Dr. Michele Angello returned to FCP to present “Clinical Issues for Transgender and Non-binary Communities.” In this important and informative workshop, Dr. Angello clearly met her stated goals:

• Expand understanding of the needs of transgender/non-binary individuals
• Explore ways to support families with transgender/non-binary people
• Offer best practices for transgender/non-binary patients

As in the past, Dr. Angello had a very dynamic style that kept the pace moving quickly. She was also able to transcend the serious nature of the material with a great sense of humor, without diluting her message in the least. The 3 hours went by quickly. During the question-and-answer time, there were only a few, but these were on target and contributed to an understanding of her material.

Central to therapy with Transgender and Non-binary children, youth and their families is the concept of “Social Location.” Dr. Angello defines using the following description:

“Location of self is the name of a process in which the therapist initiates a conversation with a family about similarities and differences in their key identities, such as race, ethnicity, gender, class, sexual orientation, and religion, and how they may potentially influence the therapy process. (Watts-Jones, 2010, p. 405).”

Dr. Angello’s workshop began with a brief discussion about the nature of sexual identity among youth and a wonderful discussion of vocabulary which I again found very useful. She pointed out all who are not “cisgender” (those aligned with their assigned sex at birth), fall under the umbrella of “transgender.” Dr. Angello also explained that Sexual Orientation and Gender Identity are two different concepts but often confused. In short, she joked that “sexual -orientation” defines who you would like to sleep with, and “gender identity” defines who you are.

Dr. Angello talked about gender identity development and transition for children and youth. Awareness of gender identity development includes:

Most children between ages 1 and 2:

• Children become conscious of physical differences between sexes (primary sex traits

Most children around 3 years old:

• Can label themselves
• “I’m a girl” “I’m a boy”

Generally, by age 4:

• Children’s awareness of gender is stable
• Recognition that gender is constant

Most between ages 4 and 6:

• Children become aware of relationship roles and how they would like to fit in

Around 7 years old:

• Begin identifying individuals they are physically attracted to

Generally, by age 10:

• Children are connecting language (definitions) to their sexual orientation

Dr. Angello pointed out that there is not a lot of research on the etiology of sexual and gender identity. Most likely this is a combination of biological and environmental factors. Typically, there are two developmental windows where awareness and expression of gender identity become prominent: childhood (4-6 years old) and puberty (10-15 years old). Factors that influence gender identity and expression include:

Family, School and Community

• Clothing
• Hair Style
• Relationships
• Jobs

Biology

• Puberty
• Body Image
• Hair
• Voice

Psychological

• Feeling Different
• Experiencing Violence
• Mental Health Concerns

Sociocultural

• Social Definitions of Sex and Gender
• Influential Individuals
• Influential Communities
• Media

Dr. Angello stated that some folks may seek surgery to better match their inner self with their body image. This is not typical during youth because it is not easily reversible, and it is very expensive. Another medical approach to transition of body image is hormonal. This is the “pause button” approach, which helps the body achieve some characteristics of the desired appearance but is less radical than surgery. This treatment slows the onset of secondary sex characteristics and allows the youth to get used to the new identity. More important, this allows those close to the adolescent to get used to the changing individual. Hormone treatment is also expensive and may be irreversible.  Regardless of any desired physical change in the body or not, Dr. Angello, emphasized that social transition to a new sexual identity must occur. Each individual will need to adapt to the new identity psychologically. This is not a quick process, and it will take years including family and social circle acceptance, often with professional support.

Of course, there are many pitfalls along the way to a new life for the transgender youth in transition. Family and others may present preconceptions and biases as barriers to successful transition or professional support for these individuals. Parents may also believe that once the topic is in the open, transition is inevitable. The goal of therapy is not to influence, but to help the youth and the family accept the natural direction of the youth’s sexual identity or preference.

