Bullying is a relevant issue for this population and we must find ways to advocate for them in order to increase their safety. This presentation will discuss the negative impacts of bullying as well as clinical applications for this population.

1. Bullying and depression among
transgender youth
Presented by:
Lisa Richards and Rachel Watkins

2. Agenda
• Questions to think about
• Introduction
• Definitions
• Bullying and Depression
• Effects of Bullying
• Clinical Applications
• References

3. Questions to think about:
• How might you treat a transgender youth presenting
with depressive symptoms differently than a
cisgender youth suffering from the same?
• How might anti-transgender bullying and harassment
affect a trans youth differently than other types of
bullying against cis youth?
• What are at least two things that you would want to
be mindful of when working with a transgender child
or adolescent? Why would this be important? Would
you change anything about your approach if you
were working with a child versus an adolescent?

4. Introduction
According to Lombardi, Wilchins, Priesing, and Malouf
(2001), over half of their sample reported experiencing
violence or harassment in their lifetime. Russell, Ryan,
Toomey, Diaz, and Sanchez (2011) found that school
bullying among the LGBT community as a whole is a
public health problem. Bullying is a relevant issue for
this population and we must find ways to advocate for
them in order to increase their safety. This presentation
will discuss the negative impacts of bullying as well as
clinical applications for this population.

5. Definitions
• Transgender: umbrella term that means to cross
gender lines. (Gibson & Catlin, 2010)
• Cisgender: not transgender, that is, having a gender
identity or gender role that society considers
appropriate for the sex one was assigned at birth.
(urban dictionary)
• Bullying: a form of aggressive behavior in which
someone intentionally and repeatedly causes another
person injury or discomfort. Bullying can take the
form of physical contact, words or more subtle
actions. The bullied individual typically has trouble
defending him or herself and does nothing to “cause”
the bullying. (APA)

6. Transgender Youth
• Important phase of development
• Previously suppressed (by self or parents), gender
expression emerges
• Some adolescents acknowledge that they are transgender, some
need help understanding their feelings
• Gender-related stress often results in depression, self-neglect, and
self-destructive behavior
• Puberty
• Urgency to decide whether or not to stop pubescent process with
puberty blockers (possibly followed later by hormone therapy)
• Adolescents may be at risk of self-mutilation in rejection of the
genitals with which they were born (Swann & Herbert, 1999)

7. Bullying and Violence

8. Statistics of Bullying
According to the Center for Transgender Equality:
 More than 4 out of 5 transgender youth (82%) reported that they
felt unsafe at school because of who they were.
 Nearly 9 out of 10 reported experiencing transphobic or
homophobic harassment from peers, and most reported that it
happened “often” or “frequently.”
 A majority of transgender students said they had been shoved,
pushed, or otherwise physically harassed at school in the last
year.
 Nearly half (44%) of transgender students said they’ve been
punched, kicked, or injured with a weapon on at least one
occasion in the last year.
 76% reported that they had experienced unwanted sexual
remarks or touching from peers.
 Large majorities reported both cyberbullying (62%) and the theft
or destruction of their property (67%) by peers.
 http://www.transequality.org/PDFs/US%20Civ%20Rts%20Comm
n%20NCTE%20statement%205%206%2011.pdf

9. Source: National Center for Transgender Equality, 2011

10. Transgender experiences with
violence and discrimination
Lombardi, Wilchins, Priesing, and Malouf (2001)
 Results:
 Over half of the sample had experienced verbal
harassment for being transgender at one point in
their lives
 59.5% reported experiencing either violence or
harassment (26.6% experienced violence, 37.1%
experienced harassment)
 14% reported being raped or someone attempted to
rape them at some point in their lives
 47% were assaulted in some way in their lives

11. LGBT Adolescent School
Victimization
Although this study includes LGB folks, I feel it contributes to
this presentation.
Russell et al., (2011)
 Females reported less victimization when compared with
males and transgender youth
 Participants who identify as queer reported more
victimization when compared with LGB participants
 LGBT youth who reported high victimization were 2.6 times
more likely to report depressive symptoms and 5.6 times
more likely to report having attempted suicide at least
once, and having a suicide that required medical attention
 Participants who reported high levels of victimization were
more than twice as likely to report having an STD
diagnosis and to have been at risk for HIV

