, London: Jessica Kingsley Publishers Lenning, E., & Buist, C. L. (2013). Social, psychological and economic challenges faced by transgender individuals and their significant others: gaining insight thorught personal narratives. Cult Health Sex, 15(1), 44-57 McNeil, J., Bailey, L., Ellis, S., Morton, J., & Regan, M. (2012). Trans Mental Health Study: Scottish Transgender Alliance. Murphy, M., Tinsley Schaefer, J., & Washington, Enjoli. (2017). Gender Dysphoria and the Role of Occupational Therapy. School of Occupational Master's Capstone Projects. 14. At: http://soundideas.pugetsound.edu/ot_capstone/14 Nealy, E. C. (2017). Transgender children and youth: cultivating pride and joy with families in transition, New York: W.W Norton & Company, Inc. Occupational Therapy Australia – Position Paper: Occupational therapy Scope of Practice Framework (2017). At: https://www.otaus.com.au/sitebuilder/advocacy/knowledge/asset/files/21/ occupationaltherapyscopeofpracticeframework13june2017.pdf (viewed 15 July 2018). Smith, E., Jones, T., Ward, R., Dixon, J., Mitchell., A. & Hillier, L. (2014). From Blues to Rainbows: Mental health and wellbeing of gender diverse and transgender young people in Australia. Melbourne: The Australian Research Centre in Sex, Health, and Society. The Royal Children’s Hospital Melbourne (2018), accessed 18 August 2018, At: https://www.rch.org.au/kidsinfo/fact_sheets/Gender_dysphoria/ Winter, S., De Cuypere, G., Green, J., Kane, R. & Knudson, G. (2016). The proposed ICD-11 gender incongruence of childhood diagnosis: a World Professional Association for Transgender Health membership survey, Archives of Sexual Behaviour, Vol 45 (7), pp 1605-1614 World Health Organisation (2018), WHO releases new International Classification of Diseases (ICD 11), accessed 12 August 2018, At: http://www.who.int/news-room/detail/18-06-2018-who-releases-new-international-classification-of-diseases-(icd-11)
Smith, E., Jones, T., Ward, R., Dixon, J., Mitchell., A. & Hillier, L. (2014). From Blues to Rainbows: Mental health and wellbeing of gender diverse and transgender young people in Australia. Melbourne: The Australian Research Centre in Sex, Health, and Society. The Royal Children’s Hospital Melbourne (2018), accessed 18 August 2018, At: https://www.rch.org.au/kidsinfo/fact_sheets/Gender_dysphoria/ Winter, S., De Cuypere, G., Green, J., Kane, R. & Knudson, G. (2016). The proposed ICD-11 gender incongruence of childhood diagnosis: a World Professional Association for Transgender Health membership survey, Archives of Sexual Behaviour, Vol 45 (7), pp 1605-1614 World Health Organisation (2018), WHO releases new International Classification of Diseases (ICD 11), accessed 12 August 2018, At: http://www.who.int/news-room/detail/18-06-2018-who- releases-new-international-classification-of-diseases-(icd-11)
Disclaimer: This ebook provides general information only. The content provided in this ebook, and in any linked materials, are not intended and should not be construed as direct medical advice. If the reader or any other person has a medical concern, they should consult with an appropriately registered health professional.
Acknowledgements
Occupational Therapy australia
Occupational Therapy Australia 2018 All copyright and publication inquiries should be directed to marketing@otaus.com.au
Occupational Therapy Australia would like to thank the author of this resource for their valuable contribution. Author: Adam Lo, Occupational Therapist and Senior Mental Health Clinician Images sourced from pexels, the noun project & unsplash
Occupational Therapy Australia (OTA) is the national professional association for occupational therapists in Australia. Our members are occupational therapists, students and those working in the profession in a variety of practice areas to enable people to participate in meaningful activities.
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