Probably oversimplified, the practitioner is not treating transgender or homosexuality in youth but treating the same behavioral health problems experienced by all youth. Some youth happen to be transgender. Of course, transgender children and youth often have more serious behavioral  health problems due to rejection by family, peers, and social institutions. Dr. Angello stated that African American transgender women have an average lifespan of only 35 years according to a 2018 study. These women and other transgender individuals with a high level of rejection have a high rate of suicide often resulting from:

• Loss of family
• Loneliness
• Loss of job
• Harassment at school
• Kicked out of house
• Discrimination

Dr. Angello emphasized the importance of family therapy in treating this population. She also emphasized the importance of being a good diagnostician. That includes developing a clear understanding of all concerns of the client and the family before deciding on the need for, or a course of treatment. The “Gender Affirmative Model” (Colt Keo-Meier & Diane Ehrensaft 2018), is recommended by Dr. Angello for therapists working with transgender individuals. Among other factors, Dr. Angello said the “Implicit in this model is a focus on resilience, coping, and wellness.”

During the presentation, Dr. Angello talked about the tasks of childhood development including:

1. Establish a distinct self, separate from parents/caregivers
2. Develop a sense of reality that is distinct from fantasy
3. Determine a sense of values to guide decision making and interests, as well as capabilities that lay the foundation for future decisions
4. Needs of the child revolve around tasks, hobbies, and skill-oriented activities
5. Being to see a personal identity based on the integration of values and a sense of self.

These tasks are often more complex for the transgender child.

The therapist should keep in mind seven signs that a child might be transgender or non-binary. These include:

1. Child presents in a way that is not congruent with sex assigned at birth
2. Child fantasizes about being a different gender
3. Child is hypervigilant about privacy
4. Child smiles when people get confused over their gender
5. Child requests a “do-over”
6. Child overtly identifies as transgender, gender fluid, non-binary, or another gender-diverse label
7. Child is happier after a social transition

(Angello and Bowman, Raising the Transgender Child: A Complete Guide for Parents, Families, and Caregivers).

During work with teens, Dr. Angello notes that the therapist should be aware of the tasks of adolescent development including:

1. Adjust to sexually maturing bodies and feelings
2. Identify meaningful moral standards, values, and belief systems
3. Understand and express more complex emotional experiences
4. Form friendships that are mutually close and supportive
5. Establish key aspects of identity
6. Renegotiate relationships with adults in parenting roles

Especially difficult components of tasks during adolescent for the transgender teen according to Dr. Angello include:

• Lack role models
• Changing bodies
• Dating
• Sexuality
• Thinking about the future
• Finding language
• Communicating with parents
• Communicating with systems

Dr. Angello provided basic elements for therapists and teachers to being a trans-friendly ally for youth. These include:

1. When a child comes out to you, immediately thank them for trusting you.
2. Ask what name/pronoun you should use (who else knows?)
3. Do they have parent/caregiver support?
4. Are they living w/ parent/caregiver?
5. How long have they known?
6. Do they have a support network?
7. Remember to assess for behavioral health issues.
8. Don’t assume a binary sense of gender.
9. Is the child safe in the home? Do they feel safe at school?
10. Consider a 504 Plan for the child who meet the criteria.
11. Keep in mind that it’s very helpful if the family can be on board (remember to include siblings).

Dr. Angello defined non-binary gender identity (NBGI) as a gender identity that is not based on a binary gender system that is limited to the gender identities of man or woman.

Noting that language history has not been friendly to transgender or non-binary children and youth, Dr. Angello provided several “micro affirmations” to support these individuals and encourage a positive self-esteem. Miro affirmations are defined as “subtle endorsements of a person’s identity through verbal acknowledgement and/or behavioral gestures” (Galupa, Pulice-Farrow, Clements, & Morris). Micro affirmations can include:

• Acknowledgement of cisgender privilege
• Using affirming language
• Affirming gender(less) presentation
• Acknowledging milestones

Themes include:

•  Identity Validations
• Identity Endorsements
•  Active Learning
• Active Defense

As in the past, Dr. Angello’s presentation was very educational with bridled passion. Clearly this is an important topic and not without the need for strong advocacy. Dr. Angello’s advocacy appears in the form of “normalizing” the discussion topic through educating the public and providing support for the transgender/non-binary community. This is a very complex topic. I expect that I missed some nuances in this Blog.

Excellent Workshop!