12. Parental Reactions
Grossman, D’Augelli, and Frank (2010)
 Participants: 31 MTF and 24 FTM youth between
the ages of 15 and 21
 54.5% classified their mothers’ first reaction as
negative or very negative, 62.9% classified their
fathers’ first reaction similarly
 At the time of study, approximately 3 years had
passed since the initial disclosure. 50% of youth
continued to describe their mothers’ reactions as
negative or very negative, 44.4% classified their
father’s reactions similarly

13. Effects of Bullying
(from parents and the school)

14. Stress in Female-Identified
Transgender Youth
Ignatavicius (2013)
• Parental Support (or lack there of)
- Parents react to a child’s gender nonconforming behavior most
commonly with anxiety, grief, confusion, or anger.
- A lack of parent support has been shown to have profound
effects on transgender youth
- Feelings of failure or disappointment, negative self-image, risk-taking
behaviors, anxiety, PTSD, hypervigilance and depression
- 3x higher suicidal rates for transgender youth without parental
support compared to those with parental support
• Depression and Suicide
- Study found that 20% of transgender youth meet the criteria
for major depressive disorder
- Youth of color tend to experience a greater level of depression
- Transgender youth with depression, low self-esteem, and under
the age of 25 who were subjected to discrimination, verbal
abuse, and physical abuse are more likely to attempt suicide
- 45% of participants in study attempted suicide at least once

15. Family Rejection, Social Isolation, and
Loneliness as Predictors of Negative Health
Yadegarfard (2014)
 260 respondents; 129 self identified as transgender
and 131 were self identified as cisgender
 The transgender participants reported significantly
higher rates of family rejection, lower social support,
higher loneliness, higher depression, lower protective
factors and higher negative risk factors related to
suicidal behavior, and were less certain in avoiding
sexual risk behaviors
 For both transgender and cisgender participants, their
experience of loneliness was the most common
predictor of their levels of depression, suicidal
thinking, and certainty in avoiding sexual risk
behaviors

16. Clinical Applications

17.  “Clinicians should be agents of change
when it comes to helping families rear
differently gendered children and
assisting schools to integrate such
children and prevent peer aggression.”
(Lev, 2004, p. 334)

18. Clinical Areas of Focus
 Affirmation & validation
 Family rejection/acceptance
 Social isolation & loneliness
 Advocacy & support

19. Areas of competency for working
with transgender youth
 Comprehensive knowledge of treatment
guidelines, protocols, and procedures as they
relate to the effective treatment of transgender
youth
 Knowledge about community resources available
 Willingness to advocate for client and family
 Continued education on contemporary research,
literature, and social issues around transgender
issues
 Strong sense of awareness of feelings, beliefs,
and values about gender diversity
(Bernal & Coolhart, 2012)

20. Affirmation & Support
 Lev’s (2004) Supportive Psychotherapy Model for
working w/ trans youth & their families:
 Psychoeducation: provide information and education on
gender diversity and transgender issues to trans youth
and their family members
 Resources: provide community resources and referrals
to reduce individual and family isolation
 Advocacy: act as an advocate for the youth and their
families in school and legal settings
 Boundaries: appropriate boundaries and limits should be
developed and encouraged
 “The focus is not on changing the child, but helping
him or her adapt to the constraints of a gendered
culture, while simultaneously working to change the
social system that encourages the abuse.” (Lev, 2004, p.
346)

21. Supporting gender expression
 Clinician can balance negative messages by
providing positive, affirmative messages around
gender diversity
 Asking and using a client’s preferred pronouns
and chosen name
 Modeling this for parents/family members and
explain the importance
 Can invite the youth to use the therapy room as a
space to fully express gender (i.e. allowing
affirmative clothing, behaviors, etc.)
(Coolhart, 2012)

22. Enhancing Resilience
 Resilience: the capacity to cope with adversity,
stress, and other negative events as well as the
capacity to avoid psychological problems while
experiencing difficult circumstances (p. 105)
 May serve as a protective factor for transgender
youth
 Predictive components:
 Sense of personal mastery
 Self-esteem
 Social support
 Coping skills
 Interventions targeting these variables may enhance
resiliency
(Grossman, D’Augelli, & Frank, 2010)

23. Treating Depression
 Must be sensitive to the role of social stigmatization,
discrimination, and victimization in client’s presenting
symptomatology
 CBT interventions (Buendia Productions, 2005):
 Cognitive triad through a social influence lens: Explore what
growing up and living in a heterosexist and homophobic
environment has taught the client about themself, others,
and the world
 Negative automatic thoughts (i.e. internalized transphobia):
Identify, evaluate, and reframe negative messages about
oneself as positive & affirming
 Core beliefs: Challenge a client’s negative core beliefs (i.e.
“there’s something wrong with me”) by pointing out
exceptions, and suggesting that rather than seeing them as
exceptions, maybe the core beliefs need to be reconsidered

24. Involving the Family
 Research suggests that trans youth w/ more accepting and
supportive parents/family may have better mental and
physical health outcomes (Ryan, Huebner, Diaz, & Sanchez, 2009)
 Framing the struggle:
“Families of gender non-conforming children need to
negotiate the interactions between two gender systems: a
rigid gender binary imported from familial, social, and cultural
experiences and a fluid gender spectrum articulated by their
child.” (Malpas, 2011, p. 453)
 Key tasks in family therapy (Coolhart, 2012):
 supporting and affirming gender non-conformity
 educating parents/family members and supporting their process
 exploring transition options
 advocacy in schools
 connecting the family with outside resources
 being a trans-affirmative clinician

25. Multi-Dimensional Family Approach
(MDFA)
 Components (Malpas, 2011):
 (1) Parental engagement and education
 During initial session w/ parents, important to inquire about
their responses to the atypical journey of their child
 Clinicians should clarify their position on gender non-conformity
as a normal human expression
 Helpful to review the difference between sex, gender, and
sexual orientation
 Emphasize the importance of parents’ roles in their ability to
find collaborative ways to nurture their children and to affirm
their choices
 (2) Individual assessment and child therapy
 Aim to create a space where children and their subjectivity can
be seen more fully; important to hear the account directly from
the child
 Should include conversations about comfort in school and
potential instances of bullying and teasing

26. MDFA (cont)
 (3) Parental coaching
 Empower parents to be a resource for their child
 Help parents identify ways in which gender non-conformity resonates in
their lives (meaning-making)
 Facilitate resolution of marital and parental discord around the issue of
gender non-conformity
 Support parents in making difficult decisions (i.e. social transition)
 (4) Systemic family therapy
 Support a positive and functional family climate where parents can
attune to the gender identity of their child and where children can respect
the limits set by their parents
 Repair the relational bond between parents and child when it has been
eroded by the conflict surrounding the gender non-conformity
 Mobilize family resilience and collaborative problem solving skills to
negotiate gender expression at home and in the social world
 (5) Parent support group
 Provides a sense of community and access to peers going through a
similar journey
 Provides processing space where information and reflections on their
own experiences can be shared

27. Affirming Youth and Parents
 One of the major goals in working w/ families of
trans youth is to move from “either/or” to
“both/and” (p. 457)
 Youth can both affirm their identity and understand
the demands of a world mostly organized the rigid
gender binary
 Parents can both nurture their child’s singularity and
operate as mediator between the child’s wish and
the social reality
(Malpas, 2011)

28. Parents
 May need to be met with separately at first
 Initial focus on supporting their process
 Provide validation and normalization for varied emotions
 Examine their reactions and beliefs and where they
come from
 Explain how society reinforces rigid rules around gender,
making gender non-conformity difficult to tolerate
 Explore other cultural factors that may be barriers to
acceptance (i.e. religion, ethnicity)
 Identify related beliefs or values that may support
acceptance (i.e. importance of family or unconditional love)
(Coolhart, 2012)

29. Parents
 Can serve as a buffer for discrimination and
bullying in other contexts, like school (Espelage et al.,
2008)
 Parental support was found to be significantly
associated w/ higher life satisfaction, lower
perceived burden of being transgender, and fewer
depressive symptoms (Simons, et al., 2013)
 Interventions that promote parental support may
significantly affect the mental health of trans youth

30. Parents
 Help parents develop scripts for talking to others about their
child
 Extended family, school, neighbors, parents of peers, etc.
 Vow of Parental Acceptance (Brill & Pepper, 2008)
 1. Speak positively about my child to them and to others about
them.
 2. Take an active stance against discrimination.
 3. Make positive comments about gender diversity.
 4. Work with schools and other institutions to make these places
safer for gender variant, transgender, and all children.
 5. Find gender variant friends and create our own community.
 6. Express admiration for my child’s identity and expression,
whatever direction that may take.
 7. Volunteer for gender organizations to learn more and to further
the understanding of others.
 8. Believe my child can have a happy future.

31. Exploring Transition Options
 Psychotherapy alone has it’s limits for many transgendered
teens, and transition options may need to be explored
 Nonmedical transition: clothing, hairstyle, preferred name &
pronouns, body language & behaviors, etc.
 Hormone blockers to delay puberty – may reduce psychological
distress
 Initiation of hormones
 Benefits of early transition (Lev, 2004):
 Avoiding the development of secondary sex characteristics that
would require medical procedures during adulthood
 Avoiding the development of a false gender identity and
expression that feels inauthentic
 Prevention of many of the struggles of coping with gender
dysphoria that can contribute to various mental health issues like
depression, suicidality, and and substance abuse
 Important to provide psychoeducation to youth and families
about their options and associated benefits and risks

32. Advocacy in Schools
 “Transgender youth are often functioning within
systems (such as school) that do not fully support or
understand their transgender identity; therapists can
help advocate and educate within these systems so
their clients may be treated with increased care and
consideration.” (Bernal & Coolhart, 2012, p. 293)
 Can help guide and support parents in advocating on
their child’s behalf within the school system
 Clinicians can facilitate a meeting with school principals
and other key school personnel
 “Attending school was reported to be the most
traumatic aspect of growing up.” (Grossman & D’Augelli, 2006,
p. 122)

33.  “It is not enough to provide competent
psychotherapeutic services, but is
incumbent on the clinicians to serve as
an advocate in addressing systemic and
macrolevel policies that interfere with
the child’s safety.”
(Lev, 2004, p. 345)

34. Advocacy in Schools (cont)
 Can include:
 The use of preferred name & pronouns
 Updating policies and forms
 Providing training and education for students, staff, & parents
 Adopting zero-tolerance policy for discrimination and bullying
that includes gender
 Allowing youth to use bathrooms, locker rooms, dress codes,
and gym activities that are congruent w/ affirmed gender
 Clinicians can write a letter of support for their client (examples
found in Brill & Pepper, 2008)
 May increase feelings of support from parents, enhancing
therapeutic alliance
(Coolhart, 2012)

35.  “A child’s experience at school can significantly
enhance or undermine their sense of self.
Furthermore, children need to feel emotionally safe in
order to learn effectively. A welcoming and supportive
school where bullying and teasing is not permitted
and children are actively taught to respect and
celebrate difference is the ideal environment for all
children. This is especially true for gender-variant and
transgender children, who frequently are the targets
of teasing and bullying. A child cannot feel emotionally
safe, and will most likely experience problems in
learning, if they regularly experience discrimination at
school.”
(Brill & Pepper, 2008, p. 153-154)

36. GSAs: Offsetting Risks & Providing
Support
 Gay-straight alliances (GSAs) are student led,
school-based clubs whose goals involve improving
the school climate for LGBT youth and educating
the school community about sexual and gender
minority issues (GLSEN, 2007)
 Can be a place for LGBT youth to spend time w/peers
and may increase social support
 May contribute to a safer atmosphere for LGBT youth
by sending a message that hate speech and
victimization will not be tolerated
 Schools w/ GSAs may be viewed as a place where
LGBT youth feel they belong and are supported
 May help LGBT youth identify supportive teachers and
staff, which may positively impact academic
achievement and experiences

37. GSAs (cont)
 Youth who attended a high school w/ a GSA
report significantly more positive outcomes
related to school experiences, alcohol use, and
psychological distress (Heck, Flentje, & Cochran, 2011)
 Youth w/ GSAs had lower scores on depression
inventory than youth w/o GSAs
 GSAs may provide a space where straight youth
can become educated about LGBT issues
 Can strengthen straight allies
 Study found that youth-led interventions in peer
networks might be effective in diminishing
transphobic bullying (Wernick, Kulick, & Inglehart, 2014)

38. LGBT Resources in Schools
 GSAs, teachers supportive of LGBT youth, and
LGBT-inclusive curricula were related to lower
levels of victimization based on sexual orientation
and gender expression
 Positive effects of GSAs found to be stronger for
trans students than cis LGB students
 Youth in schools with a comprehensive anti-bullying
policy were found to be victimized as
often as those in schools without such a policy
 Less focused on prevention
(Greytak, Kosciw, & Boesen, 2013)

39. School Psychologists
 Recommendations for how to improve the school
climate for LGBT students:
 establishing and publicizing an anti-bullying policy that is
inclusive of sexual orientation, gender, and gender
identity
 training teachers to recognize and intervene when
students engage in homophobic or transphobic
behaviors
 supporting the establishment of GSAs or similar student
organizations
 integrate information about sexual orientation and
gender identity into educational curricula and
discussions of diversity
(Russell, McGuire, Laub, & Manke, 2006)

40. Safety Precautions
 Brill and Pepper (2008) recommend that
transgender teenagers carry a letter from their
doctor or therapist explaining that they are
transgender
 A letter can be helpful if an encounter with the police
occurs. There have been situations where police officers
have spread the status of a child’s transgender gender
identity
 The letter should include the importance and need for
sensitivity and privacy around their gender identity
 Further recommendation: Make a letter into a wallet size
card and laminate it to carry with them

41. Case Example #1
 “I felt very unsafe . . . and me being a double
minority, I felt really uncomfortable having to go to
school, being called names, being picked on
verbally, physically sometimes . . . I left school in
my second year, in tenth grade. I left because I
literally had to fight my way through school, and I
said, you know what? If I have to receive an
education this way, I’ll just do it another manner,
you know?”
 Anwar, identifies as a male living a female lifestyle
(Sausa, 2005, p. 19)

42. Case Example #2
 “I was constantly running from people, because
everybody wanted to fight me for some reason. I’d get
off the school bus and somebody would come after
me, and I would run . . . Every single day that I was in
school something was thrown at me in the lunchroom
. . . I can never remember a time where someone
actually stopped someone from doing things, or took
them aside and hugged me or nothing. No one ever,
ever gave me support or nurturing . . .”
 Phoenix, assigned male at birth who identifies as a drag
queen
(Sausa, 2005, p. 20)

43. Case Example #3
 “I failed gym because of that (harassment). Every
year, every semester, I failed gym. I didn’t take
gym because of the locker room, because I would
not go in the locker room. I didn’t do any sports in
high school because I would not go in that locker
room.”
 Aidan, identifies as a feminine male
(Sausa, 2005, p. 21)

44. Resources
 Important to provide resources for youth and parents/family
 Can help reduce loneliness for youth, a major predictive factor of
depression
 Support groups (i.e. PFLAG, group therapy)
 Can be validating to hear the stories of other families w/ trans youth
 Can give youth a space to gain support while offering parents the
space to talk openly
 Bibliotherapy:
 The Transgender Child: A Handbook for Professionals and Families
(Brill & Pepper, 2008)
 Beyond Magenta: Transgender Teens Speak Out (Kuklin, 2014)
 Be aware of trans-affirmative referral sources for endocrinologists
and psychiatrists
 Provide youth-oriented literature containing LGBT-inclusive
information about HIV/AIDS and safe sex
 Provide phone numbers for youth-support hotlines

45. References
• Brill, S., & Pepper, R. (2008). The Transgender Child: A handbook for families and professionals. San Francisco:Cleis Press, Inc.
(64-71).
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47. References (cont)
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